| Overall annual limit - Unlimited |
| CATEGORY |
BENEFIT |
LIMIT PER ANNUM |
| Hospitalisation |
Accommodation & Theatres |
Subject to authorisation & referral protocols. |
Consultations & Visits
at NHRPL Rates |
Subject to authorisation & referral protocols. |
Medication: Acute
To Take Out |
Unlimited.
7 Days supply. |
| Alternative to Hospitalisation |
R13 850 per family subject to pre-authorisation. |
| Maternity: Delivery at 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 DSP, managed care
protocols and PMB requirements. |
Operations and Procedures
at NHRPL Rates |
|
Subject to authorisation & GP referral protocols. |
Maxillofacial & Oral Surgery
at NHRPL Rates |
|
Subject to pre-authorisation & dental management protocols. |
Dental Procedures
At NHRPL Rates |
|
Subject to pre-authorisation & dental management protocols. |
Physiotherapy & Bio Kinetics
At NHRPL Rates |
|
Subject to pre-authorisation & managed care protocols.
M R1 100, M+1 R2 200 (in & out of hospital). |
Pathology
At NHRPL Rate |
|
Subject to DSP management protocols R5 000 per family per annum. |
| Radiology At NHRPL Rates or Pro Sano Rates |
General Radiology |
Subject to DSP management protocols R3 000 per family per annum. |
MRI, CAT, Isotopes &
Angiography |
Subject to pre-authorisation & clinical protocols. R13 500 per family for
specialised radiology & a separate limit of R9 500 per family for angiography
(in & out of hospital). |
| Medical & Surgical Appliances |
|
R2 300 per family in & out of hospital. |
Oxygen & Home Ventilation
At NHRPL Rates |
|
Subject to pre-authorisation. |
| Blood & Blood Products |
|
Subject to pre-authorisation. |
| Prostheses |
|
Subject to pre-authorisation and prosthetic benefit limits
|
| Internal |
Subject to prosthetic benefit list. |
| External |
R4 620 per beneficiary. |
| Hearing Aids |
Subject to prosthetic benefit list. |
| Cochlear Implants |
Subject to prosthetic benefit list. |
| Renal Dialysis at Pro Sano Rates |
|
Subject to pre-authorisation & managed care protocols. |
| HIV and AIDS |
|
Subject to pre-authorisation & managed care protocols. |
| Organ Transplants at Pro Sano Rates |
|
Unlimited subject to pre-authorisation & PMB’s. |
| Oncology at Pro Sano Rates |
|
Solid tumour (cancers) - Subject to DSP and managed care protocols.
Haematological conditions (cancers) - Subject to DSP & managed care protocols. |
| Ambulance Services |
|
Subject to DSP. |
| Consultations at NHRPL Rates |
General Practitioner |
Pro Sano will pay from risk R120 of the GP consultation for visits to Pro Sano Designated GP’s. You can download the full listing here. Visits to non-Pro Sano Designated GP’s will be paid from available funds in MSA. |
| Specialists |
Specialist visits are subject to pre-authorisation & Pro Sano will pay R120 of a referred visit from risk & the balance from available funds in MSA. |
| Alternative Health Care at NHRPL Rates |
|
From available funds in MSA. |
| Procedures and Tests at NHRPL Rates |
Basic
Advanced |
M R3 180, M+1 R5 220. |
| Maternity at NHRPL Rates |
Ante-natal Consultations
|
10 Ante-natal consultations per
|
| Post-natal |
2 Post-natal consultations with midwife per beneficiary. |
| Ultrasound Scans |
2 x 2D Scans per beneficiary. |
| Mental Health and Alcoholism & Drug Dependency at NHRPL Rates |
|
15 contacts for out patient treatment by a registered mental health professional. |
Pathology
At NHRPL Rates or Pro Sano Rates |
|
Subject to DSP management protocols.
M R2 000, M+1 R3 000. |
| Radiology At NHRPL Rates or Pro Sano Rates |
General Radiology |
Subject to DSP management protocols. M R2 000, M+1 R3 000. |
Dentistry
At NHRPL Rates or Pro Sano Rates
Dental Benefit Table |
Basic
|
Subject to pre-authorisation R3 250.
|
| Specialised |
Specialised
Subject to pre-authorisation R4 050. |
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 |
R600 |
| Contact Lenses Material |
R1 250 |
Supplementary Health Services:
Homeopaths, Dieticians, etc.
At NHRPL Rates |
|
From available funds in MSA. |
Occupational therapy,
Speech therapy & Audiology
At NHRPL Rates |
|
M R2 060, M+1 R3 150, M+2 R3 630, M+3 R3 880, M+4 R4 120. |
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 or Pro Sano Rates |
Acute
|
From available funds in MSA. |
| Over the Counter |
From available funds in MSA. |
Chronic: Medication &
Consultation |
Over the Counter |
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 |
