Health Plans: Value Core Option
Value Core 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
Value Core Option: 2020 Benefits
IN-HOSPITAL BENEFITS
In-Hospital Benefits with No Annual Limit
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100% of Negotiated Tariff* -
Limited to R47 990 per family per annum -
Subject to PMB’s, pre-authorisation and protocols
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Limited to a maximum of 2 levels unless clinically motivated and approved or within PMB protocols -
R29 304 per level subject to overall limit not being exceeded -
Maximum 1 event per beneficiary per annum
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Limited to one event per annum, unless sepsis or trauma -
R40 987 per annum - Subject to the overall limit and maximum of one procedure per beneficiary per annum. Excludes cement
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Subject to protocol and PMB’s -
R5 707 per lens
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1 per lesion – maximum 3 lesions -
Bare metal stents: R13 984 per stent -
Drug eluting stents: R19 811 per stent
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Cardiac valves, aortic stent grafts, peripheral arterial stents grafts, single/dual pacemaker -
Cardiac resynchronization devices (CRT), implantable cardioverter defibrillators (ICD) with pacing capabilities (CRT-D) - Subject to overall prosthesis limit and PMB protocols -
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 -
Internal sphincters and stimulators -
Neurostimulators/internal nerve stimulator for Parkinson‘s Disease - Subject to clinical protocol and medical management being exhausted. Subject to overall limit -
Cochlear implants - Subject to overall limit for device -
Insulin pumps and monthly materials - Children under 7 years of age only. Subject to clinical protocols and overall limit
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Artificial Limbs and external prostheses including artificial eyes -
Maximum R13 984 subject to overall 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 -
Subject to Scheme protocols
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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 -
Subject to Scheme protocols
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100% of Negotiated Tariff* -
Subject to PMB’s, pre-authorisation and protocols -
Limited to 1 4 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* -
In and Out of hospital -
Subject to pre-authorisation
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100% of Negotiated Tariff* -
Limited to R42 536 per family per annum -
Subject to PMB’s, pre-authorisation and protocols
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100% of Negotiated Tariff* -
Limited to R26 803 per family per annum -
Subject to PMB’s, pre-authorisation and protocols
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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 -
R5 000 co-payment* applicable for all non-PMB spinal surgery
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100% of Scheme Tariff* -
Subject to PMB’s, pre-authorisation and protocols -
Only covered for primary central nervous system tumours
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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* except for the following circumstances where no co-payment* will apply: -
Purely diagnostic laparoscopy -
Aspiration/excision ovarian cyst -
Lap-appendicectomy -
Repair of recurrent or bilateral inguinal hernias
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Joint Replacement -
Umbilical Hernia Repair -
Hysterectomy -
Functional Nasal Surgery -
Elective caesarean section
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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 Scheme Tariff* -
Unlimited subject to pre-authorisation, use of the Netcare Hospital Group (DSP*), clinical protocols and formulary* -
Subject to sub-limits not being exceeded -
Failure to comply utilising a DSP* provider will result in non-payment -
In case of PMB voluntary use of non-DSP will result in a 10% co-payment* per admission except for emergency admissions clinical protocols and formulary*
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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 Pre-authorisation and PMB’s -
100% of Scheme Tariff* -
Authorisation must be obtained prior to the examination or within -
24 hours in case of emergency -
All specialised radiology subject to pre-authorisation
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Subject to PMB’s as prescribed -
100% of DSP Tariff* -
Limited to R287 842 per beneficiary per annum -
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* -
Subject to 21 Days per beneficiary or up to 15 out-patient contacts per annum (Subject to PMB’s) -
Non PMB’s – 14 days per family subject to a limit of R20 511 -
Payment up to 3 days for Psychologist charging therapy sessions with Psychiatrist in the same admission, thereafter pre-authorisation required with treatment plan
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Subject to PMB’s, Managed care protocols and pre-authorisation -
100% of Scheme Tariff* -
Limited to R19 345 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 pre-authorisation, and treatment protocols and PMB’s -
100% of Scheme Tariff* -
Anaesthetist and Hospital cost is payable from hospital benefit -
Provider fee subject to available Advanced Dentistry Benefit -
Benefit is payable from hospital benefit only in the following cases: -
Extensive conservative treatment for children under 7 years of age and more than 3 teeth involved -
Removal of symptomatic impacted wisdom teeth if pre-authorised as a day case only
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100% of Scheme Tariff* -
Maxillo-facial and oral surgery limited to symptomatic wisdom -
teeth and surgical exposures -
Anaesthetist and Hospital cost is payable from hospitalisation: -
Removal of symptomatic impacted wisdom teeth if pre-authorised -
as a day case only -
All other procedures subject to PMB only
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Subject to PMB’s and to pre-authorisation -
100% of Negotiated Tariff* -
Unlimited benefits for PMB admissions -
Subject to Treatment Protocols and formulary*
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Subject to pre-authorisation -
100% of Scheme Tariff* -
Sterilisation limited to R16 000 per beneficiary per annum
MONTHLY PREMIUMS
Principal Member
Sole Member Monthly Premium: R3,214
Member PLUS Adult
