Accommodation (hospital stay) and theatre fees

100% Scheme tariff.

Take-home medicine

100% Scheme tariff. Limited to 7 days' medicine

Biological medicine during hospitalisation

Limited to R27 746 per family per annum. Subject to pre-authorisation and funding guidelines.

Treatment in mental health clinic

100% Scheme tariff. Limited to 21 days per beneficiary

Treatment of chemical and substance abuse

100% Scheme tariff. Limited to 21 days or R37 352 per beneficiary. Subject to network facilities.

Consultations and procedures

100% Scheme tariff.

Surgical procedures and anaesthetics

100% Scheme tariff.

Organ transplants

100% Scheme tariff. (PMBs only)

Stem cell transplants

100% Scheme tariff. (PMBs Only). 

Major medical maxillo-facial surgery strictly related to certain conditions

100% Scheme tariff.  Limited to R15 244 per family per annum.

Dental and oral surgery (In- or out of hospital)

Limited to R11 673 per family.

Prosthesis (Subject to preferred provider, otherwise limits and co-payments apply)

100% Scheme tariff. Limited to R112 478 per family per annum.

Prosthesis – Internal Note: Sub-limit subject to the overall annual prosthesis limit. *Functional: Items utilised towards treating or supporting a bodily function.

Sub-limits per beneficiary:
  *Functional R35 700   Pacemaker (dual chamber) R65 092   Vascular R68 250   Endovascular and catheter-based procedures - no benefit   Spinal incl. artificial disk R38 864   Drug-eluting stents R21 835   Mesh R14 420   Gynaecology/Urology R10 575   Lens implants R8 239 a lens per eye

Prosthesis – External

Limited to R27 053 per family. DSPs apply. Includes artificial limbs limited to one (1) limb every 60 months.

Exclusions (Limits and co-payments applicable. Preferred provider network available.)

Joint replacement surgery (except for PMBs). PMBs subject to prosthesis limits:
• Hip replacement and other major joints R39 962   • Knee replacement R53 090   • Minor joints R16 313

Breast surgery for cancer

Treatment of the unaffected (non-cancerous) breast will be limited to PMB provisions and is subject to pre-authorisation and funding guidelines.

Orthopaedic and medical appliances

100% Scheme tariff.

Pathology

100% Scheme tariff.

Basic radiology

100% Scheme tariff.

Specialised diagnostic imaging (Including MRI scans, CT scans and isotope studies)

100% Scheme tariff

Oncology

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Peritoneal dialysis and haemodialysis

100% Scheme tariff. Subject to pre-authorisation and DSPs

Confinements (Birthing)

100% Scheme tariff.

Refractive surgery and all types of procedures to improve or stabilise vision (except cataracts)

100% Scheme tariff.  Limited to R10 850 per eye. Subject to pre-authorisation and protocols.

HIV/AIDS

100% Scheme tariff. Subject to preauthorisation and DSPs

Midwife-assisted births

100% Scheme tariff

Supplementary services

100% Scheme tariff.

Alternatives to hospitalisation

100% Scheme tariff

Advanced illness benefit

100% Scheme tariff. Limited to R99 887 per beneficiary per annum. Subject to available benefit, pre-authorisation and treatment plan.

Day procedures

Day procedures performed in a day hospital by a DSP provider will be funded at 100% network or Scheme tariff. A co-payment of R2 625 will be incurred per event if a day procedure is voluntarily done by a non-DSP provider, or if the procedure is done in an acute hospital that is not a day hospital. If the provider is a DSP and does not work in a day hospital, the procedure will be paid in full if it is done in an acute hospital.

International travel cover

Leisure Travel: Limited to 45 days and R500 000 cover for travel to the USA. All other countries covered up to 90 days, with R3 million for a family i.e. member and dependants.
Business Travel: Limited to 45 days and R500 000 cover for travel to the USA. All other countries covered up to 45 days, with R3 million for a family i.e. member and dependants. 

Overall day-to-day limit

M = R14 831, M1+ = R29 661.

