| Society Benefits List - 2008 |
| Service | Benefit Limit | Conditions / Remarks |
| Ambulance services |
| | 100% unlimited, subject to authorisation by the designated service provider | ER24 (tel 084 124) is the designated service provider for all emergency and ambulance services. The Society has no liability for the use of any other ambulance services by members. |
| Auxiliary health services |
| Audiology, chiropody, podiatry, chiropractic services, dietician services | 90% of NHRPL
R1 045 per beneficiary
Combined limit | "Combined limit" means that the total benefit that will be paid in respect of any, or all of the mentioned services together, is R1 045 per beneficiary. |
| Occupational and speech therapy | 90% of NHRPL
R1 520 per beneficiary | |
| Out of hospital care |
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. |
| Mental Health | 90% of NHRPL
R6 770 per beneficiary | For psychiatric and psychological conditions, including anorexia nervosa, bulimia, and drug and alcohol abuse consultation. Consultations by psychiatrists and clinical psychologists. |
| 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 GP, Specialist and homeopath limit of 15 visits per beneficiary | A co-payment of R65 per after-hour consultation is payable by members. |
| Homeopath | 90% of NHRPL
Included in combined GP, specialist and homeopath limit. | Must be registered with the SA Homeopathic Association. |
| Phsyiotherapy |
| Out of hospital | 90% of NHRPL
R4 800 per beneficiary | Including services rendered by a biokineticist. |
| In-hospital | Unlimited, 100% of NHRPL or scheme rate | Prior Society approval is required. |
| Dentistry (in and out of hospital) |
Conservative dentistry
(including preventative and diagnostic consultations, cleanings, fillings, extractions and X-rays) | 90% of NHRPL
No limit | For general dentistry requiring hospitalisations:- Children under the age of 9 years, or physically / mentally handicapped persons, are subject to the standard Society hospital pre-authorisation requirements.
- Specific prior Society approval is required for any other member.
- Gold fillings: maximum of R660 per beneficiary per year. Prior Society approval is required.
- Implants: Combined limit applies in respect of all services, including hospitalisation, medication, theatre fees, anaesthetist, etc.
|
Specialised dentistry
(including crowns, dentures, bridges and implants, and periodontic treatment) | 90% of NHRPL
R4 800 per beneficiary |
| Orthodontic treatment | 75% of NHRPL
R11 820 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 a request by a medical practitioner. |
| Radiology | In hospital: 100% of NHRPL or scheme rate
Out of hospital: 90% of NHRPL or scheme rate
No limit | Subject to a request by a medical practitioner. |
| MRi / CAT scans and bone density scans | 100% of NHRPL
No limit | - Subject to specialist referral.
- Prior Society approval is required.
|
| Eye care |
| Eye test | 90% of SAOA Guide to tariffs
1 eye test per beneficiary | The "standard exclusions" as determined by the SA Optometric Association (SAOA) in the Guide to tariffs, will also apply to the Society's benefits. |
| Single vision lenses (including frame) or contact lenses | 90% of SAOA Guide to tariffs
R2 130 per beneficiary
Every two years |
| Bifocal or multi- / vari-focal lenses, including frame | 90% of SAOA Guide to tariffs
R520 per beneficiary in addition to the benefit for single vision lenses.
Every two years | The "standard exclusions" as determined by the SA Optometric Association (SAOA) in the Guide to tariffs, will also apply to the Society's benefits. |
| 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 a total of 120 days in hospital, inclusive of a total limit of 30 days in ICU or 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. - In the case of emergency hospitalisation cases, the Society must be informed within 48 hours or the next working day.
- Hospital stays are subject to re-authorisation should the initial authorised period be exceeded.
|
| Hospital drugs | 100% of NHRPL or scheme rate
No limit | Take home medication forms part of your acute medicine limit. |
| Internal prosthesis | 100% of NHRPL or scheme rate
No limit | Prior Society approval is required. |
| Cochlea implants | 100% of NHRPL or scheme rate
No limit | - Treatment to commence prior to 3rd birthday, or any child dependant of 18 years or younger who meets the criteria for a cochlea implant and who was pre-lingual.
- Prior Society approval is required.
|
| Psychiatric hospitalisation | 100% of NHRPL or scheme rate
Limited to 21 days per beneficiary | Includes rehabilitation for substance abuse, 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 is required. |
| All surgical procedures | 100% of NHRPL or scheme rate
No limit | |
| Day clinic | 100% of NHRPL or scheme rate
No limit | |
| Oncology treatment | 100% of NHRPL or scheme rate
No limit | |
| For more detailed information on hospital benefits and pre-authorisation, please look here. |
| Oncology treatments as an out-patient |
| Oncology treatment | 100% of NHRPl or scheme rate
No limit | Please note that the benefit for diagnostic tests conducted out of hospital at the time of receiving treatment will be at 90% of NHRPL or scheme rate (see diagnostic testing benefits). |
| Medical equipment |
| External appliances (including orthopaedic boots, surgical collars, nebulisers, oxygen cylinders and hiring of equipment) | 50% of approved cost
R3 830 per beneficiary | Prior Society approval is required. |
| Colostomy bags and catheters | 90% of approved cost
R10 270 per beneficiary | Prior Society approval is required. |
| "COS" Continuous Oxygen Supply Machines and / or Oxygen | 90% of approved cost
R9 370 per beneficiary | Prior Society approval is required. |
| Artificial Limbs | 90% of approved cost
No limit | Prior Society approval is required. |
| Hearing Aids | 90% of approved cost
R9 370 per beneficiary every 5 years | Prior Society approval is required. |
| Wheelchair | 90% of approved cost
R13 300 per beneficiary every 5 years | Prior Society approval is required. |
| Medicines |
Acute medication
(including homeopathic medication) | 70% of the cost
R2 340 per beneficiary | - Pharmacists are permitted to dispense generic medication 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 get their medicines from retail pharmacies that have no agreement with the Society will have to pay for it themselves and submit the receipted account in order to receive 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 of R145 per script.
Part of acute medication limit. |
Chronic medication
(only at Benefit Society or other approved pharmacies) | Unlimited for prescribed minimum benefit chronic conditions (see here).
For other chronic conditions covered by the Society (see here) members need to apply for chronic medication benefits.
The overall cumulative benefit limit for both PMB and other chronic conditions is R20 750 per beneficiary per year. If this limit is reached before year-end, the PMB chronic conditions will continue to be covered in terms of PMB protocol. |
