BASIC AND ADVANCED RADIOLOGY OUT OF HOSPITAL MUST BE PERFORMED BY A REGISTERED RADIOLOGIST, ON REFERRAL FROM MEDICAL PRACTITIONER ONLY. ADVANCED SCANS SUBJECT TO PRE-AUTHORISATION 100% CBT 100% CBT 100% CBT Subject to Medical Savings Account 100% CBT limited to R 3 030 per beneficiary Basic Radiology - as per protocols (including Mammograms for females of 40+) Referrals by DSP or specialist, 100% CBT limited to R 3 030 per beneficiary PATHOLOGY OUT OF HOSPITAL PERFORMED BY A REGISTERED PATHOLOGIST AND REFERRED BY A MEDICAL PRACTITIONER 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate Subject to Medical Savings Account 100% CBT limited to R 4 440 per beneficiary Basic Pathology - as per protocols referred by DSP or specialist, 100% CBT, limited to R 4 810 per beneficiary POST-HOSPITALISATION CONSULTATIONS AND TREATMENT UP TO 90 DAYS 300% CBT for attending practitioners 100% CBT for auxiliary services 300% CBT for attending practitioners 100% CBT for auxiliary services 300% CBT for attending practitioners 100% CBT for auxiliary services Subject to Medical Savings Account No Benefit No Benefit MEDICATION FOR ADDITIONAL CHRONIC CONDITIONS (SUBJECT TO PRE-AUTHORISATION) REFER TO ADDITIONAL CHRONIC CONDITIONS LIST 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT 100% SEP plus a dispensing fee, subject to RP and DSP Consultations 100% CBT Subject to Medical Savings Account No Benefit except for Depression No Benefit EXTERNAL APPLIANCES IN AND OUT OF HOSPITAL PURCHASE, HIRE AND MAINTENANCE HEARING AIDS - 1 CLAIM PER 3 YEAR CYCLE FOR OVER 16 YEARS OF AGE YOUNGER THAN 16 YEARS OF AGE - 18 MONTH CYCLE WHEELCHAIRS - 3 YEAR CYCLE INSULIN PUMPS, SUBJECT TO PRE-AUTHORISATION - 4 YEAR CYCLE 100% of cost subject to the overall limit of R 58 400 per beneficiary and subject to the following sub-limits: Hearing Aids: R 58 400 Wheelchairs for Quadriplegics: R 58 400 Standard Wheelchairs: R 35 000 Insulin Pumps: R 35 000 Other external appliances: R 11 700 • Baby Apnoea monitors: R 1 800 • Breast pumps: R 3 000 100% of cost subject to the overall limit of R 46 700 per beneficiary and subject to the following sub-limits: Hearing Aids: R 46 700 Wheelchairs for Quadriplegics: R 46 700 Standard Wheelchairs: R 29 800 Insulin Pumps: R 30 400 Other external appliances: R 9 950 • Baby Apnoea monitors: R 1 800 • Breast pumps: R 3 000 100% of cost subject to the overall limit of R 26 900 per beneficiary and subject to the following sub-limits: Hearing Aids: R 23 300 Wheelchairs for Quadriplegics: R 23 300 Standard Wheelchairs: R 16 400 Insulin Pumps: R 26 900 Other external appliances: R 5 850 • Baby Apnoea monitors: R 1 800 • Breast pumps: R 3 000 Subject to Medical Savings Account 100% of cost in hospital and 80% of cost out of hospital with an overall limit of R 11 800 per beneficiary and subject to the following sub-limits: • Baby Apnoea monitors: R 1 600 • Breast pumps: R 2 700 100% of cost limited of R 4 500 per beneficiary and subject to DSP referral and subject to the following sub-limits: • Baby Apnoea monitors: R 1 600 • Breast pumps: R 2 700 NETCARE 911 EMERGENCY SERVICES Unlimited Subject to Netcare 911 authorisation Unlimited Subject to Netcare 911 authorisation Unlimited Subject to Netcare 911 authorisation Unlimited Subject to Netcare 911 authorisation Unlimited Subject to Netcare 911 authorisation Unlimited Subject to Netcare 911 DAY TO DAY BENEFITS BENEFITS BELOW ARE SUBJECT TO THE OVERALL ANNUAL LIMIT Annual Overall Limits Adult R 22 100 Child R 14 200 Annual Overall Limits Adult R 8 650 