FP and Specialist consultations

Savings first.
Limited to M = R3 777, M1+ = R6 728 
(Subject to overall day-to-day limit)

Basic and specialised dentistry

Savings and then from day-to-day limit.
Orthodontics are subject to pre-authorisation.
Limited to M = R6 534, M1+ = R13 124.
(Subject to overall day-to-day limit)

Medical aids, apparatus and appliances

Savings first. 100% Scheme tariff. Limited to R13 321 per family. Includes repairs to artificial limbs. (Subject to overall day-to-day limit).

Hearing aids

Subject to pre-authorisation. Limited to R12 208 per family every 24 months. 100% Scheme tariff.

Supplementary services

Savings first.
Limited to M = R5 768, M1+ = R11 714.
(Subject to overall day-to-day limit)

Wound care benefit (incl. dressings, negative pressure wound therapy -NPWT- treatment and related nursing services -out-of-hospital)

Savings first. 100% Scheme tariff.
Limited to R5 768 per family.
(Subject to overall day-to-day limit)

Optometry benefit

Benefits available every 24 months from date of service.

Network Provider (PPN)
Consultation - 1 per beneficiary.
Frame = R1 000 covered AND
100% of cost of standard lenses (single vision OR bifocal OR multifocal) OR
Contact lenses = R1 840

Non-network Provider
Consultation - R383 fee at non-network provider
Frame = R750 AND
Single vision lenses = R215 OR
Bifocal lenses = R460 OR
Multifocal lenses = R982.50
In lieu of glasses members can opt for contact lenses, limited to R1 840

Basic radiology and pathology

Savings first.
Limited to M = R3 776, M1+ = R7 690.
(Subject to overall day-to-day limit)

Specialised diagnostic imaging (Including MRI scans, CT scans, isotope studies and PET scans)

100% Scheme tariff. Limited to R19 638 per family.

Managed Healthcare - Back and Neck Preventative Programme

Benefits payable at 100% of contracted fee.  Subject to pre-authorisation, protocols and DSPs.

Oncology

Oncology programme at 100% of Scheme tariff. Subject to pre-authorisation and DSP.

HIV/AIDS

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Peritoneal dialysis and haemodialysis

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Rehabilitation services after trauma

100% Scheme tariff.

CDL and PMB chronic medicine

100% Scheme tariff. Co-payment of 20% for non-formulary medicine.

Non-CDL chronic medicine

9 conditions. 90% Scheme tariff.
Limited to M = R8 748, M1+ = R17 496. Co-payment of 20% for non-formulary medicine.

Biologicals medicine

PMBs only as per funding protocol. Subject to pre-authorisation

Other high-cost medicine

100% Scheme Tariff.

Acute medicine

Savings first. Limited to M = R3 337, M1 + = R6 742 (Subject to overall day-to-day limit)

Over-the-counter (OTC) medicine

Member choice:
1. R1 110 OTC limit per family OR
2. Access to full savings for OTC purchases (after R1 110 limit) = self-payment gap accumulation. Includes suncreen, vitamins and minerals with nappi codes on Scheme formulary.
Subject to the available savings.

Accommodation (hospital stay) and theatre fees

100% Scheme tariff.

Take-home medicine

100% Scheme tariff. Limited to 7 days’ medicine.

Treatment in mental health clinic

100% Scheme tariff. Limited to 21 days per beneficiary per beneficiary

Treatment of chemical and substance abuse

100% Scheme tariff. Limited to 21 days or R37 352 per beneficiary. Subject to network facilities.

Consultations and procedures

100% Scheme tariff.

Surgical procedures and anaesthetics

100% Scheme tariff.

Organ transplants

100% Scheme tariff. (PMBs only)

Stem cell transplants

100% Scheme tariff. (PMBs Only). 

Major medical maxillo-facial surgery strictly related to certain conditions

100% Scheme tariff.

Dental and oral surgery (In- or out of hospital)

Limited to R15 518 per family.

Prosthesis (Subject to preferred provider, otherwise limits and co-payments apply)

100% Scheme tariff. Limited to R134 028 per family.

Prosthesis – Internal Note: Sub-limit subject to the overall annual prosthesis limit. *Functional: Items utilised towards treating or supporting a bodily function.

