Health Plans: Access Option
Access Option 2020
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Unlimited hospitalisation In Network subject to sub-limits not being exceeded. Annual Member Savings Account:
Member = 5 880
Adult = 5 064
Child = 1 142
Out of hospital subject to sub limits and MSA*
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Statutory Prescribed Minimum Benefits (PMBs). Services rendered are payable at 100% of cost at designated service providers (DSPs) with no annual limit
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3 Month General Waiting Periods (Subject to the rights of interchangeability)
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12 Months condition specific waiting period for pre-existing conditions (Subject to the rights of interchangeability)
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Claims received later than the last day of the 4th month in which the service was rendered will not be covered
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100% of Scheme rates are payable in RSA currency for emergencies when travelling abroad (subject to PMBs). This is also subject to completion of documentation prior to leaving RSA and requires approval by the Scheme
Download shows Benefits across all Options
Access Option: 2020 Benefits
IN-HOSPITAL BENEFITS
In-Hospital Benefits with No Annual Limit
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100% of Negotiated Tariff* -
Limited to R30 883 per family per annum -
Subject to PMB’s, pre-authorisation and protocols
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Limited to PMB conditions only
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Subject top overall limit and core procedure per beneficiary per annum unless PMB
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R4 941 per lens
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Implantable Cardioverter Defibrillator (ICD); Subject to Scheme protocol and PMB for primary and secondary prevention -
Cardiac Resynchronization Therapy (CRT) with Pacing Capabilities (CRT-D); Subject to Scheme protocol and PMB
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Artificial Limbs and external prostheses including artificial eyes -
Maximum R11 654 subject to overall limit -
Subject to overall limits
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100% of Scheme Tariff* Subject to PMB’s, treating doctor referral and pre‑authorisation by the auxiliary service provider during the admission period Limited to PMB conditions only
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100% of Scheme Tariff* -
Subject to PMB’s, treating doctor referral and pre-authorisation by the auxiliary service provider during the admission period -
Limited to PMB conditions only
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100% of Negotiated Tariff* -
Subject to PMB’s, pre-authorisation and protocols -
Limited to 14 days per beneficiary per annum
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100% of Negotiated Tariff* -
Subject to PMB’s, pre-authorisation and protocols -
Limited to 14 days per beneficiary per annum
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100% of Negotiated Tariff* -
Limited to 14 days per beneficiary per annum -
Subject to PMB’s, pre-authorisation and protocols
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100% of Scheme Tariff* -
Subject to pre-authorisation
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100% of Negotiated Tariff* -
Subject to PMB’s, pre-authorisation and protocols
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100% of Negotiated Tariff* -
Subject to PMB conditions only
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100% of Negotiated Tariff* -
Subject to PMB’s, pre-authorisation and Scheme formulary* and protocol
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100% of Scheme Tariff* -
Subject to PMB’s, pre-authorisation and protocols -
Back surgery is subject to adherence of the conservative back treatment protocol -
Limited to PMB Conditions
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Performed in a day hospital or as a day case -
100% of Scheme Tariff* -
Subject to PMB’s, pre-authorisation and protocols -
Laparoscopic Hospitalisation will attract a R5 592 co-payment
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Skin disorders -
Arthroscopy -
Bunionectomy -
Removal of varicose veins -
Refractive eye surgery, Aphakic lenses -
Infertility treatment -
Non-cancerous breast conditions
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Umbilical and Inguinal hernia repair -
Colonoscopy -
Cystoscopy -
Gastroscopy and Oesophagoscopy -
Hysteroscopy -
Grommets -
Termination of pregnancy -
Breast biopsy -
Cataracts -
Circumcision -
ERCP -
Haemorrhoidectomy -
Vasectomy -
Tubal Ligation -
Excision of extensive skin lesions or repair of wounds and skin grafts -
Dental procedures -
Repair nail bed & Removal of toenails -
Minor orthopaedic procedures such as tennis elbow, dupuytren’s contracture, trigger finger, ganglion, carpal tunnel syndrome -
