Primary 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.
| Benefits | Description | |
|---|---|---|
| General Practitioners Network GP consultations and visits (nebulisation, circumcisions, removal of foreign bodies, stitching of wounds, electrocardiograms, drainage of abscesses, infusions, limb casts, excisions and repairs and integumentory system procedures) |
Visits are unlimited; includes defined list of minor trauma procedures subject to network protocols | 100% of Agreed Rate |
| Emergencies and out-of-network consultations and visits | 3 visits limited to R1 150 per family per year at any GP or casualty room; no benefit for out-patient facility fees, unless as specified in Annexure A: Emergency room treatment Member to pay upfront and claim from Scheme |
|
| Specialists Consultations, acute medicines, radiology and pathology as requested by network specialist |
2 visits limited to R2 110 per family per year at a network specialist; subject to referral by a network GP and pre-authorisation | 100% of Agreed Rate |
| Psychiatry conditions/Substance abuse Consultations |
PMBs only, at DSPs; subject to pre-authorisation and managed care and funding protocols | 100% of Agreed Rate |
| Basic radiology | Subject to network list of X-rays and protocols | 100% of Agreed Rate |
| Specialised radiology MRI and CT scans |
PMBs only; subject to pre-authorisation | 100% of Agreed Rate |
| Pathology | Subject to network list of pathology tests and protocols | 100% of Agreed Rate |
| Dentistry Basic/conservative dentistry - fillings, extractions, X-rays, prophylaxis and pain relief (excludes root canal treatment) |
Subject to network dental protocols | 100% of Agreed Rate |
| Dentures | Subject to network dental protocols and specified benefits; only available to beneficiaries older than 21; a 24-month benefit cycle applies | 100% of Agreed Rate |
| Specialised dentistry - orthodontics, periodontics, crowns, bridgework, dental implants and osseo-integration | No benefit | No benefit |
| Acute medication Medicines prescribed by medical practitioners, subject to the acute medication reference price list |
Subject to network formulary Medicines are obtainable at point of service from a dispensing network GP or via a prescription from a scripting GP at a Mediscor-enabled pharmacy Network acute medication formulary applies |
100% of SEP plus agreed dispensing fee; excludes administration fee |
| Pharmacy-advised therapy (PAT) Excludes contraceptives, homeopathic and naturopathic medicines, nutritional supplements and vitamins |
R115 per prescription, limited to R350 per family per year | 100% of SEP plus agreed dispensing fee; excludes administration fee |
| Optical (excludes tinting, coating, etc.) Optometric tests |
1 eye test per beneficiary every 24 months |
100% of Agreed Rate |
| Spectacles: lenses and frames | 1 pair of white, standard monofocal or bifocal lenses in a standard frame up to the value of R236 every 24 months | 100% of Agreed Rate |
| OR | ||
| Contact lenses | Contact lenses in lieu of spectacles limited to R617 every 24 months Subject to network protocols and qualifying norms For details of providers on the Optical Network, click here. |
100% of Agreed Rate |
| External surgical appliances Hearing aids, orthopaedic boots, surgical collars, wheelchairs, nebulisers, oxygen equipment, etc. |
PMBs only; limited to R6 360 per family; subject to pre-authorisation and clinical and funding protocols | 100% of cost |
| Alternative services Homeopaths, naturopaths, chiropractors, speech therapy, audiology, occupational therapy and podiatry |
No benefit Refer to Annexure A for the list of out-patient surgical procedures covered under the overall annual limit. Refer to Annexure B for list of preventative procedures covered from the day-to-day benefit, subject to the network and protocols. |
No benefit |