Principal Member: R3,214
Member PLUS 1 Child
Principal Member: R5,438
Member PLUS Adult PLUS 1 Child
Principal member: R3,214
Member PLUS Adult PLUS 2 Children
Principal Member: R 3,214
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* -
10 Visits per Beneficiary limited to 20 Visits per Family per Annum
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Subject to PMBs and protocols -
100% of Scheme Tariff* -
All specialised radiology subject to pre-authorisation
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Limited to R2 779 per beneficiary per annum
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Limited to R2 162 per beneficiary per annum
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Limited to 2 scans per beneficiary per annum -
Subject to pre-authorisation
Medicines and Injection Material
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100% of Reference Price -
Limited to R5 442 per beneficiary and R11 046 per family per annum -
Subject to Medicine formulary* and Protocols, Including Materials and -
Homeopathic Medicine
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100% of Reference Price* -
Limited to R2 021 per family per annum -
Maximum R156 per script -
Included in Acute Medication Limit above -
Consultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines -
PAT subject to acute benefit limit
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Subject to oral, injectable and patch contraceptives only -
100% of Reference Price* -
Limited to R1 399 per family per annum. Subject to oral, injectable and patch contraceptives formulary
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100% of Reference Price* -
R6 917 per beneficiary Limited to R13 960 per family per annum -
PMB’s subject to registration and pre-authorisation with the Schemes preferred provider -
Chronic Medication to be Obtained from Preferred Provider Network -
Subject to renewal of prescription every six months -
Subject to pre-authorisation, treatment protocols and medicine formulary* -
Non-formulary* products will incur a 30% co-payment* where these are obtained voluntarily by beneficiaries
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100% of Reference Price Cost Unlimited -
Benefit initially payable from limit above -
Non-formulary* products will incur a 30% co-payment* where these are obtained voluntarily by beneficiaries -
Benefit Initially payable from chronic medicine limit above -
Chronic Medication to be Obtained from Preferred Provider Network - Subject to renewal of prescription every six months -
PMB’s subject to registration and pre-authorisation with the Schemes preferred provider - Subject to pre-authorisation, treatment protocols and medicine formulary*
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 -
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* -
R1 810 per beneficiary every 24 months -
No benefit for spectacles if contact lenses purchased -
Subject to clinical protocol -
Benefit applicable to members who utilize the Scheme’s preferred provider network optometrist only
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100% of DSP Tariff* -
R795 per beneficiary -
Enhancements: In Network -
No benefit per frame if contact lenses are purchased -
Benefit applicable to members who utilize the Scheme’s preferred provider network optometrist only -
One claim per beneficiary every 24 months
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100% of DSP Tariff* -
Benefit applicable to members who utilize the Scheme’s preferred provider -
network optometrist only -
One claim 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* -
Unlimited -
Consultations, Fillings, Extractions, Root canal treatment two (2) RCT 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 intra-oral covered -
Panoramic Radiographs limited to 1 per beneficiary every 24 months -
Subject to dental treatment protocols and pre-authorisation for extensive treatment
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Subject to pre-authorisation by the Scheme and treatment protocols -
Failure to obtain pre-authorisation will result in no payment -
100% of Scheme Tariff* -
R4 452 per beneficiary limited to R6 363 per family per annum -
Crowns and Bridges, Impacted wisdoms and Orthodontics
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R15 000 per family once every five years
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Subject to the above available limit -
Limited to one (1) set per beneficiary every 5 years
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Subject to advanced dentistry limit -
Limited to 1 per beneficiary every 4 years -
Contracted Network Provider Only
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Subject to PMBs, pre-authorisation and protocols -
100% of Scheme Tariff* -
(included in advanced dentistry limit) -
Benefit is payable from hospitalisation in cases of accidents, injury, congenital abnormalities and oncology related procedures only
Auxiliary Benefits
Alternative Services (Homeopathy, naturopathy, chiropractor and podiatry)
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100% of Scheme Tariff* -
Collectively limited to R3 753 per family per annum -
Medicine dispensed limited to Acute Medication Limit
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100% of Scheme Tariff* -
Collectively limited to R3 625 per family per annum
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100% of Scheme Tariff* -
R1 701 per beneficiary limited to R2 820 per family -
per annum
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Subject to pre-authorisation -
100% of Negotiated Tariff* -
Limited to R14 007 per family per annum -
Stoma Care – Subject to a sub limit of R7 225 per family per annum -
Wheelchairs – one claim per Beneficiary every 36 months subject to pre-authorisation. -
Hearing aids – one claim per beneficiary every 24 months subject to pre-authorisation -
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* -
R2 948 per beneficiary, Limited to R7 412 per Family
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Subject to PMB’s and State/Public Facilities protocals -
100% of Scheme Tariff*
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Subject to PMBs, pre-authorisation and protocols -
100% of Negotiated Tariff* -
Subject to combined limit of a maximum period of 14 days per annum, except for PMBs
MATERNITY BENEFITS
Maternity Visit/s
Maternity Ultrasound/s
Home Delivery
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Limited to R5 826 / 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