Out-of-hospital Treatment Received in Rooms
- Consultative services (specialist treatment)
info Specialist conditions and treatment out of hospital by anaesthetists, physicians, neurosurgeons, general or other surgeons, orthopaedic specialists, ortorhinolaryngologists (ENT), radiotherapists, thoracic surgeons, urologists and cardiologists and nursing practicioners.
info M : R4 570
M+1 : R7 470
M+2 : R9 150
M+3+ : R9 830
Subject to OAL100%
of Scheme rate - General practitioners and certain specialists
info Outpatients, out-of-hospital consultations, treatment in rooms and procedures in doctors' rooms. Includes dermatologists, gynaecologists, ophthalmologists, paediatricians, neurologists, plastic surgeons and physical medication (including needles, syringes and sterile trays).
warning Subject to available MSA
No pre-authorisation required
100%
of Scheme rate - Diagnostic radiology and pathology
info Including materials
warning Pre-authorisation required for MRI, bone densitometry (DEXA), mammograms and CT scans.
Referring healthcare provider's practice number must appear on all claims.
info M : R17 880
M+1 : R29 570
M+2 : R33 420
M+3+ : R41 830
Subject to OAL100% of Scheme rate
80% of the Scheme rate for
out-of-hospital radiology and pathology
20% from MSA subject to PMB requirements - Oncology
info Chemotherapy, radiotherapy, intravenous medication and materials. Subject to registration on the Oncology Risk Management Programme.
warning This benefit is subject to the approval of a comprehensive treatment plan that must be submitted for pre-authorisation by email to [email protected]
100% of cost
- Prescribed chronic medication
info Medication prescribed or dispensed to patients registered on the Scheme’s Medicine Risk Management (MRM) Programme.
warning Subject to pre-authorisation
info M : R26 650
M+1 : R44 400
M+2 : R53 290
M+3+ : R62 290
per family per annum
Limits applicable to non-PMB chronic medication. Unlimited cover for CDL/PMB chronic medication.100% of SEP and dispensing fee
- HIV/AIDS
info Antiretroviral treatment (ART)
warning Subject to registration on the YourLife Programme
100% of cost
- Acute medication
warning Subject to available MSA
All medication, including TTO (maximum seven days' supply), except those obtained through the Medicine Risk Management (MRM) Programme. Pharmacy-advised therapy medication prescribed and dispensed by pharmacists limited to R310 per prescription. Clinically and pharmacy-dispensed vaccinations.
100% of SEP and dispensing fee
- Physiotherapy/Biokinetics
warning Subject to pre-authorisation
Subject to available MSA
100% of Scheme rate
- External appliances
info Includes nebulisers, wheelchairs, stoma products and home oxygen.
warning Subject to pre-authorisation
info R7 620 per family per annum
100% of cost
- Hearing aids
warning Subject to pre-authorisation
info R17 350 per ear per beneficiary every four years
100%
of cost