Sub-limits per beneficiary:
  *Functional R37 800   Pacemaker (dual chamber) R72 438   Vascular R68 250   Spinal incl. artificial disk R67 193   Drug-eluting stents R21 972   Mesh R21 972   Gynaecology/Urology R16 40   Lens implants R14 090 per lens per eye   Joint replacements:   Hip replacement and other major joints R60 353   Knee replacement R70 035   Other minor joints R26 022

Prosthesis – External

Limited to R31 584 per family. DSPs apply. Includes artificial limbs limited to 1 limb every 60 months.

Orthopaedic and medical appliances

100% Scheme tariff.

Pathology

100% Scheme tariff.

Basic radiology

100% Scheme tariff.

Specialised diagnostic imaging (Including MRI scans, CT scans and isotope studies. PET scans only included as indicated per option)

100% Scheme tariff

Oncology

Oncology programme. 100% of Scheme tariff. Subject to pre-authorisation and DSP.

Peritoneal dialysis and haemodialysis

100% Scheme tariff Subject to pre-authorisation and DSPs

Confinements (Birthing)

100% Scheme tariff.

Breast surgery for cancer

Treatment of the unaffected (non-cancerous) breast will be limited to PMB provisions and is subject to pre-authorisation and funding guidelines.

Refractive surgery and all types of procedures to improve or stabilise vision (except cataracts)

100% Scheme tariff. Limited to R10 848 per eye.

HIV/AIDS

100% Scheme tariff. Subject to preauthorisation and DSPs

Midwife-assisted births

100% Scheme tariff

Supplementary services

100% Scheme tariff.

Alternatives to hospitalisation

100% Scheme tariff

Advanced illness benefit

100% Scheme tariff limited to R133 182 per annum. Subject to available benefit, pre-authorisation and treatment plan.

Day procedures

Day procedures at DSPs and/or day-hospitals will be funded at 100% network or Scheme tariffs. Voluntary use of non-DSP specialists and acute hospitals will result in a co-payment of R2 625.

International travel cover

Leisure Travel: Limited to 45 days and R500 000 cover for travel to the USA. All other countries covered up to 90 days, with R3 million for a family i.e. member and dependants.
Business Travel: Limited to 45 days and R500 000 cover for travel to the USA. All other countries covered up to 45 days, with R3 million for a family i.e. member and dependants. 

Overall day-to-day limit

M = R15 750, M1+ = R31 500.

FP and Specialist consultations

Savings first.
Limited to M = R4 808, M1+ = R9 744.
(Subject to overall day-to-day limit)

Basic and specialised dentistry

Savings and then from day-to-day limit.
Limited to M = R8 009, M1+ = R16 019.
(Subject to overall day-to-day limit)

Orthodontic dentistry

Savings first. 100% Scheme tariff. Subject to pre-authorisation. Limited to R7 769 per event for beneficiaries up to 18 years of age. Subject to overall day-to-day limit.

Medical aids, apparatus and appliances

Savings first. Limited to R12 084 per family.
Includes repairs to artificial limbs.
(Subject to overall day-to-day limit)

Wheelchairs

Limited to R16 342 per family every 48 months.

Hearing aids

Limited to R33 302 per beneficiary every 24 months subject to pre-authorisation.

Supplementary services

Savings first.
Limited to M = R3 675, M1+ = R7 350.
(Subject to overall day-to-day limit)

Wound care benefit (incl. dressings, negative pressure wound therapy -NPWT- treatment and related nursing services -out-of-hospital)

Savings first. Limited to R7 535 per family.
(Subject to overall day-to-day limit)

Optometry benefit

Benefits available every 24 months from date of service.

