DAY-TO-DAY BENEFITS

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
    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

    Member family limit per annual, calculated as follows:
          R3 250 per member
          R2 440 per adult dependant
          R2 040 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

    Major Medical Expenses
    R1 560 per beneficiary per annum

    100%

    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.

    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

    100%

    of Cost

  • 2 Diagnostic Services - out of hospital
    Annual limits are calculated as a family benefit and can be used by any beneficiary
    a Radiology (X-rays) and Pathology
    Including Bone Density Scans

    Member family limit per annum, calculated as follows:
          R3 780 per member
          R3 780 per adult dependant
          R660 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 Ultrasounds

    Major 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

  • 3 Dentistry
    a Preventative dentistry

    Scaling and/or polishing and fluoride treatment

    Two per beneficiary per annum

    100%

    of Medical Scheme Rate

    Fissure sealing

    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 treatment

    R3 770 per beneficiary per annum

    85%

    of Medical Scheme Rate

    cAdvanced/Specialised dentistry

    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 older

    R10 770 per family per annum

    85%

    of Medical Scheme Rate

    dDental implants

    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 above

    R13 920 per beneficiary per annum

    100%

    of Medical Scheme Rate

    eOrthodontic treatment

    Pre-authorisation required

    R7 550 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) above

    100%

    of Medical Scheme Rate

  • 4 Prescribed Medicine
    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

    Member family limit per annum, calculated as follows:
          R6 480 per member
          R4 070 per adult dependant
          R1 230 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

    Also known as pharmacy-advised therapy (PAT), refers to medicines supplied by a registered pharmacist without a doctor's prescription

    Up to a maximum of R210 per event R1 190 per family per annum
          Subject to Acute Medication limit

    100%

    of Mediscor
    Reference Price
    (MRP)

    c Childhood Vaccines

    Childhood vaccines falls under the Wellness Benefit

    Refer to the Wellness Benefit
  • 5 Medical Auxiliaries
    out of hospital
    Podiatry, orthoptic treatment, audiometry/audiology, occupational therapy, therapeutic dietician, remedial and speech therapy, clinical technology, chiropody, biokinetics, chiropractor, social worker and homeopaths

    R7 200 per family per annum for the above listed Medical Auxuliaries disciplines

    85%

    of Medical Scheme Rate

  • 6 Physiotherapy
    out of hospital

    R4 740 per family per annum

    85%

    of Medical Scheme Rate

  • 7 Mental Health
    out of hospital

    Includes Psychologist and Psychiatrist

    R4 630 per beneficiary per annum

    85%

    of Medical Scheme Rate

  • 8 Optical Services
    aEye test

    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

    Overall Optical limit of R2 890 per beneficiary per annum

    85%

    of Cost

    c Frames

    R1000 per beneficiary per annum, included in the Overall Optical limit of R2 890

    85%

    of Cost

    dSunglasses

    not_interested No Benefit