Child R 6 050 No Benefit Limited to funds available in the beneficiary’s Medical Savings Account Annual overall limit: Beneficiary specific limits: (a) Medicines R 2 160 (b) Advanced Dentistry R 4 670 (c) Other R 2 160 GP’S, SPECIALISTS AND DENTISTS CONSULTATIONS, PROCEDURES AND RADIOLOGY PERFORMED BY THESE PRACTITIONERS; BASIC DENTISTRY 80% CBT 80% CBT No Benefit Subject to Medical Savings Account 80% CBT Subject to limit (c) General practitioner consultations: 10 per beneficiary through a DSP Specialist consultations: 100% CBT limited to R 6 870 per family, only on referral from your network GP Basic dentistry: 100% Scheme Tariff at network provider only ACUTE MEDICATION INCLUDING INJECTIONS AND MATERIALS 80% SEP plus a dispensing fee 80% SEP plus a dispensing fee No Benefit Subject to Medical Savings Account 80% SEP plus a dispensing fee, subject to MMAP. Subject to limit (a) 100% SEP plus a dispensing fee for basic formulary and 80% SEP plus dispensing fee for extended formulary, both subject to MMAP NON-DSP VISITS TO DOCTORS’ ROOMS Not applicable Not applicable Not applicable Not applicable Not applicable One non-network visit per beneficiary or two per family, 20% co-payment AND One casualty visit (facility fee, consumed meds and materials). Limited to R 1 120 CASUALTY AND OUT PATIENT TREATMENT AT A HOSPITAL ALL MEDICATIONS WILL BE PAID OUT OF ACUTE MEDICATION BENEFIT 80% CBT 80% CBT No Benefit Subject to Medical Savings Account Medication: 80% SEP plus a dispensing fee subject to limit (a) Treatment: 80% CBT subject to limit (c) HOME NURSING 80% CBT up to 21 days 80% CBT up to 21 days No Benefit Subject to Medical Savings Account 80% CBT subject to limit (c) No Benefit AUXILIARY HEALTH AUDIOLOGY, CHIROPRACTORS, DIETICIANS, HOMOEOPATHS, OCCUPATIONAL THERAPY, PHYSIOTHERAPISTS, PODIATRY AND SPEECH THERAPY 80% CBT 80% CBT No Benefit Subject to Medical Savings Account 80% CBT subject to sub-limit R 1 180 Subject to limit (c) Occupational therapy and physiotherapy only 100% CBT limited to R 1 870 per beneficiary on referral from DSP only BENEFIT SPECIFIC LIMITS ADVANCED DENTISTRY CROWNS, BRIDGES, ORTHODONTICS, DENTURES 80% CBT limited to: Mo R 11 700 M1 R 17 500 M2+ R 21 000 Subject to Annual Benefits 80% CBT limited to: Mo R 8 650 M1 R 12 500 M2+ R 16 900 Subject to Annual Benefits No Benefit Subject to Medical Savings Account 50% CBT Subject to limit (b) excluding dental implants 100% of CBT at network provider only, limited to R 2 690 per beneficiary OVER THE COUNTER MEDICATION 80% SEP plus a dispensing fee, limited to R 2 920 per beneficiary 80% SEP plus a dispensing fee, limited to R 1 290 per beneficiary No Benefit Subject to Medical Savings Account 80% SEP plus a dispensing fee, subject to MMAP, limited to R 1 240 per beneficiary. Subject to limit (a) 80% SEP plus a dispensing fee, subject to MMAP, limited to R760 per beneficiary LASER K NO APPROVAL FOR SURGERY WHERE SPECTACLES OBTAINED IN PREVIOUS 12 MONTHS 80% CBT limited to R 8 750 per eye 80% CBT limited to R 3 250 per eye No Benefit Subject to Medical Savings Account No Benefit No Benefit ANTE-NATAL FOETAL SCANS PER PREGNANCY 6 Scans at 80% CBT 4 Scans at 80% CBT No Benefit Subject to Medical Savings Account 3 scans at 80% CBT. Subject to limit(c) 3 scans at 80% CBT ANTE-NATAL CLASSES SUBJECT TO ENROLMENT ON THE MOTHER-TO-BE PROGRAMME 80% CBT limited to R 1 750 per pregnancy 80% CBT limited to R 1 290 per pregnancy No Benefit Subject to Medical Savings Account 80% CBT subject to sub-limit R 770 Subject to limit (c) No Benefit