MAJOR MEDICAL EXPENSES
All Major Medical Expenses are subject to pre-authorisation. Please call 0860 467 374.
PRO RATA BENFITS
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.
Ex gratia and additional benefits
As an employer-based restricted medical scheme, Imperial Motus Med can lawfully grant ex gratia payments to its members. Ex gratia payments are defined as payments in addition to the registered rules and benefits of the Scheme and for purposes of clarity, Imperial Motus Med will make a distinction between ex gratia payments and additional benefits.
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1 Hospitalisation - Private and Provincial
a Accommodation in general ward, recovery room, intensive care unit or high care ward
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate
b Theatre fees
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate
c Medicines used in hospital/theatre
Subject to pre-authorisation (0860 467 374)
100%
of Medicine
Priced A deductible of R1 000 applies if the following procedures are done 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 benefit for more details on in-hospital dentistry (item 19 of Major Medical Expenses)
- Nail surgeries
- Minor skin lesions
- Vasectomies
- Conservative neck and back procedures
- Circumcisions
100%
of Medical Scheme Rate. A deductible will not apply if done in doctor's rooms. Services in rooms will be paid at 100% of Medical Scheme Rate, except for dental procedures, which are still paid from day-to-day dental benefit
e Circumcision
Deductible applies, see 1a) above
R2 150 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Medical Scheme Rate
fDental Procedures
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate.
• Dental benefits which can be done in the dentist's room will have a deductible of R1000 if done in hospital.
• If done in the dentist's room, the payment will still be in accordance with the day-to-day limits and only at 85% -
2 Post-operational physiotherapy
Physiotherapy after hip, knee and shoulder replacement surgery and spinal surgery only. Physiotherapy treatment after any other procedure will be paid from the Day-to-Day physiotherapy benefit limit.
6 weeks' treatment, as per clinical protocols
Subject to pre-authorisation (0860 467 674)
100%
of Medical Scheme Rate
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3 GPs and Specialists in hospital
For prescribed minimum benefit services rendered by a specialist, the following rule applies: Rule 6.2.2 - The Scheme shall pay 100% of Medical Scheme Rate in respect of any in-hospital
services which are voluntarily obtained by a beneficiary from a service provider, other than a DSP, for a prescribed minimum benefit condition, other than medicine for a chronic condition.a Visits and consultations
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate
b Surgical procedures and anaesthetics
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate
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4 Diagnostic Services
a Radiology (X-rays) and pathology (in hospital)
100%
of Medical Scheme Rate
b MRI, CT and radio-isotope scans (in and out of hospital)
R18 080 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Medical Scheme Rate
c Ultrasound scans (in and out of hospital)
R4 850 per beneficiary per annum
100%
of Medical Scheme Rate
d PET scans (in and out of hospital)
R24 920 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Medical Scheme Rate
e Sleep studies, diagnostic polysomnograms (in and out of hospital)
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate
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5 To-take-out (TTO) Medicine
Medicines dispensed on discharge from hospital will be covered under the Major Medical Expenses
Subject to R460 per beneficiary per admission
100%
of Medicine Price
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6Out-patient Services
Private and provincial hospitals
- If the ICD-10 code is for an emergency (indicating that it is a prescribed minimum benefit), the cost of the consultation, facility, procedure, related materials and medication is to be paid at 100% of cost from the Major Medical Expenses.
- If the ICD-10 code is not for an emergency (indicating that it is not a prescribed minimum benefit), the cost of the consultation, facility, procedure, related materials and medication is to be paid at 85% of Scheme Rate from the applicable day-to-day benefit limits.
- The ICD-10 code is used to determine whether it is an emergency or non-emergency.
Emergencies are classified as prescribed minimum benefits and has to be covered in full.
