2019 OPTION OVERVIEW

OPTION ESSENTIAL CUSTOM HOSPICARE HOSPICARE NETWORK CLASSIC CLASSIC NETWORK OPTIMUM
Option Type Capitation
PMB exempt
Capitation
PMB exempt
Prescribed Minimum Benefit Prescribed Minimum Benefit Comprehensive care with Savings Comprehensive care with Savings Traditional comprehensive care
IN HOSPITAL BENEFITS: SUBJECT TO PRE-AUTHORISATION AND SCHEME PROTOCOLS
Public Hospital
Private Hospital limits Stabilisation only M: R295 380
M+: R519 100
Unlimited Any Unlimited Unlimited Any Unlimited Unlimited Any
Hospital Network:
30% co-payment for use of Non-Network Hospital
Life Health Care Life Health Care Life Health Care
Medicine to Take Out
7 day's supply per event
Internal Prosthesis limit per family per annum R8 590 R14 310 PMB only PMB only R33 516 R33 516 R39 498
External Prosthesis limit per family per annum R5 720 R 9 540 R22 344 R22 344 R26 332
Oncology Generic reference pricing applies
Non-PMB Limits per family
R66 240 PMB only PMB only R500 000
20% co-pay once limit reached
R500 000
20% co-pay once limit reached
Unlimited
Reconstructive Surgery
Non-PMB Limits per family
PMB only PMB only R61 520 R61 520 R61 520
Organ and Tissue Transplant
Non-PMB limits per family
PMB only PMB only R61 520 R61 520 R61 520
Rehabilitation: Alcohol and Drug SANCA approved facility PMB only PMB only
Mental Health R21 090 PMB only PMB only
Refractive Eye Surgery
Once per beneficiary per lifetime
Per eye: R 5 300 Both eyes: R10 600 Per eye: R 5 300 Both eyes: R10 600 Per eye: R 5 300 Both eyes: R10 600
Scans
MRI, CAT, Radio-Isotope
PMB only PMB only
Alternate Care In-lieu of hospitalisation Up to 30 days per event per beneficiary R19 920 per family PMB only PMB only R33 130 R33 130 R37 470
Ambulance Services
Emergency Road and/or air
Road only Road only
CHRONIC MEDICINE BENEFITS: REGISTRATION REQUIRED; MEDICINE FORMULARIES APPLY; 20% CO-PAYMENT APPLIED FOR NON-FORMULARY MEDICINE
Network Pharmacies
30% co-pay for non-network
Chronic Disease List (CDL) Conditions covered 5 25 26 26 26 26 26
Non-CDL conditions covered 10 10 28
Non CDL Limits M: R4 300
M+1: R8 400
M+2: R10 500
M+3: R11 500
M+4: R13 000
M+5+: R15 000
M: R4 300
M+1: R8 400
M+2: R10 500
M+3: R11 500
M+4: R13 000
M+5+: R15 000
M: R6 000
M+1: R12 000
M+2: R13 000
M+3: R15 000
M+4: R16 500
M+5+: R17 500
OUT OF HOSPITAL BENEFITS
Network Providers
Day-to- Day Benefits (D2D) M: R25 220
M+1: R 35 130
M+2: R40 660
M+3+: R47 740
Annual Savings Limits (ASL) Member: R7 286
Adult: R6 196
Child: R1 820
Member: R6 228
Adult: R5 304
Child: R1 560
Acute medication
Over the Counter
Limits and formulary apply
M: 3 scripts
M+: 5 scripts
M: 5 scripts
M+: 7 scripts
R190 per event 190 per event R190 per event
General Practitioners Unlimited Unlimited From ASL From ASL From D2D Limits
Specialists M: R3 570
M+: R7 150
From ASL From ASL From Day2D Limits
Scans:
MRI, CAT, Radio-Isotope Per beneficiary
R2 530 subject to Specialist limit 2 from risk thereafter from ASL 2 from risk thereafter from ASL 2 from risk thereafter from D2D Limits
Basic Dentistry From ASL From ASL M: R2 230
M+: R4 480 and From D2D Limits
Specialised Dentistry
Specialised Dentistry Limits
1 set of plastic dentures per Adult beneficiary every 2 years From ASL From ASL M: R12 960
M+: R19 330 and From D2D Limits
Optometry: Per Beneficiary
Annual Eye test From ASL From ASL From D2D Limits
1 Frame & 2 lenses every 24 months Frame: R185 Frame: R185 Frame: R780 Frame: R780 Frame: R1 230
Contact Lenses in Lieu of glasses Contact Lenses: R480 Contact Lenses: R480 Contact Lenses: R1 530 Contact Lenses: R1 530 Contact Lenses: R2 280
Auxiliary
Auxiliary Limits
From ASL From ASL M : R 4 890
M+1: R14 610 and from D2D limits
ADDITIONAL BENEFITS: NOT FROM DAY TO DAY OR SAVINGS
Medical and Surgical Appliances Limit per family R2 480 R6 610 PMB only PMB only R12 627 R12 627 R9 500
Sub Limits:
Glucometer (per beneficiary every 2 years) R750 R750 R750 R750 R750
Nebuliser (per family every 3 years) R750 R750 R750 R750 R750
Hearing Aid Maintenance (per beneficiary per annum) R1000 R1000 R1000
Hearing Aids PMB only PMB only From Medical and Surgical limit above From Medical and Surgical limit above Unilateral: R11 085
Bilateral: R22 170
Maternity Programme From Network Providers From Network Providers 12 Ante Natal Visits
2 x 2D scans
3D or 4D scans paid at 2D scan rate
2 Paediatric visits Pregnancy Vitamins
12 Ante Natal Visits
2 x 2D scans
3D or 4D scans paid at 2D scan rate
2 Paediatric visits Pregnancy Vitamins
12 Ante Natal Visits
2 x 2D scans
3D or 4D scans paid at 2D scan rate
2 Paediatric Visits Pregnancy Vitamins
12 Ante Natal Visits
2 x 2D scans
3D or 4D scans paid at 2D scan rate
2 Paediatric Visits Pregnancy Vitamins
12 Ante Natal Visits
2 x 2D scans
3D or 4D scans paid at 2D scan rate
2 Paediatric Visits Pregnancy Vitamins
7 Non PMB Procedures
Preventative Care/ Health maximiser For members identified as high risk and subject to GP referral Baby Immunisations (as per DOH)
Bone density scan
Cholesterol test Mammogram
PSA blood test
Tetanus Injection
Baby Immunisations (as per DOH)
Bone density scan
Cholesterol test Mammogram
PSA blood test
Tetanus Injection
Baby Immunisations (as per DOH)
Bone density scan
Cholesterol test Mammogram
PSA blood test
Tetanus Injection
ER MADE EASY
R1000 Per beneficiary
Patient Care Programs
Such as Oncology, Diabetes, HIV
Wellness