Primary Option

Primary Option Benefits Hospitalisation Benefits

Hospitalisation 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.

Benefits Description
Statutory Prescribed Minimum Benefits (PMBs) Services rendered by State hospital or DSP unlimited, subject to pre-authorisation and managed care and funding protocols 100% of cost
Hospitalisation Subject to overall annual limit of R1 462 000 for non-PMB conditions

Benefits for admission to a private hospital are subject to the utilisation of DSP hospitals appointed by the Scheme

In the event that a non-DSP hospital is voluntarily utilised, the member will be liable for 30% of the cost associated with the admission

Admissions are subject to pre-authorisation with the Scheme's managed care provider 2 working days prior to admission and within 48 hours of the incident in the case of emergencies within 48 hours of the incident in the case of emergencies

Failure to obtain authorisation within 48 hours could result in co-payments
Private hospitals (excluding rehabilitation)
100% of Agreed Rate
State hospitals
100% of UPFS or cost, whichever is the lowest
Medicines dispensed in and upon discharge from hospital To-take-out (TTO) medication limited to 7 days' supply; subject to the medication reference price list and formulary 100% of SEP and agreed dispensing fee
Alternatives to hospitalisation
(i) Step-down facilities
(ii) Hospice (ward fees and disposables)
(iii) Home nursing		 Subject to pre-authorisation and managed care and funding protocols 100% of Agreed Rate or 100% of cost in the case of a PMB
GPs and specialists

Consultations, visits and procedures/operations		 Subject to overall annual limit 100% of Agreed Rate
Psychiatric conditions/Substance abuse PMBs only, at DSPs; subject to pre-authorisation and managed care and funding protocols 100% of cost
Radiology

Basic radiology

Subject to overall annual limit and clinical and funding protcols		 100% of Agreed Rate
Specialised radiology (MRI and CT scans) PMBs only; subject to pre-authorisation 100% of cost
Pathology Subject to overall annual limit and clinical and funding protocols 100% of Agreed Rate
Blood transfusions and technician services Subject to overall annual limit 100% of Agreed Rate
Oncology treatment (in and out of hospital) PMBs only, at DSPs

Subject to pre-authorisation and managed care and funding protocols and registration on the Oncology Management Programme		 100% of cost
Surgical/Internal prostheses PMBs only; subject to pre-authorisation and managed care and funding protocols 100% of Agreed Rate
Maxillofacial surgery (excluding specialised dentistry) PMBs only, at DSPs 100% of cost
Organ transplants (hospitalisation and surgery) PMBs only, at DSPs 100% of cost
Emergency rescue services: ER24 Subject to pre-authorisation and ER24 protocols; tel: 084 124 100% of Agreed Rate
HIV/AIDS

Subject to registration on the HIV/AIDS management programme and managed care protocols

Treatment within PMB protocols at DSP is unlimited

 100% of cost
Renal dialysis

PMBs only

 100% of cost
Chronic conditions

Registration on the network chronic medicine management programme applies		 Approval is subject to the network chronic conditions and medicine formulary lists

Approved chronic medicines are obtainable at a network pharmacy; the member's preferred point of collection will be confirmed on approval

A 30% co-payment may apply if a non-network pharmacy is used

All medication will be subject to the chronic medicine reference price list at DSPs only		 100% of SEP plus agreed dispensing fee
Speech therapy, physiotherapy, audiology and occupational therapy (in hospital)

As part of a hospital event or resulting from a hospital event for a period of 6 weeks after discharge		 Subject to pre-authorisation and clinical and funding protocols 100% of Agreed Rate
Out-patient surgical procedures

Refer to Annexure A for the list of procedures covered		 Subject to overall annual limit 100% of Agreed Rate