The scheme might still cover some or all day-to-day claims. See below, and see benefits.
Extended Fund: Extra funds from the scheme for (mostly) out of hospital claims, over and above any savings account
Main= R5,300
Main+1= R8,520
Main+2= R10,650
Main+3= R11,720
Children Rates:
Child rates up to 24yrs
Only pay for 3 children
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:
Covered in full
non-Network GPs:
100% scheme rate
network GPs:
Covered in full
Hospital Choice:
Network hospital
Day Hospitals:
Must use Day Hospitals for certain procedures
Penalty for using other hospital:
non-Network long stay hospital: 30% co-payment
non-Network Day Hospital: R2,590 co-payment
You don't pay a penalty if admission was unavoidable due an emergency
Other Co-payments:
Specialized radiology: R2,130 co-payment
In-hospital-dentistry: R2,500- R5,000
R1,840 co-payment
Colonoscopy,
Conservative back treatment,
Cystoscopy,
Facet joint injections,
Flexible sigmoidoscopy,
Functional nasal surgery,
Gastroscopy,
Hysteroscopy,
Myringotomy,
Tonsillectomy and adenoidectomy,
Umbilical hernia repair,
Varicose vein surgery
R4,690 co-payment:
Arthroscopy,
Diagnostic laparoscopy,
Laparoscopic hysterectomy (except cancer and PMBs),
Percutaneous rhizotomies,
R8,680 co-payment:
Laparoscopic pyeloplasty,
Laparoscopic radical prostatectomy,
Nissen fundoplication (reflux surgery)
* 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: R15,170 per family, in and out of hospital
R2,130 co-payment, unless PMB
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
From day-to-day benefit, unless PMB
Physical rehabilitation: R57,890 per family
No limits or co-payments for PMB level care and/or for emergency
Transplants:
PMBs only
Dialysis:
Covered
Exclusions:
.
* 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): R19,130 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.
This plan has an "extra" fund, so some out of hospital costs are paid from this, from sub-limits per benefit (see below)
Remember, out of hospital costs authorised as part of PMB treatment (eg. cancer, asthma or stroke) are always paid by the scheme, even on this plan.
Wellness Extender: Available after completing a wellness screening or online wellness assessment. Get up to R3,500 per family and use for out of hospital claims like : GP consult(s), OTC medicine, etc
GP consultations:
Network GPs: see below. Some of the funds may be used for non-network GPs:
M = R2,130
M1 = R3,730
M2 = R4,790
M3 = R4,790
From day-to-day benefit
Shared with Specialist benefit
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
Paediatric consult: 2 consults for child under 1yr; 1 consult for child 1-2yr
GP consult: 1 consult per child 2-12yrs
Immunisations: Covered
Dentistry: Fissure sealants on permanent teeth for children under 16yrs
Specialists consultations:
If referred by GP, 1 consult per family, otherwise:
M = R2,130
M1 = R3,730
M2 = R4,790
M3 = R4,790
From day-to-day benefit
Shared with GP benefit
Treatment required for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here
Pathology:
Shared with standard radiology and pathology:
M = R2,130
M1 = R2,660
M2 = R3,200
From day-to-day benefit
General radiology:
Shared with standard radiology and pathology:
M = R2,130
M1 = R2,660
M2 = R3,200
From day-to-day benefit
Specialised radiology:
R15,170 per family, in and out of hospital, with a R2,130 co-payment
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)
M = R2,130
M1 = R2,660
M2+= R3,200
From day-to-day bebefit
General Appliances:
From day-to-day benefit
1.1. Hearing Aids:
From day-to-day benefit
1.2. Wheelchairs:
From day-to-day 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:
M = R2,130
M1 = R2,660
M2+= R3,200
From day-to-day bebefit
Over-the-counter:
R535 per person and R2,130 per family
Shared with Acute medicine limit, see above
From day-to-day- benefit
Birth Control:
R1,870 per family
On Discharge:
R420 per person 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
