| R500 000 Overall Annual Limit in Contracted Private and Public Hospitals |
| CATEGORY |
BENEFIT |
ANNUAL LIMIT |
| Prescribed Minimum Benefits |
|
Unlimited at contracted network facilities subject to hospital limit. Members may be transferred to a public facility when the overall hospital limit is reached. At any contracted private or public facility. |
| Hospitalisation |
100% of Agreed Tariff
|
At contracted network private or state facilities subject to hospital limit. Subject to pre-authorisation & case management. Overall limit of R500 000 and a sub-limit may apply in a private facility.
Cover for non-emergency PMB's in contracted network facility. Subject to PMB rules. No cover for experimental procedures and clinical trials. All authorisations for non-emergency admissions require referrals from a primary designated service provider. Penalty of R1 000 will apply if non-emergencies are not pre-authorised. |
| General Ward Fees and Theatre Time |
100% of Agreed Tariff |
At contracted network private facilities subject to
hospital limit. Subject to pre-authorisation & case management. |
| ICU and High Care Ward Fees |
100% of Agreed Tariff |
At contracted network facilities subject to hospital limit. Subject to pre-authorisation & case management. |
Diagnostic Procedures
(excluding radiology & pathology) |
100% of Agreed Tariff |
At contracted network private facilities subject to pre-authorisation. Experimental diagnostic procedures excluded. |
| Prescribed Medication |
100% of Agreed Tariff |
Subject to overall limit. In a contracted network facility, in accordance with pre-authorisation per admission, including medication given in Theatre, ICU, High Care, General Wards, Day Theatre & Wards. To take out medicine for a maximum of 7 days. |
| Hospital Equipment |
100% of Agreed Tariff |
At contracted network facilities subject to
hospital limit.
|
All other Materials and Consumables
in-hospital |
|
At contracted network facilities subject to
hospital limit. |
General Practitioner
Consultations and Procedures
in-hospital |
100% of Agreed Tariff |
At contracted network facilities subject
hospital limit. Subject to pre-authorisation,
protocols & case management. |
Specialist Consultations
and Procedures in-hospital |
100% of NHRPL* |
At contracted network facilities subject to hospital limit. Subject to pre-authorisation per admission, protocols & case management. Referral from primary care designated service provider required. |
|
Visits and Procedures performed by dental practitioners in hospital
|
100% of NHRPL* |
Hospitalisation only for trauma, children under 7 years & impacted wisdom teeth.
Subject to pre-authorisation. |
Oncology, Radiation and
Chemotherapy |
100% of Agreed Tariff |
At contracted network facilities subject to hospital limit. PMB rules apply. |
| Dialysis (Acute & Chronic) |
100% of Agreed Tariff |
At contracted network facilities subject to hospital limit. PMB rules apply. |
| Neonatal Care |
100% of Agreed Tariff |
At contracted network facilities subject to hospital limit. PMB rules apply.
Subject to pre-authorisation. |
Mental Health and Drug &
Alcohol Abuse |
100% of Agreed Tariff |
At contracted network facilities subject to hospital limit. PMB rules apply. |
| Burns |
100% of Agreed Tariff |
Limited to R19 000 per family per annum. |
| External Appliances |
100% of Agreed Tariff |
Limited to R1 000 per family per annum. |
| Clinical Technologists |
100% of NHRPL* |
Limited to R10 500 at contracted network facilities
subject to hospital limit. |
Radiology (Including
Specialised Radiology, MRI
and CT Scans) |
100% of NHRPL |
At contracted network facilities subject to hospital limit. Case managed and subject to sub-limit of R10 000 per family per annum. Combined in and out of hospital limit. Includes ultrasound scanning at an approved network provider medical centre. 2 Ultrasounds per pregnancy according to the network provider list of approved ultrasound codes. |
| Pathology |
100% of NHRPL |
At contracted network private facilities subject to hospital limit. Limited to R3 000 per family per annum. |
| Blood Transfusions |
100% of Agreed Tariff |
Limited to R12 000 per family per annum. |
Alternatives to
Hospitalisation |
|
Pre-authorisation required.