Network Provider (PPN)
Consultation - 1 per beneficiary.
Frame = R1 040 covered AND
100% of cost of standard lenses (single vision OR bifocal OR multifocal) AND
Lens enhancement = R750 covered OR
Contact lenses = R2 010

Non-network Provider
Consultation - R365 fee at non-network provider
Frame = R780 AND
Single vision lenses = R215 OR
Bifocal lenses = R460 OR
Multifocal lenses = R982.50
Lens enhancement = R562.50 covered
In lieu of glasses members can opt for contact lenses, limited to R2 010

Basic radiology and pathology

Savings first.
Limited to M = R3 776, M1+ = R7 554.
(Subject to overall day-to-day limit)

Specialised diagnostic imaging (Including MRI scans, CT scans, isotope studies and PET scans)

MRI/CT scans: Maximum of 2 scans per beneficiary - Limited to one (1) scan of the lumbar and cervical spine region for conservative back and neck scans per beneficiary per annum. PET scan: 1 scan per beneficiary - Subject to pre-authorisation.

Managed Healthcare - Back and Neck Preventative Programme

Benefits payable at 100% of contracted fee.  Subject to pre-authorisation, protocols and DSPs.

Oncology

Oncology programme at 100% of Scheme tariff. Subject to pre-authorisation and DSP.

HIV/AIDS

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Peritoneal dialysis and haemodialysis

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Rehabilitation services after trauma

100% Scheme tariff.

CDL and PMB chronic medicine

100% Scheme tariff.
Co-payment of 20% for non-formulary medicine.

Non-CDL chronic medicine

20 conditions. 90% Scheme tariff.
Limited to M = R10 500 M1+ = R21 000. Co-payment of 20% for non-formulary medicine.

Biological medicine

Limited to R192 126 per beneficiary.

Other high-cost medicine

100% Scheme tariff.

Acute medicine

Savings first. Limited to M = R3 150, M1 + = R6 300.
(Subject to overall day-to-day limit)

Over-the-counter (OTC) medicine

Member choice:
1. R1 110 OTC limit per family OR
2. Access to full savings for OTC purchases (after R1 110 limit) = self-payment gap accumulation. Includes suncreen, vitamins and minerals with nappi codes on Scheme formulary.
Subject to the available savings.

Accommodation (hospital stay) and theatre fees

100% Scheme tariff.

Take-home medicine

100% Scheme tariff. Limited to 7 days’ medicine.

Treatment in mental health clinic

100% Scheme tariff. Limited to 21 days per beneficiary

Treatment of chemical and substance abuse

100% Scheme tariff. Limited to 21 days or R37 352 per beneficiary. Subject to network facilities.

Consultations and procedures

100% Scheme tariff.

Surgical procedures and anaesthetics

100% Scheme tariff.

Organ transplants

100% Scheme tariff. (PMBs only)

Stem cell transplants

100% Scheme tariff. (PMBs Only). 

Major medical maxillo-facial surgery strictly related to certain conditions

100% Scheme tariff.

Dental and oral surgery (In- or out of hospital)

Limited to R19 500 per family.

Prosthesis (Subject to preferred provider, otherwise limits and co-payments apply)

100% Scheme tariff. Limited to R134 715 per family.

Prosthesis – Internal Note: Sub-limit subject to the overall annual prosthesis limit. *Functional: Items utilised towards treating or supporting a bodily function.

Sub-limits per beneficiary:
  *Functional R37 800   Pacemaker (dual chamber) R72 438   Vascular R72 450   Spinal incl. artificial disk R67 321   Drug-eluting stents R21 972   Mesh R21 972   Gynaecology/Urology R16 479   Lens implants R14 090 a lens per eye
Joint replacements:   Hip replacement and other major joints R60 422   Knee replacement R70 378   Other minor joints R26 022

Prosthesis – External

Limited to R31 723 per family. DSPs apply. Includes artificial limbs limited to 1 limb every 60 months.

Orthopaedic and medical appliances

100% Scheme tariff.

Pathology

100% Scheme tariff.

Basic radiology

100% Scheme tariff.

Specialised diagnostic imaging (Including MRI scans, CT scans, isotope studies and PET scans)

100% Scheme tariff

Oncology programme

100% Scheme tariff. DSP applies. Access to extended protocols.

Peritoneal dialysis and haemodialysis

100% Scheme tariff Subject to pre-authorisation and DSPs

Confinements (Birthing)

100% Scheme tariff.

