Benefits for 2010

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 For elective after-hours consultations the Society’s liability is limited to the RPL rate for a normal consultation
2. GP and specialist procedures	100% of RPL or scheme rate No authorisation required for procedures performed in doctors’ consultation rooms For elective after-hours consultations the Society’s liability is limited to the RPL rate for a normal consultation
3. Nursing practitioner	100% of RPL Consultations and procedures in rooms
Diagnostic Testing
4. Pathology	90% of RPL or scheme rate Subject to request by medical practitioner
5. Radiology	90% of RPL or scheme rate Subject to request by medical practitioner
6. CT and MRI scans	100% of RPL Pre-authorisation required
7. Bone density scans	100% of RPL Pre-authorisation required
Oncology
8. In and out of hospital	100% of South African Oncology Consortium (SAOC) Tier 2 Maximum of R160 000 per beneficiary Pre-authorisation required
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. 3. The Generic Reference Price (GRP) will be applied to both acute and chronic medication and any medication obtained at a value above this reference price will be the member’s liability. Refer to page 13 for more information.
9. Acute medication	70% of cost (SEP plus 26% limited to R26 per item, excluding VAT) Limited to R2 780 per beneficiary Includes homeopathic medication prescribed by a registered homeopath Subject to GRP
10. Self-medication ("OTC" pharmacy benefit)	70% of cost (SEP plus 26% limited to R26 per item, excluding VAT) Limited to R145 per script and subject to acute medication limit of R2 780 per beneficiary Subject to GRP
11. 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, page 14-15) Subject to GRP *Note:* The overall cumulative benefit limit for both PMB and other chronic conditions (see page 14-15) is R24 650 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
12. Conservative dentistry	90% of RPL Includes preventative and diagnostic consultations, cleaning, fillings, extractions and x-rays
13. Specialised dentistry	90% of RPL Limited to R5 700 per beneficiary Includes crowns, dentures, bridges, implants and periodontal treatment *Note:* Gold fillings limited to R660 per beneficiary per year
14. Orthodontic treatment	75% of RPL Limited to R14 040 per beneficiary per lifetime *Note:* Treatment may not commence after beneficiary’s 18th birthday.
15. General dentistry in-hospital	Limited to children under 9 years of age, or physically / mentally handicapped persons Pre-authorisation required
Optometry
16. 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.
17. Single vision lenses (incl. frame) or contact lenses OR Bifocal or multi-/vari-focal lenses (incl. frame)	90% of SAOA Guide to Tariffs Limited to R2 530 per beneficiary per 2-year cycle (2010 - 2011) *Note:* Standard limitations, as per the SAOA Guide to Tariffs, apply.
	90% of SAOA Guide to Tariffs Limited to R3 160 per beneficiary per 2-year cycle (2010 - 2011) *Note:* Standard limitations, as per the SAOA Guide to Tariffs, apply
18. Excimer laser eye surgery including phakic lenses	50% of RPL Limited to 1 procedure per eye per lifetime
Medical equipment
19. External appliances	50% of the cost as approved by the Society Limited to R4 550 per beneficiary Includes orthopaedic boots, surgical collars, external breast prosthesis, nebulisers, artificial eyes and hiring of equipment Pre-authorisation required
20. Colostomy bags and catheters	90% of the cost as approved by Society Limited to R12 180 per beneficiary Pre-authorisation required
21. Continuous Oxygen Supply (“COS”) machine rental and/or oxygen	90% of the cost as approved by Society Limited to R11 120 per beneficiary Pre-authorisation required
22. External Prosthesis	90% of the cost as approved by Society Limited to R30 000 per beneficiary Pre-authorisation required
23. Hearing aids	90% of the cost as approved by Society Limited to R11 120 per 5-year cycle per beneficiary Pre-authorisation required
24. Wheelchairs	90% of the cost as approve by Society Limited to R12 000 per 5-year cycle per beneficiary Pre-authorisation required
Auxilliary Health Services
25. Occupational and speech therapy	90% of RPL Limited to R1 810 per beneficiary
26. Physiotherapy and biokinetics	90% of RPL Combined physiotherapist and biokineticist limit of R5 700 per beneficiary
27. Audiology, chiropody, podiatry, chiropractic and dietician services	90% of RPL Combined limit of R1 240 per beneficiary for any or all services combined
Out-of-Hospital Care
28. Hospice (in- and out-patient)	90% of RPL at a registered hospice (Hospice Association of SA) Limited to R10 500 per beneficiary Pre-authorisation required
29. Private nursing and frail care by registered nurse	90% of RPL Limited to R7 000 per beneficiary and R132 per day Pre-authorisation required
30. Mental health	90% of RPL, limited to R8 050 per beneficiary 100% of RPL for PMB-related services, provided a DSP is used Includes consultations by psychiatrists and clinical psychologist for psychiatric and psychological conditions such as anorexia nervosa, bulimia, drug and alcohol abuse. Pre-authorisation required *Note:* The overall cumulative benefit limit for both PMB and non-PMB conditions is R8 050 per beneficiary per year. If this limit is reached before year-end, the PMB conditions will continue to be covered in terms of PMB protocols.
In-Hospital
31. Hospitalisation	100% of RPL or scheme rate (scheme rate applies to network hospitals only) No co-payment required Pre-authorisation required
32. Professional fees in hospital	100% of RPL or scheme rate (scheme rate applies to network hospitals only)
33. Surgical procedures	100% of RPL or scheme rate Pre-authorisation required
34. Maxillofacial and oral surgery	100% of RPL or scheme rate Pre-authorisation required
35. Blood transfusions	100% of RPL or scheme rate
36. Psychiatric admissions	100% of RPL or scheme rate Limited to 21 days per beneficiary Includes rehabilitation for substance abuse Pre-authorisation required
37. Internal prosthesis	100% of RPL or scheme rate Limited to R30 000 per beneficiary Pre-authorisation required
38. Cochlea implants	100% of RPL or scheme rate Pre-authorisation required *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.
39. Prescribed medication	100% of cost (SEP or scheme rate) TTO medication (medicine to take home after discharge from hospital) subject to acute medicine limit, which carries a 30% co-payment, up to a maximum of 7 days
40. Physiotherapy	100% of RPL or scheme rate Pre-authorisation required
41. Pathology	100% of RPL or scheme rate Pre-authorisation required
42. Radiology (including MRI and CT scans)	100% of RPL or scheme rate Pre-authorisation required
43. Day clinic	100% of RPL or scheme rate Pre-authorisation required
Emergency Transport
44. Emergency road and air transport	100% unlimited, subject to pre-authorisation by ER24 No benefit for use of any other ambulance services. ER24 is the DSP for all emergency and ambulance services.