Out-of-hospital Treatment Received in Rooms

  • Consultative services (specialist treatment)
    Specialist conditions and treatment out of hospital by anaesthetists, physicians, neurosurgeons, surgeons, orthopaedic specialists, otorhinolaryngologists (ENT), radiotherapists, thoracic surgeons, urologists and cardiologists and nursing practitioners.

    M = R4 085
    M+1 = R6 680
    M+2 = R8 180
    M+3+ = R8 790
    Subject to OAL

    100%

    of Scheme rate

  • General practitioners and certain specialists
    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).

    Subject to available MSA

    No pre-authorisation required

    100%

    of Scheme rate

  • Diagnostic radiology and pathology
    Including materials

    Pre-authorisation required for MRI, bone densitometry, mammograms and CT scans.

    Referring healthcare provider's practice number must appear on all claims.

    M = R15 990
    M+1 = R26 440
    M+2 = R29 890
    M+3+ = R37 410
    Subject to OAL

    100%

    of Scheme rate

    80%

    of the Scheme tariff for Out-of-hospital radiology and pathology

    20%

    from MSA subject to PMB requirements

  • Oncology
    Chemotherapy, radiotherapy, intravenous medication and materials.

    This benefit is subject to the approval of a comprehensive treatment plan that must be submitted to the pre-authorisation department via [email protected] or via post to PO Box 2070, Bellville 7535

    100%

    of cost

  • Prescribed chronic medication
    Medication prescribed or dispensed to patients registered on the Scheme's Medicine Risk Management Programme

    Subject to pre-authorisation

    M = R 23 830
    M+1 = R 39 710
    M+2 = R 47 650
    M+3+ = R 55 700
    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
    Antiretroviral treatment (ART)

    Subject to registration on the HIV Management Programme

    100%

    of cost

  • Acute medication

    Subject to available MSA

    All medication, including TTO (maximum seven days' supply), except those obtained through the Medicine Risk Management Programme. Pharmacy-advised therapy medication prescribed and dispensed by pharmacists limited to R275 per prescription. Clinically and pharmacy-dispensed vaccinations.

    100%

    of SEP and dispensing fee

  • Physiotherapy/Biokinetics

    Subject to pre-authorisation

    Subject to available MSA

    100%

    of Scheme rate

  • External appliances
    Includes nebulisers, wheelchairs, stoma products, hearing protectors and home oxygen.

    Subject to pre-authorisation

    R6 810 per family per annum

    100%

    of cost

  • Hearing aids

    Subject to pre-authorisation

    R15 520 per ear per beneficiary every four years

    100%

    of cost