100%
of Cost from Major Medical Expenses for an emergency
85%
of Scheme Rate for non-emergency
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7 Blood Transfusions
In hospital
Subject to pre-authorisation (0860 467 374)100%
of Cost
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8 Nursing Services, Sub-acute Care and Hospice Services
Including medicines, dressings, ointments, etc
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate or Cost, whichever is the lesser
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9 Ambulance Services
R9 160 per beneficiary per annum
Subject to approval and pre-authorisation by preferred provider, Europ Assistance (0861 737 283)
Emergency air ambulance not subject to the above limit, subject to Scheme approval100%
of Cost
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10 Internal Prostheses
Including all accompanying temporary or permanent devices used to assist with the guidance, alignment or delivery of these internal prostheses and devices
Patients may obtain pre-authorisation 10 (ten) working days prior to admission for a joint replacement or spinal fusion operation
Cardiac stents (including carrier)
Subject to a limit of R28 370 per stent (maximum of three) per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsCardiac stents - drug eluting
Subject to a limit of R29 180 per stent (maximum of three) per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsCardiac pacemakers
Subject to a limit of R58 045 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsCardiac valves
Subject to a limit of R37 960 per valve (limited to two) per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsCardiac pacemakers with defibrillator
Subject to a limit of R99 230 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsAortic stents
Subject to a limit of R94 290 per stent (including the delivery system), limited to one stent per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsCarotid stents
Limited to R16 490 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsDetachable platinum coils
Limited to R37 200 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsEmbolic protection devices
Limited to R37 100 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsPeripheral arterial stent grafts
Limited to R34 000 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsEVAR (Endovascular repair)/Anaconda
Subject to a limit of R66 150 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsHernia mesh
Subject to a limit of R6 970 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsHernia mesh - umbilical repair
Subject to a limit of R11 610 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsTotal hip replacement
Subject to a limit of R55 160 per hip, including cement and antibiotics, per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsTotal knee replacement
Subject to a limit of R54 220 per knee, including cement and antibiotics, per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsTotal shoulder replacement
Subject to a limit of R46 110 per shoulder, including cement and antibiotics, per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsSpinal instrumentation
Subject to a limit of R39 170 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsOther approved spinal implantable devices and intervertebral discs
Limited to R43 190 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsBone lengthening devices
Limited to R35 070 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsNeuro-stimulation/Abalation devices for Parkinson's disease
Limited to R37 380 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsVagal stimulator for intractable epilepsy
Limited to R31 860 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsIntraocular lenses
Limited to R8 840 per lens per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limitsAny other internal prostheses
Subject to a limit of R44 270 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
PMBs not subject to sub-limits100%
of Cost
Non-PMBs subject to sub-limits -
11 Renal Dialysis
Inclusive of all related costs
Benefit is subject to the submission of a treatment plan by the treating Specialist to the specialist care coach and approval of the treatment plan before treatment starts
Subject to pre-authorisation (0860 467 374)
100%
of the Negotiated Rate
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12 Organ Transplants
a Hospital accommodation and surgically related services and procedures
Subject to Pre-authorisation (0860 467 374)
PMBs covered in full, i.e. heart, kidneys and liver
Non-PMBs covered at Medical Scheme Rate, i.e. other organs100%
of Negotiated Rate
b Heart, kidneys and liver
Including organ search (nationally only), harvesting and transportation. The benefit covers the donor if the recipient is an Imperial Motus Med member
Subject to pre-authorisation (0860 467 374)
Unlimited
100%
of Cost
c Corneal transplant
Including organ search (nationally only)
Subject to pre-authorisation (0860 467 374)
R19 910 per beneficiary per event100%
of Cost
d Other organs
Including organ search (nationally only), harvesting and transportation. The benefit covers the cost of the donor if the recipient is an Imperial Motus Med member
Subject to pre-authorisation (0860 467 374)
Limited to R21 500 for organs from a cadaver
or limited to R104 310 for live donor organ(s) per beneficiary per annum100%
of Medical Scheme Rate
e Anti-rejection drugs
Subject to pre-authorisation (0860 467 374)
100%
of Medicine
Price -
13 HIV and AIDS
All consultations, pathology and medicine related to diagnoses and treatment of the disease
Subject to Pre-authorisation (0861 888 300) and clinical guidelines and protocols.
HIV resistance tests provided only if pre-authorised by a relevant specialist care coach on the YourLife Programme.
Polymerase chain reaction funded from Major Medical Expenses for babies 18 months and younger where the diagnosis relates to HIV testing.Medicine subject to Mediscor Reference Price.
Members are encouraged to make use of the Scheme's Preferred Provider Pharmacies.
