Day-to-day Benefits - Health 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.
- 1 GPs 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
info Member family limit per annual, calculated as follows:
R4 210 per member
R3 160 per adult dependant
R2 650 per child dependant (maximum of three children)85%
of Medical Scheme Rate
b All procedures
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 940 per beneficiary per annum100%
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 Rate100%
of Cost - 2 Diagnostic Services - out of hospital
info Annual 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:
R4 670 per member
R4 670 per adult dependant
R810 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 Rate
100%
of Cost - 3Dentistry
a Preventative dentistry
Scaling and/or polishing and fluoride treatment
info Two per beneficiary per annum
100%
of Medical Scheme Rate
Fissure sealing
info Once-off for permanent molars in persons under 24 years
100%
of Medical Scheme Rate
bBasic dentistry
Oral examination
Diagnostics (X-rays, etc.)
Restorations (fillings)
Non-surgical extractions
Root canal treatmentinfo R4 660 per beneficiary per annum
85%
of Medical Scheme Rate
cAdvanced/Specialised dentistry
warning Pre-authorisation required
Inlays, onlays, veneers, crowns and bridges
Study models
Dentures
Dental implants, placements, exposure and related procedures such a jaw ridge, sinus lifts, augmentations, etc.
Orthodontic retainers, space maintainers and biteplates
Periodontal (gum) treatment
Wisdom teeth
Orthodontic treatment for beneficiaries 22 years of age or olderinfo R13 310 per family per annum
85%
of Medical Scheme Rate
dDental implants
warning Pre-authorisation required
Includes the cost of the implants only - the anaesthetist and hospital fees are covered as part of Major Medical Expenses
The treating dental specialist fee subject to the Advanced/Specialised Dentistry limit aboveinfo R18 060 per beneficiary per annum
100%
of Medical Scheme Rate
eOrthodontic treatment
warning Pre-authorisation required
info R10 200 per beneficiary per annum
Only for beneficiaries under the age of 21 year's
Orthodontic treatment for beneficiaries over 21 years of age is subject to the specialised dentistry limit under 3(c) above100%
of Medical Scheme Rate - 4Prescribed Medicine
info Annual 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:
R8 000 per member
R5 030 per adult dependant
R1 520 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 R300 per event R1 500 per family per annum
Subject to Acute Medication limit100%
of Mediscor
Reference Price
(MRP)
c Childhood Vaccines
warning Childhood vaccines falls under the Wellness Benefit
Refer to the Wellness Benefit
- 5Medical Auxiliaries
info out of hospital
Podiatry, orthoptic treatment, audiometry/audiology, occupational therapy, therapeutic dietician, remedial and speech therapy, clinical technology, chiropody, biokinetics, chiropractor, social worker and homeopathsinfo R8 890 per family per annum for the above listed Medical Auxuliaries disciplines
85%
of Medical Scheme Rate - 6Physiotherapy
info out of hospital
info R5 850 per family per annum
85%
of Medical Scheme Rate - 7Mental Health
info out of hospital
Includes Psychologist and Psychiatrist
info R6 260 per beneficiary per annum
85%
of Medical Scheme Rate - 8Optical Services
aEye 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
lensesinfo Overall Optical limit of R3 570 per beneficiary per annum
85%
of Cost
c Frames
info R1 240 per beneficiary per annum, included in the Overall Optical limit of R3 410
85%
of Cost
dSunglasses
not_interested No Benefit
- 9Contraceptives
info R2 390 per female beneficiary
Oral contraceptives
Injectable contraceptives
Intrauterine devices used for contraception only
limited to one prescription per month to a maximum of R200 per prescription100%
of Mediscor Reference Price (MRP)