Plus Option
Day-to-day Benefits
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Effective 1 January 2024
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Members and their dependants are entitled to the following benefits, subject to the provisions of the rules of the Scheme, and in particular the provisions of the statutory Prescribed Minimum Benefits (PMBs).
This summary is for information purposes only and does not supersede the rules of the Scheme. In the event of any discrepancy, the rules will prevail.
Medical Spending AccountMembers have a Medical Spending Account (MSA), which is used to pay for day-to-day benefits. The amount available in the MSA is in addition to the insured benefit.
Benefits | Description | |
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General practitioners (GPs) and visits (out of hospital) Consultations and visits, including clinical psychology and psychiatric consultations (excluding educational counselling) |
Subject to MSA balance | 150% of Scheme Rate |
Hello Doctor General practitioner video consultations | Subject to MSA balance Once MSA is depleted, 2 Hello Doctor consultations per family will be paid from Insured Benefits. This does not include any associated claims prescribed or referred by the HelloDoctor provider. |
100% of Agreed Rate |
Specialists | Subject to MSA balance | 100% of the Agreed Rate at a Preferred Provider Specialist 155% of Scheme Rate at a non-Preferred Provider Specialist. Co-payments may apply at a non-Preferred Provider |
Clinical psychology (excluding educational counselling) Non-PMB services |
Subject to MSA balance | 150% of Scheme Rate |
Psychiatric consultations (PMB conditions only) | Subject to registration on the Mental Wellness Programme, in which case an appropriate treatment plan based on clinical protocols may be issued; benefit will be paid from the MSA if not registered on the Mental Wellness Programme | 100% of agreed rate at preferred provider 155% of Scheme rate at a non-preferred provider, co-payments may apply at non-preferred provider |
Radiology Excluding specialised radiology |
Subject to MSA balance | 100% of Agreed Rate |
Pathology | Subject to MSA balance | 100% of Agreed Rate |
Dentistry (i) Conservative dentistry, fillings, extractions, X-rays and prophylaxis (ii) Specialised dentistry, orthodontic, periodontic, crowns, bridgework, dentures, dental implants and osseo-integration |
R2 750 per family per year, payable from the insured benefit, thereafter subject to MSA balance Subject to MSA balance |
100% of Scheme Rate 150% of Scheme Rate |
Acute medication Subject to MRP |
Subject to MSA balance | 100% of SEP plus agreed dispensing fee; excludes administration fee |
Pharmacy-advised therapy (PAT) Including homeopathic and naturopathic medication |
Subject to MSA balance and a limit of R500 per beneficiary per day | 100% of Agreed Rate of SEP plus agreed dispensing fee; excludes administration fee |
Optical (i) Optometric tests (including all visual tests) |
1 eye test per beneficiary per every second year, payable from the insured benefit. The Opticlear Network of Optometrists is the Preferred Provider. Click here to view the Optical Network List |
100% of Agreed Rate at the Preferred Provider Optometrist. co-payment may apply at a non-Preferred Provider |
(ii) Spectacles, additional eye tests, lenses (including contact lenses), frames and readers | Subject to MSA balance | 100% of Agreed Rate at the Preferred Provider Optometrist. Co-payment may apply at a non-Preferred Provider |
External surgical appliances (i) Hearing aids, orthopaedic boots, surgical collars, wheelchairs, nebulisers, oxygen equipment, etc. (ii) Stoma therapy products |
Subject to MSA balance Subject to pre-authorisation and managed care protocols |
100% of cost 100% of Scheme Rate |
Alternative services Homeopaths, naturopaths and chiropractors (excluding X-rays and appliances) |
Subject to MSA balance |
100% of Scheme Rate |
Auxiliary services Includes speech therapy and audiology, occupational therapy, podiatry, homeopathy, naturopathy, chiroprators, etc (excluding X-rays and appliances) |
Subject to MSA balance |
100% of Scheme Rate |
Step-down facilities | Subject to MSA balance | 100% of Scheme Rate |