100%
of Cost, unlimited
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14 Maternity Benefits
a Labour and ward accommodation
Normal delivery limited to three days
Additional days are subject to submission of a motivation by the attending doctor and approval by the specialist care coach
Subject to pre-authorisation (0860 467 374)
100%
of Cost
Elective caesarean delivery limited to four days
Additional days are subject to submission of a motivation by the attending doctor and approval by the specialist care coach
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate (MSR)
b Midwife
Delivery by a midwife, confinement in a registered birthing unit or home delivery, including birth attendant and birth bath
Midwife must be registered with the Board of Healthcare Funders and Nursing Council
If a gynaecologist is not used, benefit covers pre- and post-confinement costs
Subject to pre-authorisation (0860 467 374)
Four post-natal consultations with a midwife per event100%
of Medical Scheme Rate
cBenefits listed below are subject to enrolment on the Maternity Programme; if not registered on the Maternity Programme, benefits c1, c2, c3 and c4 are to be paid from day-to-day limits
c1 Antenatal classes
Only registered midwives
BELLYBABIES ONLINE SUPPORT
If you like the idea of enjoying your antenatal classes and consultations in the comfort of your own home, we invite you to make use of the unique Belly Babies online support programme, paid for by the Scheme from your available antenatal classes/antenatal consultations limits.
By registering on www.bellybabies.co.za, you will be provided with expert antenatal and post-natal support in the comfort of your own home, through:
- Access to an online antenatal course made up of a comprehensive collection of videos presented by experts within the maternity field;
- An online consultation with a highly qualified lactation (breastfeeding) specialist to help you and your baby establish and maintain a happy breastfeeding routine; and
- A follow-up online consultation with a lactation specialist, if needed.
- If not registered on the maternity programme, this will be paid from the day-to-day limits
R1 180 per beneficiary per annum
100%
of Cost, subject to pre-authorisation and registration on the Maternity Programme
c2 Ultrasound scans during pregnancy
Two 2D or 3D or 4D scans per pregnancy, up to 100% of the 2D scan at Medical Scheme Rate
If not registered on the maternity programme, this will be paid from the day-to-day limits100%
of Cost, subject to pre-authorisation and registration on the Maternity Programme
c3 Antenatal vitamins during pregnancy
R130 per month
If not registered on the maternity programme, this will be paid from the day-to-day limits100%
of Cost, subject to pre-authorisation and registration on the Maternity Programme
c4Gynaecologist consultations during pregnancy (as per treatment plan)
100%
of Cost, subject to pre-authorisation and registration on the Maternity Programme
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15 Rehabilitation
The benefit covers beneficiaries who are acutely disabled as a result of strokes, spinal cord injuries or brain injuries.
The condition must be non-progressive.
All associated accounts will be paid subject to this limit. R77 700 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Medical Scheme Rate
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16 Psychiatric Institutions and Substance and Alcohol Abuse
Maximum of 21 days per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Medical Scheme Rate
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17 Stoma Care Products
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate
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18 Cochlear Implants
All requests are subject to approval by the Clinical Advisory Committee
R262 500 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Cost
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19 Dentistry
a Dental alveolar surgery
Surgical procedures involving the teeth and supporting jawbone ridges, such as:
- Basic dental procedures in children under the age of eight
- Surgical dental procedures in exceptional clinical scenarios in children older than eight and adults
• Surgical removal of multiple/impacted teeth or roots
• Apicectomies
• Tooth exposures
• Corticotomies
• Surgical preparation of mouth for dentures, etc.
