The scheme might still cover some or all day-to-day claims. See below, and see benefits.
Children Rates:
Child rates up to 24yrs
Pay for all
Note:
Exclusions: Note that all schemes have extensive exclusions. We've tried to list the major ones, but you must consult with your scheme to get the full list.
All treatments and procedures are subject to authorisation and protocols
All benefits are listed as an indication only. Please verify with your broker and scheme
Assume scheme pays all these costs, unless otherwise stated
non-Network Specialists:
100% scheme rate
Scheme rate is set by Bonitas
network Specialists:
100% scheme rate
non-Network GPs:
100% scheme rate
network GPs:
100% scheme rate
Hospital Choice:
Long stay: BonStart Network
Day procedure: Day network
Day Hospitals:
Must use Day Hospitals for certain procedures
Penalty for using other hospital:
non-Network hospital: R12,050
You don't pay a penalty if admission was unavoidable due an emergency
Other Co-payments:
R1,130 co-payment per admission, except for motor vehicle accidents, maternity confinements and emergency treatment
Laparoscopic Hysterectomy: R2,890 co-payment
Arthroscopy (when done as part of a surgical procedures): R2,890 co-payment
Specialized radiology: R2,130 co-payment
* There might be other co-payments if you don't use scheme-chosen provider for some services.
* Treatment required for PMB level care is always paid by scheme, with no co-payment, if you follow the protocols. That means that these co-payments might not apply in your case! More info here
Specialised Radiology:
MRI and CT Scans: R18,180 per family
R2,130 co-payment, unless PMB
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
PMBs only
Physical rehabilitation: R50,600 per family
No limits or co-payments for PMB level care and/or for emergency
Transplants:
PMBs only
Dialysis:
PMBs only
Exclusions:
Back and neck surgery
Correction of Hallux Valgus
Non-cancerous breast conditions
Nail disorders
Skin disorders, including benign growths and lipomas
Knee and shoulder surgery
Joint replacement surgery
C-sections for non-medical reasons
Functional nasal and sinus surgery
Varicose vein surgery
Reflux and Hernia repair surgery
All endoscopies
In-hospital dental surgery
* Treatment required for PMB level of care is always paid by scheme, if you follow the protocols. It cannot be excluded. More info here.
* All schemes have extensive exclusions. We've tried to list the major ones here, but please consult your scheme or broker to get the full list
Alternatives to hospitals:
Alternatives to hospitalisation (hospice, step-down): R19,100 per family
Palliative care (oncology): Unlimited, including hospice/private nursing, home oxygen, pain management, psychologists, social workers
Home-care: Home based care as alternative to general ward admission
All medical aids must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here.
This can include consults with specialists, blood or other tests, radiology and medicine
The benefit is paid by the scheme, and not out of your savings account
If you have no day-to-day funds, you still have cover for PMBs
Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
Wellness Extender: Available after completing a wellness screening or online wellness assessment. Get up to R1,100 per family and use for out of hospital claims like : GP consult(s), OTC medicine, etc
GP consultations:
Network GPs: Unlimited, with R120 co-payment
Virtual consults: Unlimited
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Childcare:
Hearing screening: Newborns, in or out of hospital
Congenital hypothyroidism screening: Infants under 1 month old
Immunisations: Covered
Dentistry: Fissure sealants on permanent teeth for children under 16yrs
Specialists consultations:
GP referred: 1 consult per family, up to R1,250, and R250 co-payment
Includes: acute meds, basic radiology, specialised radiology and pathology
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Pathology:
GP referred: R3,160 per family
Benefit shared with acute medicine, x-rays and blood tests
General radiology:
GP referred: R3,160 per family
Benefit shared with acute medicine, x-rays and blood tests
Specialised radiology:
PMBs only
Scans required for PMB level care are paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Supplementary Services: (Physio, etc)
Physiotherapy: 4 consults for sport-related injuries with a R65 co-payment
Otherwise, PMBs only
General Appliances:
R6,270 per family
1.1. Hearing Aids:
No benefit
1.2. Wheelchairs:
No benefit
Note:
PMBs: Prescribed Minimum Benefits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
If you voluntarily use medicine that is not on Bonitas's list ("formulary"), you pay a 40% co-payment
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
GP referred: R3,160 per family, with 20% co-payment
Benefit shared with acute medicine, x-rays and blood tests
Over-the-counter:
R165 per event, and R785 per family per year
Birth Control:
R1,460 per family
On Discharge:
R440 per person and max 7 days, per admission
Biological:
PMBs only
Treatment that is required (by law) for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here.)
Note:
Schemes have very strict rules about where you can get your medicine to get full benefit. We do not list the requirements here, so confirm with your scheme before you collect your medicine.
Formulary: A pre-defined list of approved medicines. Each plan has a different list, and might not pay for non-listed medicine. Confirm with your scheme whether your required medicine is covered by them.
PMBs: Prescribed Minimum Benfits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
A quick guide to how you can change your medical aid plan, including the resignation procedure, and things to look out for, such as imposed waiting periods from your new scheme
