| No. | BENEFIT DESCRIPTION | NOTES RE EXTENT OF Benefit/ ANNUAL LIMIT/ CONDITIONS |
| Prescribed Minimum Benefits (PMBs) |
| 1. | Statutory Prescribed Minimum Benefits | · Benefit is 100% of the cost of the prescribed minimum benefit treatment · For all services relating to PMBs, please ensure that you make use of a Designated Service Provider, where it exists, otherwise co-payments will apply · Benefits are subject to the provisions set out in paragraph 2 of Annexure B of the Rules and shall, insofar as may be applicable, override any restrictions or limitations imposed in respect of benefits set out below |
CONSULTATIONS (Out-of-hospital) |
2. | General Practitioners, Specialists and registered Homeopaths | · Benefit is 90% of SRPL · Combined GP, specialist and homeopath limit of 15 consultations per beneficiary · For elective non-emergency after hours consultations, the benefit shall be limited to the SRPL for a normal consultation. · Doctors’ house calls and/or consultations at, for example, frail care centres will be paid at normal consultation rates unless clinically assessed to be medical emergencies |
3. | General Practitioner and Specialist procedures | · Benefit is 100% of SRPL · Pre-authorisation is required for a procedure to be performed in rooms (e.g. gastroscopy) |
4. | Nursing practitioner | · Benefit is 100% of SRPL |
DIAGNOSTIC TESTING |
5. | Pathology | · Benefit is 100% of SRPL or Scheme Rate in hospital · Benefit is 90% of SRPL out of hospital · Subject to request by medical practitioner |
6. | Radiology | · Benefit is 100% of SRPL or Scheme Rate in hospital · Benefit is 90% of SRPL out of hospital · Subject to request by medical practitioner |
7. | CAT and MRI scans (In and out of Hospital) | · Benefit is 100% of SRPL · Limited to three scans per beneficiary per year · Pre-authorisation is required from hospital pre-authorisation department |
8. | Bone density scans | · Benefit is 90% of SRPL out of hospital · No benefit in hospital |
| ONCOLOGY |
9. | Treatment in and out of hospital | · Benefit is 100% of SRPL or Scheme Rate In- and Out-of-hospital at the DSP · Maximum benefit limited to R176 400 per beneficiary including all PET, CT and related planning scans · Pre-authorisation is required from hospital pre-authorisation department · Voluntary use of a non-DSP will attract a 25% co-payment on all professional services rendered · All medicine for oncology treatment must be obtained from the chronic medicine DSP |
MEDICATION Please note:
1. Pharmacists are legally obliged to dispense generic medication, unless expressly prohibited in writing by your doctor on the prescription, in which case you remain liable for the additional expense as outlined below. 2. The Generic Reference Price (GRP) will be applied to both acute and chronic medication and in cases where medication is obtained at a value above this reference price, the additional cost will be the member’s liability. 3. In circumstances where a beneficiary is due to travel outside of South Africa, the quantity of medication supplied may be increased to a maximum of a three month supply, subject to pre-approval by the Society’s hospital pre-authorisation department. |
10 | Acute medication | · Benefit is 70% of the GRP limited to R3 070 per beneficiary · Includes homeopathic medication prescribed by a registered homeopath |
11 | Self-medication (OTC pharmacy benefit) | · Benefit is 70% of the GRP · Limited to R145 per script and subject to acute medication limit of R3 070 per beneficiary |
12 | Chronic medication | · Benefit is 100% of the GRP provided it is dispensed by a DSP · Unlimited for CDL PMBs provided it is dispensed by a DSP · Benefit is 70% of GRP if a non-DSP is voluntarily used · Subject to Society approval for chronic conditions · Note: The overall cumulative benefit limit for both PMB and other chronic conditions is R27 170 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, provided a DSP is used |
DENTAL |
13. | Conservative dentistry | · Benefit is 90% of SRPL · Includes preventative and diagnostic consultations, cleaning, fillings, extractions and x-rays · Pre-authorisation is required for hospitalisation and only minors under the age of nine years, physically handicapped and mentally retarded persons will be routinely authorised |
14. | Specialised dentistry | · Benefit is 90% of SRPL · Limited to R6 290 per beneficiary · Includes crowns, dentures, bridges, implants and periodontal treatment |
15. | Orthodontic treatment | · Benefit is 75% of SRPL · Limited to R15 480 per beneficiary per lifetime · Note: Treatment may not commence after beneficiary’s 18th birthday · Pre-authorisation is required from hospital pre-authorisation department |
OPTOMETRY |
16. | Eye test, single vision, bi-focal, multi-focal lenses (including contact lenses) and frames. | · Benefit is limited to 90% of the tariffs as per the Optical Assist Guide · Overall limit of R3 500 per beneficiary with a sub-limit of R1 000 on frames every two year cycle. (This includes eye test(s), single vision, bi-focal, multi-focal lenses, contact lenses and frames) · Two year cycle starts January 2012 |
17. | Intra-ocular lenses | · Benefit is 100% of SRPL limited to single vision lenses and to a maximum of R1 500 per lens |