• Wisdom teeth
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate for hospitalisation, operating theatre, sedationist and anaesthetist's fee
Note that the associated dental procedures will still be funded at 85% of the Medical Scheme Rate from the respective Dental Benefit categories and sub-limits, as indicated under day-to-day benefits
b Orthodontic-related surgery
Surgical procedures of:
the jaw, facial bones, mouth and its various internal and surrounding structures, where required as part of an orthodontic treatment plan to improve the orthodontic malocclusion and related functional discrepancies; and/or to complement the non-surgical portion of the orthodontic treatment planR10 550 per beneficiary per annum, applies to surgeon's fee
Subject to pre-authorisation (0860 467 374)
100% of Medical Scheme Rate for hospitalisation, operating theatre and anaesthetist's fee
100%of Medical Scheme Rate for Surgical fee
c Maxillofacial surgery
- Oral/facial trauma, such as fractured jaw or facial bones for which hospitalisation is required
- Oral cancer and similar aggressive oral pathologies
- Cleft lip/Palate repair
- Salivary gland pathology
- Serious life-threatening infection of dental origin
- Internal temperomandibular joint (jaw-joint) pathology
Subject to pre-authorisation (0860 467 374)
100%
of Medical Scheme Rate for surgical procedures and related hospitalisation
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20 Excimer Laser, Radial Keratotomy, Holmium Procedures, LASIK, Phakic lenses and intra-stromal rings
Surgically related services and procedures
In line with clinical protocols R6 230 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Medical Scheme Rate
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21 Breast Reduction, Mammoplasty and other cosmetic surgery
If deemed clinically appropriate
Approval of Medical Advisor
Subject to pre-authorisation (0860 467 374)100%
of Medical Scheme Rate
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22 Prosthetic Limbs and Eyes
Prosthetic leg
Subject to a limit of R72 500 per leg per beneficiary per annum
Subject to pre-authorisation (0860 467 374)The submission of a quotation prior to purchase is required
Benefit is available every two to five years, as per clinical protocols
100%
of Cost
Prosthetic arm
Subject to a limit of R72 500 per arm per beneficiary per annum
Subject to pre-authorisation (0860 467 374)The submission of a quotation prior to purchase is required
Benefit is available every two to five years, as per clinical protocols
100%
of Cost
Prosthetic eye
Subject to a limit of R22 370 per eye per beneficiary
Subject to pre-authorisation (0860 467 374)The submission of a quotation prior to purchase is required
Benefit is available every two to five years, as per clinical protocols
100%
of Cost
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23 Infertility
Benefit limited to the treatment guidelines applied by State hospitals
Limited to PMBs only
Subject to pre-authorisation (0860 467 374)100%
of Cost
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24 Oncology
a Treatment
Subject to a treatment plan and enrolment on the Oncology Programme
Overall Oncology limit of R305 590 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Medical Scheme Rate
if non-PMB;100%
of Cost if PMBb Brachytherapy materials
Including seeds and disposables and equipment
Limited to R42 400 per beneficiary per annum and included in the Overall Oncology limit
Subject to pre-authorisation (0860 467 374)100%
of Medical Scheme Rate
if non-PMB;100%
of Cost if PMBc Pathology, X-rays, MRI, CT and radio-isotope scans
Limit of R33 490 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)
Not subject to the Overall Oncology limit100%
of Medical Scheme Rate
if non-PMB;100%
of Cost if PMBd Oncology medicine
Subject to R305 590 Overall Oncology limit
Subject to pre-authorisation (0860 467 374)100%
of Mediscor Reference Pricing
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25 Services Rendered Abroad by a foreign supplier
No benefit for beneficiaries travelling outside the borders of the Republic of South Africa for more than 90 consecutive days
R1 000 000 per beneficiary per annum
Paid in accordance with applicable benefits in the Scheme Rules and at Medical Scheme Rate
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26 Home Oxygen cylinders, concentrators and ventilation expenses
R16 800 per beneficiary per annum
Subject to pre-authorisation (0860 467 374)100%
of Medical Scheme Rate
if non-PMB;100%
of Cost if PMB -
27 External Medical Appliances
Permanent or temporary devices that are not surgically implanted
Seen to improve the function of a diseased organ, e.g. wheelchair, crutches, CPAP machine, Baumanometer and all orthopaedic braces. Incontinence diapers, which are required as part of a chronic condition, are included
R12 190 per beneficiary per annum
Motivation required for devices and appliances above R1000
(Two-year cycle applies to Blood Pressure Monitors, Glucometers, and Nebulisers only)
Subject to pre-authorisation (0860 467 374)100%
of Cost
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28 Hearing Aids
R17 860 per beneficiary per ear over a three-year cycle
Subject to an audiology report and pre-authorisation (0860 467 374)
The three-year cycle is determined on the last claim date100%
of Cost
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29 Prescribed Medicines
Chronic medicine
Prescribed for PMB and/or additional chronic conditions
Subject to the chronic medicine formulary only
25% co-payment applies when using a non-formulary medicine
R23 300 per beneficiary per annum
Once limit is depleted, authorised PMB medication will still be paid
Subject to pre-authorisation (0860 467 374)
You have to register your chronic medication with the Scheme by either completing the chronic medication application form or your treating doctor can contact the Chronic Medicine Management Team.
The Scheme's dispensing fee is set at 26% for medicine below R100 and R26 for medicine above R100, or as agreed to by the Trustees from time to time at a non-network pharmacy or in accordance with the agreed fee at preferred provider pharmacies100%
of Mediscor Reference Price (MRP)