Refractive surgery and all types of procedures to improve or stabilise vision (except cataracts)

100% Scheme tariff. Limited to R11 673 per eye.

Breast surgery for cancer

Treatment of the unaffected (non-cancerous) breast will be limited to PMB provisions and is subject to pre-authorisation and funding guidelines.

HIV/AIDS

100% Scheme tariff. Subject to preauthorisation and DSPs

Midwife-assisted births

100% Scheme tariff

Supplementary services

100% Scheme tariff.

Alternatives to hospitalisation

100% Scheme tariff

Advanced illness benefit

100% Scheme tariff limited to R133 182 per annum. Subject to available benefit, pre-authorisation and treatment plan.

International travel cover

Leisure Travel: Limited to 45 days and R500 000 cover for travel to the USA. All other countries covered up to 90 days, with R3 million for a family i.e. member and dependants.
Business Travel: Limited to 45 days and R500 000 cover for travel to the USA. All other countries covered up to 45 days, with R3 million for a family i.e. member and dependants. 

Day procedures

Day procedures at DSPs and/or day-hospitals will be funded at 100%  network or Scheme tariffs. Voluntary use of non-DSP specialists and acute hospitals will result in a co-payment of R2 625.

Overall day-to-day limit

M = R21 047, M1+ = R43 496.

FP and Specialist consultations

Savings first. 100% Scheme tariff.
M = R5 082, M1+ = R10 299.
(Subject to overall day-to-day limit)

Basic and specialised dentistry

Savings first and then from day-to-day limit.
Limited to M = R8 630, M1+ = R16 089.
(Subject to overall day-to-day limit)

Orthodontic dentistry

100% Scheme tariff. Subject to pre-authorisation.
Limited to R9 989 per event for beneficiaries up to 18 years of age. Subject to overall day-to-day limit.

Medical aids, apparatus and appliances

Savings first. Limited to R12 084 per family.
Includes repairs to artificial limbs.
(Subject to overall day-to-day limit)

Wheelchairs

Limited to R16 342 per family every 48 months.

Hearing aids

Limited to R37 490 per beneficiary every 24 months subject to pre-authorisation.

Continuous/Flash Glucose Monitoring (CGM/FGM)

100% Scheme tariff. Limited to R22 197 per family per annum. Subject to pre-authorisation.

Supplementary services

Savings first.
Limited to M = R3 104, M1+ = R6 523.
(Subject to overall day-to-day limit)

Wound care benefit (incl. dressings, negative pressure wound therapy -NPWT- treatment and related nursing services -out-of-hospital)

100% Scheme tariff. Savings first.
Limited to R10 500 per family.
(Subject to overall day-to-day limit)

Optometry benefit

Benefits available every 24 months from date of service.

Network Provider (PPN)
Consultation - 1 per beneficiary.
Frame = R1 040 covered AND
100% of cost of standard lenses (single vision OR bifocal OR multifocal) AND
Lens enhancement = R750 covered OR
Contact lenses = R2 010

Non-network Provider
Consultation - R365 fee at non-network provider
Frame = R780 AND
Single vision lenses = R215 OR
Bifocal lenses = R460 OR
Multifocal lenses = R982.50
Lens enhancement = R562.50 covered 
In lieu of glasses members can opt for contact lenses, limited to R2 010

Basic radiology and pathology

Savings first.
Limited to M = R4 120, M1+ = R8 170.
(Subject to overall day-to-day limit)

Specialised diagnostic imaging (Including MRI scans, CT scans, isotope studies and PET scans)

MRI/CT scans: Maximum of 2 scans per beneficiary - Limited to one (1) scan of the lumbar and cervical spine region for conservative back and neck scans per beneficiary per annum. PET scan: 1 scan per beneficiary - Subject to pre-authorisation.

Managed Healthcare - Back and Neck Preventative Programme

Benefits payable at 100% of contracted fee.  Subject to pre-authorisation, protocols and DSPs.

Oncology

Oncology programme at 100% of Scheme tariff. Subject to pre-authorisation and DSP.
Access to extended protocols.

HIV/AIDS

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Peritoneal dialysis and haemodialysis

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Rehabilitation services after trauma

100% Scheme tariff.

