Notwithstanding any other provisions in the rules, the Society will cover in full the diagnosis, medical management and medication for the prescribed chronic conditions to the extent that this is provided for by way of a therapeutic algorithm for a specified condition, as published by the Minister of Health by notice in the Government Gazette.
If you wish to claim under the prescribed minimum benefits (PMB's), please note the following conditions:
The Society designates the following service providers for the delivery of prescribed minimum benefits to its beneficiaries:
To qualify for cover where you wish to claim for prescribed minimum benefits, you must obtain pre-authorisation from the Society by calling 0800 111 669 and indicating that you wish to obtain authorisation in terms of the prescribed minimum benefits rule.
| Society Benefits List - 2007 |
| Ambulance services |
| | 100% unlimited, subject to pre-authorisation by the designated service provider | ER24 is the designated service provider for all emergency and ambulance services. The Society has no liability for any other ambulance services. |
| Auxiliary health services |
| Audiology, Chiropody, Podiatry, Chiropractic services, Dietician services | 90% of NHRPL
R980 per beneficiary
Combined limit | |
| Occupational and speech therapy | 90% of NHRPL
R1 430 per beneficiary | |
| Care not in hospital |
Hospice
In- and out-patient | 90% of NHRPL
Maximum of R10 500 per beneficiary | The Hospice must be registered with the Hospice Association of SA.
Prior Society approval is required. |
| Private nursing and frail care | 90% of NHRPL
R7 000 per beneficiary
Limited to R132 per day | Prior Society approval is required. |
Blood transfusions
(Not in hospital) | 90% of NHRPL
No limit | Prior Society approval is required. |
| Mental Health | 90% of NHRPL
R6 360 per beneficiary | For psychiatric and psychological conditions, including anorexia nervosa, bulimia, drug and alcohol abuse consultation.
Consultations by psychiatrist and clinical psychologist. |
| Consultations |
| Nursing practitioner | 100% of NHRPL
No limit | Consultations in rooms |
| GP and Specialist procedures | 100% of NHRPL or scheme rate
No limit | |
| GP and Specialist Consultations | 90% of NHRPL or scheme rate
Combined limit of 15 visits per beneficiary | - A co-payment of R60 per after-hour consultation is payable by members.
|
| Homeopath | 90% of NHRPL
Included in GP/Specialist limit | Must be registered with the SA Homeopathic Association.
Homeopathic treatment is subject to the GP & Specialist limit of 15 visits per beneficiary per annum. |
| Physiotherapy |
| Out of hospital | 90% of NHRPL
R4 510 per beneficiary | |
| In hospital | Unlimited, 100% of NHRPL or scheme rate | Prior Society approval required. |
| Dentistry (in and out of hospital) |
Conservative dentistry
Which includes preventative and diagnostic consultations, cleanings, fillings, extractions and X-rays. | 90% of NHRPL
No limit | For general dentistry requiring hospitalisation, specific prior Society approval is required, with the exception of minors under the age of 9 years, physically handicapped and mentally retarded persons. In addition, the standard hospital pre-authorisation requirements apply. |
Specialised dentistry
Which includes crowns, dentures, bridges and implants, and periodontic treatment. | 90% of NHRPL
R4 510 per beneficiary | Gold Fillings: maximum of R660 per beneficiary per annum; prior Society approval required.
