Day-to-day Benefits - Budget Plan
PRO RATA BENEFITS
Benefit limits are usually allocated in calendar year cycles (from 1 January to 31 December) and is only applicable to the current year. Most benefits follow a one-year cycle.
Benefit limits will be adjusted on a pro rata basis should a member join during the year.
- 1GPs and Specialists - out of hospital
info Annual limits are calculated as a family benefit and can be used by any beneficiary
a Visits, consultations and treatment by a GP or Specialist
warning These benefits are covered on the Momentum Health Solutions Network
Specialists only on referral by a GP
info Member family limit per annum, calculated as follows:
R1 350 per member
R1 010 per adult dependant
R820 per child dependant (maximum of three children)
Benefits applicable to the nomination of two GPs per dependant
Two out-of-network GP visits allowed per family85%
of Medical Scheme Rate
b All procedures
warning To be done by a nominated Network GP
The following procedures will be paid at 100% of Medical Scheme Rate if done in the doctors rooms and not in hospital: Scopes (arthroscopies, gastro-intestinal endoscopies, gastroscopies, colonoscopies, sigmoidoscopies); urological scopes and cystoscopies; gynaecological scopes; biopsies; minor dermatological procedures; dental procedures - refer to dental benefits for more details on in-hospital dentistry (item 19 of Major Medical Expenses)
100%
of Medical Scheme Rate
c Circumcision
Done in doctor's rooms
info Major Medical Expenses
R1 850 per beneficiary per annum at a nominated Network GP100%
of Medical Scheme Rate
d PMB Treatment Plan Services
The Scheme will pay 85% of Medical Scheme Rate in respect of out-of-hospital services which are voluntary obtained by a beneficiary from a service provider, other than a DSP, for a prescribed minimum benefit condition, other than medicine for a prescribed minimum benefit chronic condition.
warning Subject to Treatment plan authorisation
Major Medical Expenses
Services in excess of the treatment plan will be paid from the GP/Specialist Benefit limit at 85% of Medical Scheme Rate
PMB treatment plan consultations only at nominated Network GP100%
of Cost - 2Diagnostic Services - out of hospital
infoAnnual limits are calculated as a family benefit and can be used by any beneficiary
a Radiology (X-rays) and Pathology
Including Bone Density Scansinfo Member family limit per annum, calculated as follows:
R1 480 per member
R1 480 per adult dependant
R270 per child dependant (maximum of three children)85%
of Medical Scheme Rate
b Radiology and Pathology services as authorised on a PMB treatment plan
Including Cardiac UltrasoundsMajor Medical Expenses
Subject to treatment plan authorisation
Services in excess of the treatment plan will be paid from Radiology and
Pathology Benefit limit at 85% of Medical Scheme Rate100%
of Cost - 3Dentistry
aPreventative dentistry
not_interested No Benefit
b Basic dentistry
- Oral examination
- Diagnostics (X-rays, etc.)
- Restorations (fillings)
- Non-surgical extractions
- Root canal treatmentinfo R3 130 per family per annum
85%
of Medical Scheme Rate
cAdvanced/Specialised dentistry
not_interested No Benefit
dDental implants
not_interested No Benefit
eOrthodontic treatment
not_interested No Benefit
- 4Prescribed Medicine
infoAnnual limits are calculated as a family benefit and can be used by any beneficiary
a Acute medicines
Acute medicines and injection material, including flu vaccines
info Member family limit per annum, calculated as follows:
R2 550 per member
R1 610 per adult dependant
R500 per child dependant (maximum of three children)100%
of Mediscor Reference Price (MRP) after deduction of R30 levy per prescription
b Over-the-counter (OTC) medication
warning Also known as pharmacy-advised therapy (PAT), refers to medicines supplied by a registered pharmacist without a doctor's prescription
info Up to a maximum of R240 per event R460 per family per annum
Subject to Acute Medication limit100%
of Mediscor
Reference Price
(MRP)
cChildhood vaccines
not_interested No Benefit
- 5Medical Auxiliaries
infoout of hospital
Clinical psychology, psychiatry and physiotherapy
info R6 340 per family per annum for the medical auxiliaries disciplines listed above
85%
of Medical Scheme Rate - 6Physiotherapy
infoIncluded in the Medical Auxiliary - out of hospital limit under 5 above
85%
of Medical Scheme Rate - 7Mental Health
infoIncluded in the Medical Auxiliary - out of hospital limit under 5 above
Includes Psychologist and Psychiatrist
85%
of Medical Scheme Rate - 8Optical Services
a Eye test
info One test per beneficiary per annum from Major Medical Expenses
85%
of Medical Scheme Rate
b Spectacles
Lenses, replacements, repairs and adjustments, contact lenses and fitting of contact lenses
info Overall Optical limit of R1 560 per beneficiary per annum
85%
of Cost
c Frames
info R470 per beneficiary per annum; included in the Overall Optical limit of R1 560
85%
of Cost
dSunglasses
not_interested No Benefit
- 9Contraceptives
infoout of hospital
info R2 280 per female beneficiary
Limited to 1 per month up to a max of R190 per month100%
of Mediscor Reference Price (MRP)