Minor Gynaecological procedures – cone biopsy, colposcopy, D&C
In-Hospital Benefits that are Limited and Subject to Authorization
Subject to pre-authorisation, clinical protocols, formulary* and PMBs
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100% of DSP Tariff* and clinical protocols -
Unlimited benefits for PMB conditions subject to pre-authorisation, use of a Designated Service Provider (DSP*) hospital network and prevailing clinical protocols and formulary* -
Failure to comply utilising a DSP* provider will result in a 10% co-payment* per admission except for emergency admissions
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Subject to Pre-authorisation and PMB’s -
100% of Scheme Tariff* -
TTO benefit for 7 days -
Subject to formulary*
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Subject to Pre-authorisation and PMB’s -
100% of Scheme Tariff*
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Subject to clinical protocols and PMB’s -
100% of Scheme Tariff* -
Authorisation must be obtained prior to the examination or within 24 hours in case of emergency -
Pathology Unlimited -
Radiology Unlimited -
Specialized Radiology subject to pre-authorization
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Subject to PMB’s as prescribed -
100% of DSP Tariff* -
Limited to PMB Conditions only -
Based on DSP* ICON* Enhanced Protocols -
Treatment subject to designated service provider guidelines and pre-authorisation
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100% of Scheme Tariff* -
Subject to 21 Days per beneficiary or up to 15 out-patient contacts per annum -
Subject to PMB’s, managed care protocols and pre-authorization by the Scheme
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PMB based on clinical protocols -
100% of Scheme Tariff* -
Limited to R12 353 per family per annum
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Subject to PMB’s and Pre-Authorisation -
100% of Scheme Tariff* -
PMB based on Department of Health Protocols -
Unlimited
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Subject to PMB conditions only -
100% of Scheme Tariff* -
Subject to pre-authorization
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Subject to PMB’s and to pre-authorisation -
100% of Negotiated Tariff* -
Unlimited benefits for PMB admissions and PMB level of Care -
Subject to Treatment Protocols and formulary*
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Subject to PMB Conditions only -
100% of Scheme Tariff* -
Sterilisation limited to R16 000 per beneficiary per annum
MONTHLY PREMIUMS
Principal Member
Sole Member Monthly Premium: R 2,450
Member PLUS Adult
Principal Member: R 2,450
Member PLUS 1 Child
Principal Member: R5,438
Member PLUS Adult PLUS 1 Child
Principal member: R 2,450
Member PLUS Adult PLUS 2 Children
Principal Member: R 2,450
Family (Member PLUS Adult PLUS 3 Children)
A maximum of three children will be charged:
OUT-OF-HOSPITAL BENEFITS
Consultations and Diagnostic Benefits
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100% of Scheme Tariff* -
Paid from MSA -
6 Additional GP Visits per Family per Annum once MSA is depleted
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Paid from MSA* -
Specialist consultations requires GP referral or payment will be made at GP rates
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Subject to PMBs and protocols -
100% of DSP Tariff* -
Paid from MSA -
All specialised radiology subject to pre-authorisation
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Subject to PMBs
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Subject to PMBs
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Limited to 2 scans per beneficiary per annum -
In and out of hospital -
Subject to pre-authorisation
Medicines and Injection Material
Acute Medicines (Including material)
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100% of Reference Price* -
Paid from MSA* -
Subject to Medicine formulary* and Protocols, Including Materials -
Homeopathic Medication excluded -
Acute Medication Obtained from Pharmacy: Subject to funds available in MSA
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100% of Reference Price* -
Paid from MSA* -
Consultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines -
PAT subject to acute benefit limit
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100% of Reference Price* -
Paid from MSA
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100% of Reference Price Cost Unlimited -
Chronic Medication to be Obtained from Preferred Provider Network -
Subject to renewal of prescription every six months -
Paid from Risk Pool
Optical Benefits
Spectacle Lenses: In Network
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100% of DSP Tariff* -
R185 per lens – clear single vision, or -
R420 per lens – clear bifocal vision, or -
R745 per lens – base multifocal -
Fixed tints up to 35% -
No benefit for contact lenses if spectacles purchased -
Benefit applicable to members who utilize the Scheme’s Preferred Provider -
