Plus Option

Plus Option Benefits Day-to-day Benefits

Day-to-day Benefits

  • Effective 1 January 2024

  • 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 Account

    Members 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
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