CDL and PMB chronic medicine

100% Scheme tariff.
Co-payment of 15% for non-formulary medicine.

Non-CDL chronic medicine

20 conditions. 90% Scheme tariff.
Limited to M = R16 136, M1+ = R32 272. Co-payment of 15% for non-formulary medicine.

Biological medicine

Limited to R384 507 per beneficiary.

Other high-cost medicine

100% Scheme tariff.

Acute medicine

Savings first. Limited to M = R2 100, M1 + = R4 725.
(Subject to overall day-to-day limit)

Over-the-counter (OTC) medicine

Member choice:
1. R1 110 OTC limit per family OR
2. Access to full savings for OTC purchases (after R1 110 limit) = self-payment gap accumulation. Includes suncreen, vitamins and minerals with nappi codes on Scheme formulary.
Subject to the available savings.

Accommodation (hospital stay) and theatre fees

100% Scheme tariff.

Take-home medicine

100% Scheme tariff. Limited to 7 days’ medicine.

Treatment in mental health clinic

100% Scheme tariff. Limited to 21 days per beneficiary

Treatment of chemical and substance abuse

100% Scheme tariff. Limited to 21 days or R37 352 per beneficiary. Subject to network facilities.

Consultations and procedures

100% Scheme tariff.

Surgical procedures and anaesthetics

100% Scheme tariff.

Organ transplants

100% Scheme tariff.

Stem cell transplants

100% Scheme tariff. (PMBs Only). 

Major medical maxillo-facial surgery strictly related to certain conditions

100% Scheme tariff.

Dental and oral surgery (In- or out of hospital)

Limited to R23 345 per family.

Orthopaedic and medical appliances

100% Scheme tariff.

Pathology

100% Scheme tariff.

Basic radiology

100% Scheme tariff.

Specialised diagnostic imaging (Including MRI scans, CT scans and isotope studies).

100% Scheme tariff

Prosthesis (Subject to preferred provider, otherwise limits and co-payments apply)

100% Scheme tariff. Limited to R155 450 per family.

Prosthesis – Internal Note: Sub-limit subject to the overall annual prosthesis limit. *Functional: Items utilised towards treating or supporting a bodily function.

Sub-limits per beneficiary:
  *Functional R42 000   Pacemaker (dual chamber) R72 438   Vascular R72 450   Spinal incl. artificial disk R77 732   Drug-eluting stents R25 886   Mesh R22 796   Gynaecology/Urology R18 814   Lens implants R20 832 per lens per eye
Joint replacements:   Hip replacement and other major joints R69 555   Knee replacement R80 540   Other minor joints R25 886

Prosthesis – External

Limited to R35 842 per family per annum. DSPs apply. Includes artificial limbs limited to 1 limb every 60 months.

Oncology

Oncology programme. 100% of Scheme tariff.  Subject to pre-authorisation and DSP. Access to extended protocols.

Peritoneal dialysis and haemodialysis

100% Scheme tariff Subject to pre-authorisation and DSPs

Confinements (Birthing)

100% Scheme tariff.

Refractive surgery and all types of procedures to improve or stabilise vision (except cataracts)

100% Scheme tariff. Limited to R11 673 per eye.

Breast surgery for cancer

Treatment of the unaffected (non-cancerous) breast will be limited to PMB provisions and is subject to pre-authorisation and funding guidelines.

Medically necessary breast reduction surgery (Including fees for the surgeon and anaesthetist)

100% Scheme tariff. R55 493 per family per annum (for surgeon and anaesthetist). Theatre and hospital cost will be funded from Scheme risk. Subject to funding protocols, pre-authorisation.

HIV/AIDS

100% Scheme tariff. Subject to pre-authorisation and DSPs

Midwife-assisted births

100% Scheme tariff

Supplementary services

100% Scheme tariff.

Alternatives to hospitalisation

100% Scheme tariff

Advanced illness benefit

100% Scheme tariff Limited to R133 182 per annum. Subject to available benefit, pre-authorisation and treatment plan.

