Benefits for 2009

Out-of-hospital (day to day) benefits
Consultations
1. GP and specialist	90% of RPL Combined GP, specialist and homeopath limit of 15 visits per beneficiary After-hour co-payment of R72 per consultation payable by members
2. GP and specialist procedures	100% of RPL or scheme rate No authorisation required for procedures performed in doctors consultation rooms No limit
3. Homeopath	90% of RPL at registered homeopath (SA Homeopathic Association) Combined GP, specialist and homeopath limit of 15 visits per beneficiary
4. Nursing practitioner	100% of RPL No limit Consultations in rooms
Diagnostic Testing
5. Pathology	90% of RPL or scheme rate No limit Subject to request by medical practitioner
6. Radiology	90% of RPL or scheme rate No limit Subject to request by medical practitioner
7. CT and MRI scans	100% of RPL No limit Subject to specialist referral Subject to pre-approval by Society
8. Bone density scans	100% of RPL No limit Subject to specialist referral Subject to pre-approval by Society
Oncology
9. Out-patient treatment	100% of RPL or scheme rate No limit Note: The benefit for diagnostic tests conducted out of hospital at the time of receiving treatment will be at 90% of RPL or scheme rate - see diagnostic test benefits above.
Medication Please note: 1. Pharmacists are permitted to dispense generic medication unless expressly prohibited by your doctor. 2. In circumstances where a beneficiary is due to travel outside Southern Africa, the quantity of medication supplied may be increased to a maximum of a 3-month supply, subject to pre-approval by the Society.
10. Acute medication	70% of SEP plus 26% limited to R26 per item, excluding VAT Limited to R2 574 per beneficiary Includes homeopathic medication prescribed by a registered homeopath
11. Self-medication ("OTC" pharmacy benefit)	70% of SEP plus 26% limited to R26 per item, excluding VAT Limited to R145 per script and subject to acute medication limit of R2 574 per beneficiary
12. Chronic medication	100% unlimited for CDL PMBs provided it is dispensed by a Society DSP Subject to Society approval for other chronic conditions (see Frequently Asked Questions) Note: The overall cumulative benefit limit for both PMB and other chronic conditions is R22 825 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 protocols.
Dental
13. Conservative dentistry	90% of RPL No limit Includes preventative and diagnostic consultations, cleaning, fillings, extractions and x-rays
14. Specialised dentistry	90% of RPL Limited to R5 280 per beneficiary Includes crowns, dentures, bridges, implants and periodontal treatment Note: Gold fillings limited to R660 per beneficiary per year and subject to pre-approval by Society.
15. Orthodontic treatment	75% of RPL Limited to R13 000 per beneficiary per lifetime Note: Treatment may not commence after beneficiary's 18th birthday
16. General dentistry in-hospital	Limited to children under 9 years of age, or physically / mentally handicapped persons Subject to standard pre-authorisation requirements Specific pre-approval by Society required for any other beneficiary
Optometry
17. Eye examinations	90% of SA Optometrist Association (SAOA) Guide to Tariffs Limited to 1 test per beneficiary per year Note: Standard limitations, as per the SAOA Guide to Tariffs, apply.
18. Single vision lenses (incl. frame) or contact lenses OR Bifocal or multi-/vari-focal lenses (incl. frames)	90% of SAOA Guide to Tariffs Limited to R2 340 per beneficiary per 2-year cycle Note: Standard limitations, as per the SAOA Guide to Tariffs, apply.
	90% of SAOA Guide to Tariffs Limited to R2 925 per beneficiary per 2-year cycle Note: Standard limitations, as per the SAOA Guide to Tariffs, apply.
