Health Plans: Essential Option
Essential Option 2020
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Annual limits are limited to PMB conditions only for in and out of hospital benefits and are subject to sub-limits not being exceeded
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Prorated benefits are applicable if you join after the 1st of January of a benefit year
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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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The Essential Package does not cover emergencies when travelling abroad
Download shows Benefits across all Options
Essential Option: 2020 Benefits
IN-HOSPITAL BENEFITS
In-Hospital Benefits with No Annual Limit
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100% of Negotiated Tariff* -
Limited to R19 641 per family per annum
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Limited to PMB conditions only
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Excluded unless PMB. Prosthesis limited to equivalent available in the state.
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Subject to PMB
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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 R9 323 subject to overall prosthesis limit
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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* -
Limited to PMB conditions only
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100% of Negotiated Tariff* -
Limited to PMB conditions only
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100% of Negotiated Tariff* -
Limited to PMB conditions only
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100% of Scheme Tariff* -
Limited to PMB conditions only
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100% of Negotiated Tariff* -
Limited to PMB conditions only as per public hospital protocols
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100% of Negotiated Tariff* -
Limited to PMB conditions only
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Limited to PMB conditions only
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Back surgery is subject to conservative back treatment -
Limited to PMB conditions only
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Biopsy -
Breast Biopsy -
Cataract -
Colonoscopy -
Cone Biopsy/ Colposcopy -
Cystoscopy -
ERCP -
Excision of Extensive Skin lesions /Repair/Skin Graft -
Gastroscopy or Colonoscopy or Oesophagoscopy -
Haemorrhoidectomy -
Hysteroscopy, D&C, Minor Gynaecological Procedures -
Grommets -
Repair of Wounds -
Termination of Pregnancy -
Umbilical and Inguinal Herniaoscopy, 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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Unlimited benefits for PMB conditions subject to preauthorisation and 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
- 100% of Scheme Tariff*
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TTO benefit for 7 days -
Subject to formulary* -
Limited to PMB conditions only
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Limited to PMB conditions only -
100% of Scheme Tariff*
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100% of Scheme Tariff* -
Subject to Clinical protocols and PMB’s -
Limited to PMB conditions only -
Combined limited of R6 177 per beneficiary per annum -
Pathology and Radiology: Network Provider Only. Limited to PMB conditions only -
Specialised Radiology: MRI/PET/CT Scans Limited to 2 per beneficiary per annum for In and Out Hospital -
Limited to PMB conditions only
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Limited to PMB conditions -
100% of DSP Tariff* -
Based on DSP* ICON* Enhanced Protocols -
Treatment subject to designated service provider guidelines and pre-authorisation
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Subject to PMB’s, managed care protocols and pre-authorisation by the Scheme -
100% of Scheme Tariff* -
Limited to PMB conditions only -
Subject to 21 Days per beneficiary or up to 15 out-patient contacts per annum (Subject to PMB’s)
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Subject to PMB’s and pre-authorisation -
Limited to PMB conditions only -
100% of Scheme Tariff* -
PMB based on Department of Health Protocols
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Subject to PMB’s and Pre-Authorisation -
100% of Scheme Tariff* -
PMB based on Department of Health Protocols -
Limited to PMB conditions only
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100% of Scheme Tariff* -
Limited to PMB conditions only -
Subject to pre-authorisation
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Subject to PMB’s and to pre-authorisation -
100% of Negotiated Tariff* -
Limited to PMB conditions only -
Unlimited benefits for PMB admissions and PMB level of care -
Subject to Treatment Protocols and formulary*
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100% of Scheme Tariff* -
Limited to PMB conditions only
MONTHLY PREMIUMS
Principal Member
Sole Member Monthly Premium: R 2,131
Member PLUS Adult
Principal Member: R 2,131
Member PLUS 1 Child
Principal Member: R 2,131
Member PLUS Adult PLUS 1 Child
Principal member: R 2,131
Member PLUS Adult PLUS 2 Children
Principal Member: R 2,131
Family (Member PLUS Adult PLUS 3 Children)
A maximum of three children will be charged:
OUT-OF-HOSPITAL BENEFITS
Consultations and Diagnostic Benefits
Consultations (Including General Practitioners, Specialist and Outpatient Facilities)
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100% of DSP Tariff* -
Unlimited visits & acute medication from any GP within the DSP* Network at 100% of DSP* Tariff*
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100% of Scheme Tariff* -
Limited to 3 Visits per family per annum only on referral from DSP* GP. -
Subject to pre-authorisation -
Limited to PMB conditions only
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Subject to PMBs and protocols -
Pathology: Limited to R863 per beneficiary per annum Network Provider -
Only Limited to PMB conditions only -
Radiology: Limited to R863 per beneficiary per annum Referral by Network Provider Only Limited to PMB conditions only
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Limited to 2 scans per beneficiary per annum -
Subject to pre-authorisation -
Referral by Network Provider only -
Limited to PMB conditions only
Medicines and Injection Material
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100% of Reference Price* -
DSP* GP -
Unlimited Acute medication dispensed by the DSP* GP -
Subject to Medicine formulary* and Protocols, Including Materials. -
Homeopathic Medication excluded -
Acute Medication Obtained from Pharmacy: R1 266 per beneficiary limited to R3 534 per family per annum
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100% of Reference Price* -
Limited to R646 per family per annum -
Maximum R95 per script -
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* -
Limited to R64 per beneficiary per month, subject to R767 per family per annum. -
Subject to oral and injectable contraceptives only -
Subject to the contraceptive formulary*
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100% of Reference Price Cost Unlimited -
Provider Network Only
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 -
R420 per lens – base multifocal -
No Benefit for Fixed Tints No benefit for contact lenses if spectacles purchased Limited to one pair of spectacles per beneficiary every 24 months
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100% of DSP Tariff* -
R615 per beneficiary every 24 months -
No benefit for spectacles if contact lenses purchased Provider Network Only -
Subject to clinical protocol
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100% of DSP Tariff* -
R300 per beneficiary -
No benefit per frame if contact lenses are purchased -
One claim per beneficiary every 24 months
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100% of DSP Tariff* -
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* Consultations, Fillings, Extractions -
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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Limited to PMB conditions only -
Acrylic (Plastic) Dentures -
1 set of Acrylic/plastic dentures per beneficiary every 4 years. -
Cover available for realigning and repairing every 12 months Including Repairs of Dentures
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Limited to PMB conditions only
Auxiliary Benefits
Remedial and Other Therapies (Audiology, speech therapy, dieticians, hearing aid acousticians, occupational therapy, orthotics, social workers and speech therapy)
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Limited to PMB conditions only
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Limited to PMB conditions only and clinical protocols -
Cardiac and Respiratory conditions: Subject to provision of treatment plan and therapy goals. -
Maximum of 6 sessions per beneficiary, thereafter subject to progress report and evidence of response. -
Treatment for Back pain: Subject to treatment plan for back pain
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Subject to pre-authorisation -
100% of Negotiated Tariff* -
Limited to R2 914 per family per annum In and Out of Hospital Limited to PMB conditions only -
Blood Pressure Monitors Subject to a sub-limit of R550 for beneficiaries 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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Limited to PMB conditions only
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Limited to PMB conditions only ast State/Public facilities
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Subject to PMBs, pre-authorisation and protocols -
100% of Negotiated Tariff* -
Limited to PMB conditions only
MATERNITY BENEFITS
Maternity Visit/s
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100% of Scheme Tariff* -
Subject to DSP* -
GP and Specialist consultation limit as per Consultations
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