Network Optometrists only -
Limited to one pair of spectacles per beneficiary every 24 months
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100% of DSP Tariff* -
Paid from Risk Pool -
R950 per beneficiary every 24 months -
No claim for specialists if contact lenses purchased -
Subject to clinical protocol
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100% of DSP Tariff* -
Paid from Risk Pool -
R548 per frame -
No benefit per frame if contact lenses are purchased -
One claim per beneficiary every 24 months
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100% of DSP Tariff* -
Paid from Risk Pool -
One comprehensive consultation per beneficiary every 24 months
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Contact the Scheme’s preferred provider network for availability and locality of network optometrists -
Benefits applicable to members who utilise the Scheme’s preferred provider network optometrists only
Dental Benefits
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Conscious sedation: Extensive dental treatment (more than 4 fillings or extractions) subject to dental treatment protocols and preauthorisation -
100% of Scheme Tariff* -
Paid from Risk Pool -
Consultations, Fillings, Extractions, Two (2) root canal treatments per family per annum -
Preventative scale and polish -
Fluoride treatment limited to beneficiaries below the age of -
12 years -
Conscious sedation for children up to the age of 12 years -
Root Canal treatment included in conservative dentistry -
X-rays (limited to intra-oral) -
Dental protocols apply and pre-authorisation required for extensive treatment plans -
Quantity Limitations Apply -
Contracted Network Provider Only
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Non-PMB’s Paid from MSA* -
All clinically valid specialised dental treatment covered from MSA* including 1 set of Acrylic (plastic) denture per beneficiary every 4 years. -
Cover available for realigning and repairing every 12 months -
Including Repairs of Dentures -
Subject to PMB conditions only
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Subject to PMB conditions only
Auxiliary Benefits
Alternative Services (Homeopathy, naturopathy, chiropractor and podiatry)
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100% of Scheme Tariff* -
Non-PMB’s paid from MSA* -
Appropriate referral by GP/Specialist, failing to do so will result in no payment -
Subject to PMB’s and Protocols
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100% of Scheme Tariff* -
Subject to PMB conditions and clinical protocols -
Non-PMBs from MSA -
Appropriate referral by GP/Specialist
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100% of Scheme Tariff* -
R2 727 per beneficiary limited to R4 370 per family -
per annum
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Subject to pre-authorisation -
100% of Negotiated Tariff* -
Limited to R6 526 per family per annum -
Paid from Risk Pool subject to sub-limit -
In & Out of Hospital - PMBs only -
Blood Pressure Monitors Subject to a sub-limit of R550 for ben eficiaries registered for Hypertension
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Other Benefits
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100% of Scheme Tariff -
The Schemes preferred provider must be contacted should you require an Ambulance – failure to adhere to this could result in you being held liable for costs incurred
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Emergency response by road or air to scene of incident and transfer from scene, to closest, most appropriate facility -
Escort return of stranded minors can be arranged
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Facilitation of medically justified inter-facility transfers -
Medical repatriation
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Subject to PMB’s and referral from GP or Specialist, failure to do so will result in no payment -
Subject to confirmed diagnosis, treatment plan and managed care protocols -
100% of Scheme Tariff* -
Subject to PMB conditions only -
Non-PMBs paid from MSA
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Subject to PMB conditions only -
Non-PMBs paid from MSA -
100% of Scheme Tariff*
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Subject to PMBs, pre-authorisation and protocols -
100% of Negotiated Tariff* -
Subject to PMB conditions only -
Non-PMBs paid from MSA
MATERNITY BENEFITS
Maternity Visit/s
Maternity Ultrasound/s
Home Delivery
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Limited to R4 661 / pregnancy. -
100% of Negotiated Tariff
Hospital Confinement
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NVD – Limited to 2 days -
Caesarean – Limited to 3 Days
Immunisation Benefit
Antenatal Classes
WELLNESS BENEFITS
Papsmear
Mammogram
HPV Vaccination
Prostate Specific Antigen (PSA
HIV Testing Benefit
Cholesterol Test
Blood Sugar Test
Blood Pressure Check
Flu Vaccination
All beneciaries
Pneumococcal Vaccinati
CHRONIC BENEFITS
Chronic Conditions Covered
Accessing Your Chronic Medication