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 785
M+1 : R7 821
M+2 : R9 580
M+3+ : R10 292
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 R278 per consultation
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 : R18 720
M+1 : R30 960
M+2 : R34 990
M+3+ : R43 796
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 : R27 903
M+1 : R46 487
M+2 : R55 795
M+3+ : R65 218
per family per annum
Limits applicable to non-PMB chronic medication.100% of SEP and dispensing fee
- Specialised Chronic Medicines
warning 20% co-payment applied.
info R100 000 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 R25 000 per beneficiary per year
The Scheme agreed to the introduction of a new benefit for CGM devices and consumables, and is 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 R325 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 000 per beneficiary once every four years Home oxygen R15 000 per beneficiary per year Stoma products R15 000 per beneficiary per year CPAP machine R12 000 per beneficiary every four years CPAP machine consumables R3 000 per beneficiary per year Orthopaedic appliances R4 000 per beneficiary per year Other appliances (e.g blood pressure monitors, glucometers, nebulizers, etc.) R1 500 per beneficiary every four years - Hearing aids
warning Subject to pre-authorisation
info R20 000 per ear per beneficiary every four years
100%
of cost - Hearing Aid Maintenance Benefit
warning Batteries excluded from this benefit
info R1 500 per beneficiary each year