| Overall annual limit - Unlimited |
| CATEGORY |
BENEFIT |
LIMIT PER CATEGORY |
| Hospitalisation |
Accommodation & Theatres Consultations & Visits |
Unlimited subject to pre-authorisation |
| Up to 300% of NHRPL Rates |
Unlimited subject to pre-authorisation and managed care protocols. |
| Medication: Acute To Take Out |
Unlimited.
7 Days supply. |
| Alternative to Hospitalisation |
Subject to pre-authorisation. |
Maternity: Delivery
Up to 300% of NHRPL Rates |
|
Unlimited subject to pre-authorisation. |
Mental Health and Alcoholism & Drug
Dependency at NHRPL Rates |
|
21 days at a registered facility and subject to managed care
protocols and PMB requirements. |
Operations and Procedures
Up to 300% of NHRPL Rates |
|
Unlimited subject to pre-authorisation. |
Dental Procedures
Up to 300% of NHRPL Rates |
|
Unlimited subject to pre-authorisation and managed care protocols. |
Physiotherapy & Bio Kinetics
At NHRPL Rates |
|
Unlimited subject to specialist motivation. |
Pathology
At NHRPL Rates or Pro Sano Rates |
|
Unlimited subject to managed care protocols and as per approved list. |
| Radiology At NHRPL Rates or Pro Sano Rates |
General Radiology |
R5 000 per family. |
MRI, CAT, Isotopes &
Angiography (In & out of
hospital) |
R15 000 per family and a separate limit of R10 000 per family for angiograms. |
| Medical & Surgical Appliances |
|
From available funds in MSA. |
Oxygen & Home Ventilation
At NHRPL or Pro Sano rates. |
|
Subject to pre-authorisation. |
| Blood & Blood Products |
|
Subject to pre-authorisation. |
| Prostheses |
Internal
|
Subject to pre-authorisation and prosthetic benefit limits. R50 000 per beneficiary per annum. |
| External |
R12 000 per family per annum. |
| Hearing Aids |
R10 000 per family. One hearing aid payable over a two year period. |
| Cochlear Implants |
R100 000 per family per annum. |
| Renal Dialysis at Pro Sano Rates |
|
Unlimited subject to pre-authorisation. |
| HIV and AIDS |
|
Unlimited subject to pre-authorisation. |
Organ Transplants
At Pro Sano Rates |
|
Unlimited subject to pre-authorisation. |
Oncology
At Pro Sano Rates |
|
Subject to DSP and managed care protocols.
R250 000 per beneficiary and subject to pre-authorisation. |
| Ambulance Services |
|
Subject to DSP service provider. |
| |
|
|
Consultations
At NHRPL Rates |
General Practitioners |
M - 10 visits, M+1- 15 visits, M2+ - 20 visits. |
| Specialists |
Specialist visits are paid from available funds in MSA. |
| Alternative Health Care at NHRPL Rates |
|
From available funds in MSA. |
| Procedures and Tests NHRPL Rates |
|
Unlimited subject to managed care protocols and as per approved list. |
Maternity
At NHRPL Rates |
Ante-natal Consultations |
10 Ante-natal consultations. |
| Post-natal |
2 Post-natal consultations with midwife. |
| Ultrasound Scans |
2 x 2D Scans. |
Mental Health and Alcoholism
& Drug Dependency at NHRPL Rates |
|
20 contacts for out patient treatment by a registered mental health
professional. |
Pathology
At NHRPL Rates or Pro Sano Rates |
|
Unlimited subject to managed care protocols and as per approved list. |
| Radiology At NHRPL Rates or Pro Sano Rates |
General Radiology |
R3 000 per family. |
Dentistry
At NHRPL Rates or Pro Sano Rates
Dental Benefit Table |
Basic |
Subject to pre-authorisation and managed care protocols.
Unlimited subject to managed care protocols. |
| Specialized |
R5 000 per family per annum. |
Optical
At NHRPL Rates or Pro Sano Rates |
Comprehensive Cover for each Beneficiary, every two years |
Subject to Pro Sano rates and managed care protocols. |
| Eye Examination |
R280 |
| Lenses (single, bi & multifocal) |
Included in benefit. |
| Frames / Lens Enhancements |
R1 000 |
| Contact Lenses Material |
R1 650 |
Allied health practitioners
(Physiotherapy, Bio Kinetics,
Services
Occupational therapy,
Speech therapy)
At NHRPL Rates |
Trauma and Rehabilitative
Services
|
10 sessions per family per annum. |
| Other Consultations & Services |
From available funds in MSA. |
| Screening benefit at NHRPL Rates |
|
1 Blood pressure, blood glucose & cholesterol screening test per beneficiary per annum by a GP, registered nurse or pharmacist. |
Medicines
At SEP Rates |
Acute
|
R2 000 per family per annum. |
| Over the Counter |
From available funds in MSA. |
| Chronic: Meds & Consultation |
Unlimited for the prescribed chronic conditions. |
Please Note:
NHRPL = National Health Reference Price List
SEP = Single Exit Price
MSA = Medical Savings Account
PMB = Prescribed Minimum Benefits
DSP = Designated Service Provider
GP = General Practitioner |