Day procedures

Day procedures at DSPs and/or day-hospitals will be funded at 100% network or Scheme tariffs. Voluntary use of non-DSP specialists and acute hospitals will result in a co-payment of R2 625.

International travel cover

Leisure Travel: Limited to 45 days and R500 000 cover for travel to the USA. All other countries covered up to 90 days, with R3 million for a family i.e. member and dependants.
Business Travel: Limited to 45 days and R500 000 cover for travel to the USA. All other countries covered up to 45 days, with R3 million for a family i.e. member and dependants.

Overall day-to-day limit

M = R41 472, M1+ = R66 878.

FP and Specialist consultations

Limited to M = R6 523, M1+ = R10 575.
(Subject to overall day-to-day limit)

Basic and specialised dentistry

Limited to M = R14 403, M1+ = R24 310.
(Subject to overall day-to-day limit)

Orthodontic dentistry

100% Scheme tariff. Subject to preauthorisation.
Limited to R12 208 per event for beneficiaries up to 18 years of age.

Medical aids, apparatus and appliances

Limited to R12 084 per family. 
Includes repairs to artificial limbs. 
(Subject to overall day-to-day limit)

Wheelchairs

Limited to R16 342 per family every 48 months.

Hearing aids

Limited to R41 746 per beneficiary every 24 months subject to pre-authorisation.

Insulin pump (excluding consumables)

100% Scheme tariff.
Limited to R48 572 per beneficiary every 24 months.
Subject to pre-authorisation.

Continuous/Flash Glucose Monitoring (CGM/FGM)

100% Scheme tariff. Limited to R27 746 per family per annum. Subject to pre-authorisation.

Supplementary services

Limited to M = R6 523, M1+ = R12 839.
(Subject to day-to-day overall limit)

Wound care benefit (incl. dressings, negative pressure wound therapy -NPWT- treatment and related nursing services -out-of-hospital)

Limited to R15 930 per family.
(Subject to overall day-to-day limit)

Optometry benefit

Benefits available every 24 months from date of service.

Network Provider (PPN)
Consultation - 1 per beneficiary.
Frame = R1 040 covered AND
100% of cost of standard lenses (single vision OR bifocal OR multifocal) AND
Lens enhancement = R750 covered OR
Contact lenses = R2 375

Non-network Provider
Consultation - R365 fee at non-network provider
Frame = R780 AND
Single vision lenses = R215 OR
Bifocal lenses = R460 OR
Multifocal lenses = R982.50
Lens enhancement = R562.50 covered
In lieu of glasses members can opt for contact lenses, limited to R2 375

Basic radiology and pathology

Limited to M = R6 523, M1+ = R12 839.
(Subject to overall day-to-day limit)

Specialised diagnostic imaging (Including MRI scans, CT scans, isotope studies and PET scans)

MRI/CT scans: Maximum of 2 scans per beneficiary - Limited to one (1) scan of the lumbar and cervical spine region for conservative back and neck scans per beneficiary per annum. PET scan: 1 scan per beneficiary - Subject to pre-authorisation.

Managed Healthcare - Back and Neck Preventative Programme

Benefits payable at 100% of contracted fee.  Subject to pre-authorisation, protocols and DSPs.

Oncology

Oncology programme at 100% of Scheme tariff. Subject to pre-authorisation and DSP.
Access to extended protocols.

HIV/AIDS

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Peritoneal dialysis and haemodialysis

100% Scheme tariff. Subject to pre-authorisation and DSPs.

Rehabilitation services after trauma

100% Scheme tariff.

CDL and PMB chronic medicine

100% Scheme tariff.
Co-payment of 10% for non-formulary medicine.

Non-CDL chronic medicine

29 conditions. 100% Scheme tariff.
Limited to M = R23 000, M1+ = R46 209. Co-payment of 10% for non-formulary medicine.

Biological medicine

Limited to R569 070 per beneficiary.

Other high-cost medicine

100% Scheme tariff.

Acute medicine

Limited to M = R9 809, M1+ = R15 237.
10% co-payment.
(Subject to overall day-to-day limit)

Over-the-counter (OTC) medicine

Subject to available savings.