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CUSTOM OPTION

Targeted at young and healthy members, this plan is a network option that has an overall annual hospital limit and sub-limits for associated providers. Access to unlimited day to day benefits. Cover for comprehensive pre- and post-natal health services for maternity and early childhood. 25 chronic conditions are covered subject to use of our formulary and designated service provider. This option includes separate cover for Over the Counter medicines (OTC).

MONTHLY CONTRIBUTION

SALARY BANDMEMBERADULTCHILD
R0 – R3 200R938R753R235
R3 201 – R5 800R985R787R246
R5 801 – R8 500R1 078R865R271
R8 501 – R10 500R1 237R990R310
R10 501 +R1 717R1 375R429

DESIGNATED SERVICE PROVIDERS (DSPs)

MHC’s philosophy is to provide quality, comprehensive healthcare while maintaining affordable contributions. In order to strike the necessary balance to achieve our philosophy, it is necessary to introduce DSPs. In this way, MHC can contain spiralling healthcare costs but nevertheless ensure that members receive the most appropriate treatment.

Members may choose not to use the DSP but will be liable for any co-payment over and above what is charged by the DSP.

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View the Chronic Conditions covered by the Custom Option

Click here to look up your Medication Formulary

View the Chronic Conditions covered by the Custom Option

OUT-OF-HOSPITAL BENEFITS

Not sure what we mean? Refer to glossary.

PRIMARY CARE NETWORK ONLY
General practitioners (GPs) Unlimited at the primary care network service provider
Specialists

M = R3 570
M+ = R7 150
Subject to network GP referral, pre-authorisation and managed care/Scheme protocols

Medicines  
Acute Unlimited at the primary care network service provider - subject to network formulary
Over the counter (OTC) Single member = 5 prescriptions
Family = 7 prescriptions
Chronic 25 conditions (see page 12 of benefit guide)
Subject to primary network service provider protocols
No benefit if a non-network provider is used
Optometry
Optical benefit available per beneficiary every 24 months
1 optical test per beneficiary per year
1 pair of clear, standard mono- or bifocal lenses in a standard frame
OR
Contact lenses to the value of R480
R185 towards a frame outside the standard range
Dentistry
Basic - per beneficiary per annum
Per beneficiary per annum:
• one dental examination
• scaling
• eight primary extractions
• eight fillings
• polishing
Specialised Per adult beneficiary – 1 set of acrylic dentures every 24 months
MRI, CT, PET and radio isotope scans Sub-limit per beneficiary = R2 530, subject to specialist limit
External prostheses R9 540 per family per annum. Subject to clinical protocols
Medical and surgical appliances (in- and out-of-hospital) The following appliances are subject to the annual limit of R6 610 per family
Glucometers R750 per beneficiary every 2 years
Nebulisers R750 per family every 3 years
Other Appliances – once every 4 years Subject to clinical protocols
ADDITIONAL BENEFITS
Maternity Antenatal care from the primary care provider
2x 2D Scans per pregnancy. 3D and 4D scans are paid up to the rate of 2D scans
Out-of-area or emergency visits Per family = three visits to a maximum of R1 000
Patient care programmes
(Diabetes, HIV, oncology)
Subject to registration and managed care protocols

IN-HOSPITAL BENEFITS

Overall Annual Limit (OAL) Single member = R295 380
Family = R519 100
All services are subject to pre-authorisation and managed care protocols
Public hospital Unlimited treatment in accordance with Scheme and state protocols
Private hospital Subject to the overall annual limit and use of the Scheme network hospitals
Network hospital: Life Healthcare A 30% co-payment will be applied for voluntary use of a non-network provider
GPs and specialists Unlimited treatment in accordance with Scheme protocols and use of Network Providers
Admission to private hospital subject to overall annual limit
Claims paid up to the agreed rate with the provider
To-take-out medicine Up to 7 days
Internal Prostheses Per family per annum = R14 310 where approved during hospital admission
Alternate care instead of hospitalisation Per family = 30 days to a maximum of R19 920
Mental health (in and out of hospital) Subject to the overall annual limit and up to a sub-limit of R21 090
Subject to clinical protocols
Alcohol and drug rehabilitation 100% of the negotiated rate, at a South African National Council on Alcoholism and Drug
Dependence (SANCA)-approved facility, subject to the mental health sub-limit
Oncology Per family = R66 240, subject to overall annual limit
Pathology Per beneficiary = R6 950, subject to overall annual limit
Radiology Per beneficiary = R6 950, subject to overall annual limit
Medical and surgical appliances
(in and out of hospital)
Per family = R6 610, subject to overall annual limit
Maternity Confinement:
Public hospital – Treatment in accordance with Scheme protocols
Private hospital – Subject to private overall annual limit and use of the hospital network
providers
Ambulance Emergency road transport only

This option is exempt from PMBs. Terms and conditions apply including specific exclusions.