19. Refractive eye surgery	50% of RPL Limited to 1 procedure per eye per lifetime
Medical equipment
20. External appliances	50% of the cost as approved by the Society Limited to R4 213 per beneficiary Subject to pre-approval by Society Includes orthopaedic boots, surgical collars, external breast prosthesis, nebulisers, oxygen cylinders and hiring of equipment
21. Colostomy bags and catheters	90% of the cost as approved by Society Limited to R11 280 per beneficiary Subject to pre-approval by Society
22. Continuous Oxygen Supply ("COS") machine and/or oxygen	90% of the cost as approved by Society Limited to R10 300 per beneficiary Subject to pre-approval by Society
23. Artificial limbs	90% of the cost as approved by Society No limit Subject to pre-approval by Society
24. Hearing aids	90% of the cost as approved by Society Limited to R10 300 per beneficiary per 5-year cycle Subject to pre-approval by Society
25. Wheelchairs	90% of the cost as approve by Society Limited to R14 650 per beneficiary 5-year cycle Subject to pre-approval by Society
Auxilliary Health Services
26. Occupational and speech therapy	90% of RPL Limited to R1 672 per beneficiary
27. Physiotherapy	90% of RPL R5 280 per beneficiary Includes services rendered by a biokineticist
28. Audiology, chiropody, podiatry, chiropractic and dietician services	90% of RPL Combined limited of R1 150 per beneficiary for any or all services combined
Out-of-Hospital Care
29. Hospice (in- and out-patient)	90% of RPL at a registered hospice (Hospice Association of SA) Limited to R10 500 per beneficiary Subject to pre-approval by Society
30. Private nursing and frail care by registered nurse	90% of RPL Limited to R7 000 per beneficiary and R132 per day Subject to pre-approval by Society
31. Mental health	90% of RPL Limited to R7 450 per beneficiary Includes consultations by psychiatrists and clinical psychologist for psychiatric and psychological conditions such as anorexia nervosa, bulimia, drug and alcohol abuse
32. Blood transfusions (not in-hospital)	90% of RPL No limit Subject to pre-approval by Society
In-Hospital
33. Hospitalisation	100% of RPL or scheme rate (scheme rate applies to network hospitals only) Limited to a total of 120 days in hospital, inclusive of total limit of 30 days in ICU or High Care wards per beneficiary Note: Hospital stays are subject to pre-authorisation (except in the case of emergencies). Pre-authorisation can be obtained by contacting the Society at 0800 111 669. In case of emergency hospitalisation, the Society must be informed within 48 hours or the next working day. Hospitalisation is subject to re-authorisation by the Society if the initial authorised period is exceeded.
34. Surgical procedures	100% of RPL or scheme rate No limit Prior approval by the Society required for all surgery
35. Maxillofacial and oral surgery	100% of RPL or scheme rate No limit Subject to pre-approval by Society
36. Blood transfusions	100% of RPL or scheme rate No limit
37. Oncology treatment	100% of RPL or scheme rate no limit
38. Psychiatric admissions	1005 of RPL or scheme rate Limited to 21 days per beneficiary Includes rehabilitation for substance abuse, limited to once per lifetime
39. Internal prosthesis	100% of RPL or scheme rate No limit Subject to pre-approval by Society
40. Cochlea implants	1005 of RPL or scheme rate No limit Subject to pre-approval by Society Note: Treatment to commence prior to beneficiary's 3rd birthday, or any child dependant of 18 years or younger who meets the criteria for a cochlea implant and who was pre-lingual
41. Prescribed medication	100% of RPL or scheme rate No limit TTO medication (medicine to take home after discharge from hospital) subject to acute medicine limit, up to a maximum of 7 days
42. Physiotherapy	100% of RPL or scheme rate No limit Subject to pre-approval by the Society
43. Pathology	100% of RPL or scheme rate Subject to request by a medical practitioner
44. Radiology (including MRI and CT scans)	100% of RPL or scheme rate Subject to request by a medical practitioner Subject to pre-approval by the Society
45. Day clinic	100% of RPL or scheme rate No limit
Emergency Transport
46. Emergency road and air transport	100% unlimited, subject to authorisation by ER24 No benefit for use of any other ambulance services