SPECTACLES AND LENSES FROM OPTOMETRIST ONLY ANNUAL BENEFIT, UNLESS OTHERWISE STATED Consultation: See Preventative Wellness Add ons R 930 Single vision R 1 170 OR Bifocal R 2 340 OR Varifocal R 3 520 AND Frames R 4 650 OR Contact lenses R 5 850 Lenses, frames etc 80% Optical Assistant Rates Consultation: See Preventative Wellness Add ons R 760 Single vision R 760 OR Bifocal R 2 060 OR Varifocal R 3 160 AND Frames R 2 110 OR Contact lenses R 2 920 Lenses, frames etc 80% Optical Assistant Rates Consultation: Part of Preventative Wellness Subject to Medical Savings Account HOSPITAL ACCOMMODATION INCLUDING CONFINEMENTS, SUBJECT TO PRE-AUTHORISATION 100% of Negotiated Rate in general ward and specialised units. Private ward for confinements (subject to availability) 100% of Negotiated Rate in general ward and specialised units 100% of Negotiated Rate in general ward and specialised units 100% of Negotiated Rate in general ward and specialised units 100% of Negotiated Rate in general ward and specialised units 100% DSP tariff as per protocols ATTENDING DOCTORS AND SPECIALISTS CONSULTATIONS MEDICAL AND SURGICAL PROCEDURES INCLUDING CONFINEMENTS Up to 300% CBT 100% of Scheme Rate Up to 300% CBT 100% of Scheme Rate Up to 300% CBT 100% of Scheme Rate Up to 200% CBT 100% of Scheme Rate Up to 100% CBT 100% CBT Up to 100% CBT 100% CBT AUXILIARY HEALTHCARE IN HOSPITAL (EG. PHYSIOTHERAPY AND PSYCHOTHERAPY) 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT Physiotherapy limited to R 8 700 per family BLOOD TRANSFUSIONS (IN AND OUT OF HOSPITAL) 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost RADIOLOGY IN HOSPITAL ADVANCED SCANS SUBJECT TO PRE-AUTHORISATION 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT limited to R 23 600 per beneficiary - in or out of hospital 100% CBT 100% CBT limited to R 26 000 per family - in or out of hospital PATHOLOGY IN HOSPITAL 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% CBT 100% CBT INTERNAL PROSTHESIS SUBJECT TO PRE-AUTHORISATION 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost 100% of cost limited to R 26 000 per family HOME NURSING UP TO 21 DAYS, SUBJECT TO PRE- AUTHORISATION 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT 100% CBT (in lieu of hospitalisation only) STEP DOWN APPROVED FACILITIES ONLY, UP TO 90 DAYS SUBJECT TO PRE-AUTHORISATION 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% Negotiated Rate 100% DSP Tariff MEDICATION IN HOSPITAL 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee TTO MEDICATION UP TO ONE WEEK’S SUPPLY 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee 100% SEP plus dispensing fee INFERTILITY TREATMENT Treatment limited to R 58 400 per family Treatment limited to R 40 900 per family No benefit No benefit No benefit No benefit SUBSTANCE ABUSE PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days PMB applied to hospital based treatment and limited to one rehabilitation treatment per beneficiary per year, subject to pre-authorisation and limited to 21 days CHRONIC PMB CDL MEDICATION AND TREATMENT - SUBJECT TO PRE- AUTHORISATION AND PROTOCOLS REFER TO CHRONIC DISEASE LIST 100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) 100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) 100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) 100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) 100% SEP plus a dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) 100% SEP plus a dispensing fee, subject to MMAP and based on a formulary and DSP (Consultations and procedures - at cost) PMB DTP TREATMENT OUT OF HOSPITAL TREATMENT SUBJECT TO REGISTRATION OF CONDITION AND PRE-AUTHORISATION Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) Medication - SEP plus dispensing fee, subject to RP and DSP. (Consultations and procedures - at cost) CAMAF LIFESTYLE PROGRAMME PER ADULT BENEFICIARY ONE GP CONSULTATION ONLY ICD 10 CODE SPECIFIC TO GENERAL CHECK UP ONLY 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary Refer to GP, Specialist and Dentist under Other Benefits ONE SPECIALIST CONSULTATION *ICD 10 CODE SPECIFIC TO GENERAL CHECK UP ONLY. GYNAECOLOGISTS, UROLOGISTS, OR SPECIALIST PHYSICIANS FOR BENEFICIARIES OVER 16 YEARS. PAEDIATRICIAN FOR BENEFICIARIES UNDER 16 YEARS. 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary Refer to GP, Specialist and Dentist under Other Benefits PSYCHOTHERAPY SUBJECT TO REGISTRATION ON EMOTIONAL WELLNESS PROGRAMME 100% CBT limited to R 8 100 per beneficiary 100% CBT limited to R 8 100 per beneficiary 100% CBT limited to R 8 100 per beneficiary 100% CBT limited to R 8 100 per beneficiary 80% CBT limited to R 7 000 per beneficiary 100% CBT for PMB DTP conditions, in or out of hospital DIETICIAN CONSULTATION One per beneficiary per annum 100% CBT One per beneficiary per annum 100% CBT No Benefit Subject to Medical Savings Account No Benefit No Benefit ONE DENTISTRY CONSULTATION GENERAL CHECK UP ONLY 100% CBT per beneficiary 100% CBT per beneficiary 100% CBT per beneficiary Subject to Medical Savings Account 80% CBT per beneficiary Refer to GP, Specialist and Dentist under Other Benefits ECG (PERFORMED BY GP OR SPECIALIST PHYSICIAN) *ICD 10 CODE SPECIFIC TO GENERAL CHECK UP ONLY *Refer to website for relevant ICD 10 codes 100% CBT per adult beneficiary 100% CBT per adult beneficiary 100% CBT per adult beneficiary Subject to Medical Savings Account 80% CBT per adult beneficiary Refer to GP, Specialist and Dentist under Other Benefits ONE CONSULTATION AT AN OPTOMETRIST 100% Optical Assistant Rates 100% Optical Assistant Rates 100% Optical Assistant Rates Subject to Medical Savings Account Refer to spectacle and lenses benefits Refer to spectacle and lenses benefits METABOLIC SCREENING FOR NEW BORN BABIES 100% Negotiated Rate per new born baby 100% Negotiated Rate per new born baby 100% Negotiated Rate per new born baby Subject to Medical Savings Account 80% Negotiated Rate per new born baby No Benefit IMMUNISATION (COST OF IMMUNISATION ONLY) SEP plus a dispensing fee, limited to R 3 520 per beneficiary SEP plus a dispensing fee, limited to: Adults R 1 750 - Child R 2 920 SEP plus a dispensing fee, limited to R 1 170 per beneficiary SEP plus a dispensing fee, limited to R 1 170 per beneficiary. SEP plus a dispensing fee, subject to MMAP, limited to R 1 170 per beneficiary SEP plus a dispensing fee, subject to MMAP, limited to R 1 170 per beneficiary CERVICAL CANCER VACCINE (COST OF VACCINE ONLY) Females between 9 and 16 years of age (SEP plus dispensing fee) Females between 9 and 16 years of age (SEP plus dispensing fee) Females between 9 and 16 years of age (SEP plus dispensing fee) Females between 9 and 16 years of age (SEP plus dispensing fee) Females between 9 and 16 years of age (SEP plus dispensing fee) Females between 9 and 16 years of age (SEP plus dispensing fee) SCREENING SCANS SUCH AS BONE DENSITOMETRY AND MAMMOGRAMS AT PROVIDERS WHO ARE NOT RADIOLOGISTS 100% of CBT limited to R 1 500 per beneficiary 100% of CBT limited to R 1 200 per beneficiary No Benefit Subject to Medical Savings Account No Benefit No Benefit