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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.
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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 580 per member
R2 690 per adult dependant
R2 250 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 640 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.
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
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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 970 per member
R3 970 per adult dependant
R690 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
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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 960 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 R11 310 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
R15 350 per beneficiary per annum
100%
of Medical Scheme Rate
eOrthodontic treatment
Pre-authorisation required
R8 330 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
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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 800 per member
R4 270 per adult dependant
R1 290 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 R220 per event R1 250 per family per annum
Subject to Acute Medication limit100%
of Mediscor
Reference Price
(MRP)c Childhood Vaccines
Childhood vaccines falls under the Wellness Benefit
Refer to the Wellness Benefit
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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 560 per family per annum for the above listed Medical Auxuliaries disciplines
85%
of Medical Scheme Rate
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6 Physiotherapy
out of hospital
R4 980 per family per annum
85%
of Medical Scheme Rate
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7 Mental Health
out of hospital
Includes Psychologist and Psychiatrist
R5 320 per beneficiary per annum
85%
of Medical Scheme Rate
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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 R3 030 per beneficiary per annum
85%
of Cost
c Frames
R1 050 per beneficiary per annum, included in the Overall Optical limit of R3 030
85%
of Cost
dSunglasses
not_interested No Benefit