Limited to R5 000 per family per annum. |
Emergency Ambulance
Services |
|
Netcare 911
Out of hospital benefits |
| |
|
|
| General Practitioner |
100% of Agreed Tariff |
Unlimited at network providers only |
General Practitioner
Emergency Consultations
outside Designated
Services |
100% of Agreed Tariff |
Limited to a maximum of R700 per event (including all general practitioner consultations, procedures, medication, pathology). Limited to 2 visits per family per annum. No benefit for facility fees. Only emergencies and after hours services.
Member to settle account & submit to network provider for re-imbursement. |
| Specialists |
100% of Agreed Tariff |
5 Consultations per family or R2 800 to a maximum of 3 per beneficiary or R2 000 per annum for all out-of-hospital consultations and procedures in specialists' rooms. Authorisations only on referral from network General Practitioner. 2 Additional Gynaecologist consultations per pregnancy per family per annum. |
| Acute Medication |
100% of Single
Exit Price |
According to a fixed network provider medicines formulary. Only medication prescribed by an approved network provider General Practitioner or contracted service provider according to the network provider formulary. |
| Self Medication Benefit |
100% of Agreed Tariff |
Limited to R180 per year, maximum R60 per beneficiary per event. Subject to medication formulary at network provider only. |
| Chronic Medication |
100% of Agreed Tariff |
Subject to registration by a network provider.
Approval as per medication formulary. |
Basic Dentistry
Dental Benefit Table |
100% of Agreed Tariff |
Consultation examination 1 per beneficiary per annum (code 8101). Preventative treatment 1 per beneficiary per year, includes Fluoridefor children under 12 years.Treatment, cleaning, scaling and polishing.Subject to case management and pre-authorisation. According to the network provider list of approved codes. Treatment - follow up consultations (unlimited and managed). Fillings (white or amalgam). Pain and Sepsis. Infection Control. Oral Hygiene Instruction. Extractions. Intra Oral Radiograph (X-rays as per the network provider approved dental list of codes). Emergency Root Canal. |
Dentures
Dental Benefit Table |
100% of Agreed Tariff |
Limited to 1 set of dentures per family per
24 months cycle per family. Only members over the age of 21 years. Co-payment 20% of total fee. At network provider dental contracted provider and accredited dental laboratories only. |
Specialised Dentistry
|
|
No benefit. |
| Optical |
100% of Agreed Tariff |
Limited to one pair of spectacles per beneficiary per every 24 months. Includes frames, lenses and eye examination. Single vision or bi-focal spectacles only. Qualifying norms for near and distance vision. Network provider only. |
| HIV and AIDS |
100% of Agreed Tariff |
Unlimited. Contracted network provider only.
No cover in respect of lost or destroyed medication.
Where non-compliance by member results in viral resistance and requirement for second or third line therapy, member will be obliged to make a co-payment of 50% of all ARV medication costs. Treatment subject to registration on the HIV and AIDS Programme and treatment according to an evidence based treatment protocol and medicine formulary. |
| Physiotherapy |
100% of NHRPL |
Pre-authorisation required.
Limited to PMB's only. |
Dieticians, Occupational
Therapy, Speech Therapy,
Social Workers and Allied
Workers |
100% of NHRPL |
At contracted network private facilities subject to hospital limit. Pre-authorisation required.
PMB's only. |
| Basic Radiology |
100% of Agreed Tariff |
According to the network provider list of codes listed in formulary. Black & white X-rays and soft tissue ultrasound only. Requested by a network
provider General Practitioner, or a specialist
(subject to a prior referral by a DSPN General
Practitioner to the specialist only). |
| Pathology |
100% of Agreed Tariff |
According to the network provider list of codes listed in formulary. Requested by a network provider General Practitioner, or a specialist (subject to a prior referral by a contracted network
General Practitioner to the specialist only). |
| Maternity |
100% of Agreed Tariff |
Ante-natal and follow up post-natal care at General Practitioners. Referral to specialists subject to referral by contracted network provider and subject to pre-authorisation. 2 Specialist gynaecologists consultations per pregnancy.
Referral to specialists subject to referral by contracted network provider and subject to pre-authorisation. |
Please Note:
NHRPL = National Health Reference Price List
DSPN = Designated Service Provider Network
PMB = Prescribed Minimum Benefits |