Implants: The benefit is in respect of all services, which includes hospitalisation, medication, theatre fees, anaesthetist, etc. |
| Orthodontic treatment | 75% of NHRPL
R11 100 per beneficiary per lifetime | Treatment may not commence after 18th birthday unless authorised by the Society. |
| Diagnostic Testing |
| Pathology | In hospital: 100% of NHRPL or scheme rate
Out of hospital: 90% of NHRPL or scheme rate
No limit | Subject to request by medical practitioner. |
| Radiology | In hospital: 100% of NHRPL or scheme rate
Out of hospital: 90% of NHRPL or scheme rate
No limit | Subject to request by medical practitioner. |
| MRI/CAT scans and bone density scans | 100% of NHRPL
No limit | Prior Society approval required and on specialist referral only. |
| Eye care |
| Eye test | 90% of SAOA Guide to tariffs
1 eye test per beneficiary | Liability of the Society excludes "standard exclusions" as determined by the SA Optometrist Association (SAOA) in the Guide to tariffs. |
| Single vision lenses (or contact lenses) including the frame or Bifocal or multi-focal lenses including the frame | R2 000 per beneficiary
Every two years
R2 500 per beneficiary
Every two years |
| Refractive eye surgery | 50% of NHRPL | Refractive surgery is limited to one procedure per eye per lifetime. |
| Hospitalisation |
| Hospital stays | 100% of NHRPL or scheme rate
Limited to 120 days in hospital and 30 days ICU and High Care wards per beneficiary | - Authorisation must be obtained from the Society before a beneficiary is admitted to hospital or day clinic (except in the case of an emergency). Phone 0800 111 669.
- Hospital stays are subject to re-authoristion for:
- General wards after 5 days
- High Care wards after 3 days
- Intensive Care after 3 days
- Step down facilities after 3 days. - Limited to in-patient treatment only.
|
| Hospital drugs | 100% of NHRPL or scheme rate
No limit | |
| Internal prosthesis | 100% of NHRPL or scheme rate
No limit | Prior Society approval required. |
| Cochlea implants | 100% of NHRPL or scheme rate
No limit | Prior Society approval required and treatment to commence prior to 3rd birthday. |
| Psychiatric hospitalisation | 100% of NHRPL or scheme rate
Limited to 21 days per beneficiary | Includes substance abuse, which is limited to once per lifetime. |
| Blood transfusion | 100% of NHRPL or scheme rate
No limit | |
| Maxillo facial and oral surgery | 100% of NHRPL or scheme rate
No limit | Prior Society approval required. |
| All surgical procedures | 100% of NHRPL or scheme rate
No limit | |
| Day clinic, radiation and chemotherapy | 100% of NHRPL or scheme rate
No limit | |
| For more detailed information on hospital benefits and pre-authorisation, please look here. |
| Medical equipment |
External appliances
Which includes: orthopaedic boots, surgical collars, prosthesis, nebulisers, oxygen cylinders and hiring of equipment. | 50% of agreed cost
R3 600 per beneficiary | The type of appliance covered by this benefit will be at the discretion of the Board; prior Society approval required. |
| Colostomy bags and catheters | 90% of agreed cost
R9 650 per beneficiary | |
| "COS" Continuous Oxygen Supply Machine and/or Oxygen | 90% of agreed cost
R8 800 per beneficiary | Prior Society approval required. |
| Artificial Limbs | 90% of agreed cost
No limit | Prior Society approval required. |
| Hearing Aids | 90% of agreed cost
R8 800 per beneficiary every 5 years | Prior Society approval required. |
| Wheelchair | 90% of agreed cost
R12 500 per beneficiary every 5 years | Prior Society approval required. |
| Medicines |
Acute medication
(Includes Homeopathic medication) | 70% of the cost
R2 200 per beneficiary | - Pharmacists are permitted to dispense generic items at the request of the medical practitioner.
- A maximum of a 30-day supply of medicine per prescription. Each repeat prescription will be deemed to be a separate prescription. In circumstances where a member or dependant is to travel outside Southern Africa, the quantity supplied may be increased to a maximum of a three-month supply - please apply to the Society.
- In Mining areas, members who obtain their medicines from retail pharmacies with which the Society does not have an agreement, will have to pay the account and submit the receipted account for a refund of 70% benefit.
- Refer here for the prescribed and non-prescribed chronic conditions covered.
|
Over the counter (OTC) medication
(Only at Benefit Society or other approved Pharmacies) | 70% of the cost
Maximum R138 per script
part of acute medication limit |
Chronic medication
(Only at Benefit Society or other approved Pharmacies) | 100% of the cost
R19 950 per beneficiary for both the prescribed and non-prescribed conditions and thereafter unlimited for the prescribed minimum benefits |
| For more detailed information on chronic medication benefits and the required authorisation procedures, please look here. |
