Out-of-hospital benefits

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  • book Glossary
    Agreed rate The agreed rate is the negotiated tariff fee payable to any designated service provider, including those listed on the network.
    GRP The generic reference price – the Fund bases its medicine benefits on the cost of generic medicines instead of brand-name medicines.
    Momentum Health Momentum Health is contracted to the Scheme for all managed healthcare services and the management of the Scheme's provider network.
    Scheme rate The Scheme rate is the tariff set by the Fund for reimbursement of claims, in the absence of any other agreed or contracted tariff with any service provider.
    SEP The single exit price is the legislated price of medicine.
    UPFS The uniform patient fee schedule is the fee schedule applied by the public sector.
    PMB CDL Prescribed Minimum Benefits (PMB) Chronic Disease List (CDL): PMBs are benefits that medical schemes must offer in terms of the Medical Schemes Act, 131 of 1998.

Advanced Option

  • General practitioners (GPs)
    Network and non-network general practitioner consultations

    A co-payment equal to the difference between the Scheme rate and GP rate may apply

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400 
    Member + 4: R37 000

    100%

    of Scheme rate
    Emergency consultations

    A co-payment equal to the difference between the Scheme rate and GP rate may apply

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of Scheme rate
    Acute medication (GP and emergency)

    Subject to R400 per beneficiary per day

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of single exit price (SEP), formulary medication and generic reference price (GRP); subject to overall annual day-to-day limit
  • Over-the-counter (OTC) medication
    OTC medication (includes homeopathic, herbal and natural medication)

    Subject to R450 per beneficiary per day, with a maximum of R1 970 per family per year

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of single exit price (SEP) and generic reference price (GRP); subject to overall annual day-to-day limit
  • Specialists
    Consultations (non-network provider)

    A co-payment equal to the difference between the Scheme rate and specialist rate may apply

    The member is responsible for ensuring that an authorisation number is obtained before consulting a specialist

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    up to 160%

    of Scheme rate, subject to overall annual day-to-day limit
    Consultations (network provider)

    The member is responsible for ensuring that an authorisation number is obtained before consulting a specialist

    Subject to overall annual day-to-day limit

    Single member:  R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of Agreed rate, subject to overall annual day-to-day limit
    Acute medication

    The medication may be obtained at any pharmacy

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of single exit price (SEP) and generic reference price (GRP), subject to overall annual day-to-day limit
  • Gynaecology

    Limited to R2 000 per beneficiary per year

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%
    of agreed rate
  • Emergency room/casualty department (hospital unit)

    Excludes facility fee

    Primary care benefits for acute illnesses or injuries which may require immediate attention

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%
    of agreed rate
  • Dental
    Basic dentistry, specialised dentistry, dentures, procedures under conscious sedation in a doctor's rooms
    Dentistry

    Members are liable for all costs related to dental care by any general or specialist dentist where costs exceed the dental rate and/or dental limit

    Includes the following:
    - Basic dentistry
    - Advanced/Specialised dentistry
    - Dentures
    - Procedures under conscious sedation in a doctor's rooms
    - Clinical guidelines apply

    Annual limit:

    Single member: R7 900
    Member + 1: R9 500
    Member + 2: R11 200
    Member + 3: R11 400
    Member + 4: R11 700

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of Scheme rate; dental limit subject to overall annual day-to-day limit
    Dental therapist

    Members are liable for all costs related to dental care by any general or specialist dentist where costs exceed the dental rate and/or dental limit

    Annual limit:

    Single member: R7 900
    Member + 1: R9 500
    Member + 2: R11 200
    Member + 3: R11 400
    Member + 4: R11 700

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    80%

    of Scheme rate; dental limit subject to overall annual day-to-day limit
  • Orthodontics

    Beneficiaries 18 years of age and younger
    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of Scheme rate, subject to overall annual day-to-day limit
  • Optometrists
    Frames, lenses, contact lenses, tints and eye tests

    Optometrists must obtain authorisation for patient referral to a specialist

    Optical limit: R3 420 per beneficiary every two years i.e. 2025 to 2026

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000


    100%

    of Scheme rate; optical limit subject to overall annual day-to-day limit
  • Radiology

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of Scheme rate, subject to overall annual day-to-day limit
  • Pathology

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of Scheme rate, subject to overall annual day-to-day limit
  • Allied health services
    Nursing services, speech therapist, dietician, occupational therapist, social worker, audiologist, chiropody, chiropractor, physiotherapy and antiretroviral therapy

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of Scheme rate, subject to overall annual day-to-day limit
  • Appliances
    Nebulisers, crutches, glucometers, hearing aids, hire of oxygen cylinders, etc

    Subject to registration with the appropriate Disease Risk Management Programme

    Written motivation from a general practitioner is required, subject to approval from medical advisor

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400 
    Member + 4: R37 000

    100%

    of Scheme rate, subject to overall annual day-to-day limit
  • Clinical psychology

    The member is responsible for ensuring that an authorisation number is obtained before consulting a specialist

    Subject to overall annual day-to-day limit

    Single member: R18 200
    Member + 1: R26 700
    Member + 2: R35 500
    Member + 3: R36 400
    Member + 4: R37 000

    100%

    of Scheme rate, subject to overall annual day-to-day limit
  • Chronic medication

    To obtain benefits for chronic medication, the patient must be registered with the Medicine Risk Management Programme

    The Fund's approved chronic condition list is applicable
    Medication approved as per the Chronic Disease Medication formulary

    PMB CDL conditions: Unlimited

    Non-CDL conditions: Limited to R3 310 per beneficiary per year

    100%

    of single exit price (SEP) and generic reference price (GRP)
  • Ambulance services

    Members must make use of Netcare 911

    Members must call 082 911 for all ambulance services

    For voluntary use of any other emergency service provider, members will be liable for a 20% co-payment

    Netcare 911

    only


  • HIV/AIDS
    This benefit includes medication, doctor's consultations and blood tests required for the treatment of the condition, as well as the cost of prophylaxis for preventative treatment

    This benefit is subject to enrolment on the HIV/AIDS Programme

    Medicine and hospital pre-authorisation are required

    R16 800

    100%

    of Scheme rate
    Medicine: 100% of single exit price (SEP) and generic reference price (GRP)

Benefit Summary - 0.61mb