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 988
M+1 : R8 153
M+2 : R9 987
M+3+ : R10 729
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 - Hello Doctor Virtual Consults
info R284 per consultation (tariff code 0130)
warning Subject to savings
100%
of cost - 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 : R19 516
M+1 : R32 276
M+2 : R36 477
M+3+ : R45 657
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.
warning Subject to registration on the Oncology Programme.
- Oncology (subject to PMBs)
info For the treatment of cancer.
warning Subject to pre-authorisation
Subject to an annual limit of R400 000 per beneficiary, a treatment plan and clinical protocols.100% of cost
- Mental health
info This benefit is applicable to consultations for non-PMB mental health conditions with psychiatrists, psychologists, GPs and social workers only.
Medication is not covered under this benefit and is subject to available savings.warning Subject to pre-authorisation
info R6 000 per family, subject to a 20% co-payment
Subject to OAL100% of Scheme rate
- 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 : R29 089
M+1 : R48 463
M+2 : R58 166
M+3+ : R67 990
per family per annum
Limits applicable to non-PMB chronic medication.100% of SEP and dispensing fee
- Specialised Chronic Medicines
warning 10% co-payment applied.
info R104 250 per beneficiary per year
This benefit aims to facilitate access for members with rare or severe diseases requiring high-cost specialised treatments.
- Glucose Monitoring Device and Consumables
info R26 063 per beneficiary per year
CGM devices and consumables are not subject to the medical appliance benefit. This benefit would require pre-authorisation and adherence to strict managed care protocols, with consumables subject to reference pricing.
- 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 R339 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 medical appliances
warning Subject to pre-authorisation
Wheelchairs R8 340 per beneficiary once every four years Home oxygen R15 638 per beneficiary per year Stoma products R15 638 per beneficiary per year CPAP machine R12 510 per beneficiary every four years CPAP machine consumables R3 128 per beneficiary per year Orthopaedic appliances R4 170 per beneficiary per year Other appliances (e.g blood pressure monitors, glucometers, nebulizers, etc.) R1 564 per beneficiary every four years - Hearing aids
warning Subject to pre-authorisation
info R20 850 per ear per beneficiary every four years
100%
of cost - Hearing Aid Maintenance Benefit
warning Batteries excluded from this benefit
info R1 564 per beneficiary each year