18. | Refractive Surgery | · Benefit is 50% of SRPL or Scheme Rate · Limited to one procedure per eye per lifetime · Lenses limited to single vision lenses · Including but not limited to Excimer Laser and eye surgery required for Astigmatism, Hypermetropia, Presbyopia, Myopia and Hypermyopia |
MEDICAL EQUIPMENT The type of appliance covered by this benefit will be at the discretion of the Society and all repairs to and maintenance of medical equipment is included in the limit set for the particular term of the benefit cycle. |
19. | External appliances | · Benefit is 50% of the cost as approved by the Society · Limited to R5 020 per beneficiary · Includes orthopedic boots, surgical collars, external breast prosthesis, nebulisers, artificial eyes and hiring of equipment · Pre-authorisation is required from hospital pre-authorisation department |
20. | Colostomy bags and catheters | · Benefit is 90% of the cost as approved by the Society · Limited to R13 420 per beneficiary · Pre-authorisation is required from hospital pre-authorisation department |
21. | Continuous Oxygen Supply (COS) machine rental and/or oxygen | · Benefit is 90% of the cost as approved by the Society · Limited to R12 265 per beneficiary · Pre-authorisation is required from hospital pre-authorisation department |
22. | External Prosthesis (such as artificial limbs) | · Benefit is 90% of the cost as approved by the Society · Limited to R33 000 per beneficiary · Pre-authorisation is required from hospital pre-authorisation department |
23. | Hearing aids | · Benefit is 90% of the cost as approved by the Society · Limited to R12 265 per beneficiary per five-year cycle from date of first supply · Pre-authorisation is required from hospital pre-authorisation department · No benefit is payable in respect of replacement hearing aid batteries |
24. | Wheelchairs | · Benefit is 90% of the cost as approved by the Society · Limited to R13 230 per beneficiary per five-year cycle from date of first supply · Pre-authorisation is required from hospital pre-authorisation department |
CARE NOT IN HOSPITAL |
25. | Audiology, Chiropody, Podiatry, Acupuncture, Dietician services, Occupational and Speech Therapy | · Benefit is 90% of SRPL · Combined limit of R2 100 per beneficiary |
26. | Physiotherapy including Biokinetics and Chiropractic Services | · Benefit is 90% of SRPL · Limited to R6 290 per beneficiary |
27. | Hospice in and out patient including private nursing and wound care | · Benefit is 90% of SRPL · Combined limit of R10 500 per beneficiary · The facility must be registered with the Hospice Association of SA or the provider must be a registered nurse |
28. | Psychological and psychiatric treatment | · Benefit is 90% of SRPL, limited to R8 870 per beneficiary |
IN HOSPITAL |
29. | Hospitalisation | · Benefit is 100% of SRPL or Scheme Rate where a network hospital has been authorised · Pre-authorisation is required from hospital pre-authorisation department for all services provided in hospital · Co-payment of R1 500 levied per in-hospital procedure pre-authorised for all colonoscopies, arthroscopies, laparoscopies, circumcisions and male sterilization. Where two or more of these in-hospital procedures are performed simultaneously, only one co-payment will be levied · No co-payment will be levied should the above procedures be pre-authorised to take place out-of-hospital |
30. | Professional fees charged by service providers in hospital | · Benefit is 100% of SRPL or Scheme Rate where a network hospital has been authorised · Pre-authorisation is required from hospital pre-authorisation department |
31. | Maxilla facial and oral surgery | · Benefit is 100% of SRPL · Pre-authorisation is required from hospital pre-authorisation department · This excludes surgery in preparation for Osseo-integrated implants and Orthognathic surgery |
32. | Blood transfusions | · Benefit is 100% of SRPL |
33. | Psychiatric admissions for treatment of mental disorders and alcohol and drug dependency | · Benefit is 100% of SRPL · Limited to 21 days per beneficiary provided that the treatment of PMB conditions are limited as per Annexure A of the Regulations. · Pre-authorisation is required from hospital pre-authorisation department |
34. | Internal prosthesis (such as plates, screws, stents and pacemakers, etc.) | · Benefit is 100% of SRPL · Limited to R33 000 per beneficiary · Pre-authorisation is required from hospital pre-authorisation department |
35. | Cochlea implants | · Benefit is 100% of SRPL · Pre-authorisation is required from hospital pre-authorisation department |
36. | Hospital medicines | · Benefit is 100% of agreed price · TTO medication up to a maximum of seven days’ supply |
37. | Physiotherapy | · 100% of SRPL or Scheme Rate where a network hospital has been authorised · Pre-authorisation is required from hospital pre-authorisation department |
38. | Pathology | · Benefit is 100% of SRPL or Scheme Rate |
39. | Radiology | · Benefit is 100% of SRPL or Scheme Rate · Pre-authorisation is required from hospital pre-authorisation department |
EMERGENCY TRANSPORT |
40. | Emergency road and air transport | · Benefit is 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 · Coverage only in RSA and limited to residents in Botswana and Namibia subject to conditions as outlined elsewhere |
