| Overall annual limit - Unlimited |
| CATEGORY |
BENEFIT |
LIMIT PER ANNUM |
| Hospitalisation |
Accommodation & Theatres
|
Unlimited LIMIT PER CATEGORY Unlimited subject to pre-authorisation.
|
| Consultations & Visits Up to 150% of NHRPL Rates |
Unlimited subject to pre-authorisation within 24hrs of event and managed care protocols. R2 000 per annum - for after hours at an out-patient facility (benefit applicable to dependents under the age of 14 years old only). |
| Medication: Acute To Take Out |
Unlimited.
7 Days supply. |
| Alternative to Hospitalisation |
R12 600 per family subject to authorisation. |
| Maternity: Up to 150% of NHRPL Rates |
Delivery |
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 & PMB requirement. |
Operations and Procedures
Up to 150% of NHRPL Rates |
Surgical Procedures
|
Unlimited subject to pre-authorisation.
|
| Non-Surgical Procedures |
M R2 900, M+1 R4 750 (In & out of hospital). |
| Maxillofacial & Oral Surgery Up to 150% of NHRPL Rates |
|
Subject to pre-authorisation & dental management protocols. |
| Physiotherapy & Bio Kinetics At NHRPL Rates |
|
Physiotherapy & Bio Kinetics At NHRPL Rates |
| Pathology At NHRPL Rates or Pro Sano Rates |
|
Subject to DSP management protocols R4 000 per family per annum. |
| Radiology At NHRPL Rates or Pro Sano Rates |
General Radiology
|
Subject to DSP management protocols R2 800 per family per annum.
|
| MRI, CAT, Isotopes & Angiography |
Subject to pre-authorisation & clinical protocols. R12 000 per family for specialised radiology & a separate limit of R8 400 per family for angiography (in & out of hospital). |
| Medical & Surgical Appliances |
|
R2 100 per family in & out of hospital. |
| Oxygen & Home Ventilation At NHRPL Rates |
|
Subject to pre-authorisation. |
| Blood & Blood Products |
|
Subject to pre-authorisation. |
| Prostheses |
Internal
|
Subject to pre-authorisation and managed care protocols.
|
| External |
R4 200 per beneficiary. |
| 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. |
| Maternity at NHRPL Rates |
Ante-natal Consultations
|
10 Ante-natal consultations per beneficiary.
|
| Post-natal |
2 Post-natal consultations with midwife per beneficiary. |
| Ultrasound Scans |
2 x 2D Scans per beneficiary. |
| 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 |
Chronic: Medication & Consultation |
As per PMB’s & subject to pre-authorisation & formulary. |
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 |
