| Subject to overall annual limit of R750 000 per family |
| CATEGORY |
BENEFIT |
ANNUAL LIMIT |
Hospitalisation
At NHRPL Rates |
Accommodation & Theatres |
Subject to authorisation & referral protocols.
R500 co-payment on non-PMB elective procedures. |
Consultations & Visits
at NHRPL Rates |
Subject to authorisation & referral protocols. |
Medication: Acute
To Take Out |
Unlimited.
7 Days supply. |
| Alternative to Hospitalisation |
R6 000 per family subject to 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 & referral protocol. |
Maxillofacial & Oral Surgery
at NHRPL Rates |
|
Subject to pre-authorisation, dental management & referral 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 000, M+1 R1 200, M+2 R1 400, M+3 R1 700 (in & out of hospital). |
Pathology
At NHRPL Rates or Pro Sano Rates |
|
Subject to DSP management protocols R3 000 per family per annum. |
| Radiology At NHRPL Rates or Pro Sano Rates |
General Radiology
|
Subject to DSP management protocols R2 500 per family per annum. |
MRI, CAT, Isotopes &
Angiography |
Subject to pre-authorisation & clinical protocols. R8 500 per family for
specialised radiology & a separate limit of R8 400 per family for angiography
(in & out of hospital). |
| Medical & Surgical Appliances |
|
Refer to Supplementary Health Services. |
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 |
Overall limit of R22 500 per family. |
| External |
R4 200 per family. |
Hearing Aids
Cochlear Implants |
Included in the external prosthesis benefit. |
| 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 |
For Pro Sano Designated GP’s: The following combined limits are available Pro Sano tariff for GP’s, specialists & medicines for Pro Sano Designated GP’s. You can download the full listing here.
M0 - R2 500 per family, M1 - R3 300 per family, M2 - R4 200 per family, M3 R5 000 per family.
For Non- Pro Sano Designated GP’s: A co-payment of R100 is payable for consultation for non-Pro Sano Designated GP’s - subject to above limits. |
| Specialists |
Designated GP referrals: The above combined limits are available tariff for specialists & medicines where a member is referred by Designated GP.
Unauthorised referrals: A co-payment of R100 is payable for each where there is no referral by the GP - subject to above limits. |
| Procedures and Tests at NHRPL Rates |
|
M R1 500, M+1 R2 000. |
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. |
Mental Health and Alcoholism
& Drug Dependency at NHRPL Rates |
|
10 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 R1 000, M+1 R1 200, M+2 R1 400, M+3 R1 700. |
Radiology
At NHRPL Rates or Pro Sano Rates |
General Radiology. Subject
to DSP management protocols. |
M R1 000, M+1 R1 500. |
Dentistry
At NHRPL Rates or Pro Sano Rates
Dental Benefit Table |
Basic
|
Subject to pre-authorisation & managed care protocols. M R 1 100, M+1 R1 300, M+2 R1 470. |
| Specialised |
Included in Basic Dentistry. |
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 benefits |
Frames / Lens Enhancements
|
R400 |
| Contact Lenses Material |
R1 050 |
Supplementary Health Services:
Audiologist, Chiropractor etc.
At NHRPL Rates |
|
R1 700 per family. |
| 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 & Over the Counter
|
Refer to Consultations. |
| Chronic: Meds & 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 |
