Health Squared Optimum medical aid plan: 2020

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Optimum
Total Cost pm:

Main member:

R5,046

Adult:

R4,207

Child:

R1727
Savings: R9072 R7572 R3108
Extended Fund: RM = R7,790
M1 = R9,436
M2 =R10,863
M3 =R12,339
M4+ =R13,935
R R

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IN HOSPITAL PROCEDURES:
Optimum
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • 100% scheme rate
network Specialists:
  • 100% scheme rate
non-Network GPs:
  • 100% scheme rate
network GPs:
  • 100% scheme rate
Hospital Choice:
  • Choose any hospital, but a DSP (designated service provider) must be used for planned PMB procedures
Penalty for using other hospital:
  • 30% or minimum R7,000 if a non-DSP is used for planned PMB procedures
  • n/a
Specialised Radiology:
  • R17,227 per family, unless PMB
  • R2,090 co-payment
Supplementary Services: (Physio, etc)
  • Physiotherapy: 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • PMB only
Co-payments:
  • Cystoscopy, Excision nail bed, skin lesions, specialised radiology: R2,090 co-payment
  • Myringotomy: R2,612 co-payment
  • Circumcision, Vasectomy, colonoscopy, dental admissions: R3,135 co-payment
  • Arthroscopy: R4,000 co-payment
  • Endometrial ablation, laparoscopic procedures, urinary incontinence repair, varicose veins: R4,180 co-payment
  • Gatroscopy, Hernia repair: R5,225 co-payment
  • Nasal surgery, conservative neck and back/spine treatment, hysteroscopy, hysterectomy: R6,270 co-payment
  • Tonisllectomy, Adenoidectomy, Tympanoplasty: no co-payment
  • Rotator cuff surgery: R10,450 co-payment
  • Spinal surgery: R12,000 co-payment
  • Joint replacement, Spinal surgery: R12,450 co-payment
  • Reflux surgery: R12,540 co-payment
Alternatives to hospitals:
  • Home nursing: authorisation required
  • Rehab and subacute facilities: R9,436 per family
Casualty:
  • PMB: Paid by scheme
  • Otherwise: from day-to-day benefit
  • Both the Blue Plan and Red Plan gap cover will pay up to R10,000 per person for unpaid casualty costs in event of emergency
Other: 2020 benefits coming soon
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R165,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R165,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Optimum
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Extended Fund: RM = R7,790
M1 = R9,436
M2 =R10,863
M3 =R12,339
M4+ =R13,935
R R
General info:
  • Consider getting Primary Health Care (PHC) (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
GP consultations:
  • From day-to-day benefit, unless PMB
  • See Primary Health Care benefit above
Childcare: 2020 benefits coming soon
Specialists consultations:
  • From day-to-day benefit, unless PMB
  • See Primary Health Care benefit above
Pathology:
  • From day-to-day benefit, unless PMB
  • See Primary Health Care benefit above
General radiology:
  • From day-to-day benefit, unless PMB
  • See Primary Health Care benefit above
Specialised radiology:
  • R17,227 per family, unless PMB
  • R2,090 co-payment
Supplementary Services: (Physio, etc)
  • From day-to-day benefit, unless PMB

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MATERNITY BENEFITS:
Optimum
Scheme Benefits Notes and Links:
Hospital stay:
  • Elective C-section: R11,521 limit, unless pre-authorisation is obtained.
  • Otherwise, 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
  • From day-to-day benefits
Scans:
  • 4 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Optimum
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • Unlimited, subject to specific protocols and formularies
  • Biological and targeted therapies: R230,423

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DENTISTRY:
Optimum
Scheme Benefits Notes and Links:
Standard Dentistry:
  • From day-to-day benefit (Savings, not extra fund)
  • Consider getting Primary Health Care (medical insurance) that will cover you for a lot of out of hospital claims, including standard dentistry like scaling, polishing, fillings, extractions, root canals and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Specialised Dentistry:
  • From day-to-day benefit, (fund)
  • Sublimits:
    • M =R5,760
    • M1 =R7,242
    • M2 =R8,614
    • M3 =R10,150
    • M4 =R11,631
    • Implants: R4,225 per implant, max 2 per year
In-Hospital Dentistry:
  • Impacted wisdom teeth and treatment for children under 5yrs
  • R3,135 co-payment
Orthodontics:
  • Shared with standard dentistry
Maxillo Facial Surgery: 2020 benefits coming soon

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MEDICATION:
Optimum
Scheme Benefits: Notes and Links:
Chronic:
Acute (presrcibed) medication:
  • From day-to-day benefit, unless PMB
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Over-the-counter:
  • From day-to-day benefit, unless PMB
Birth Control:
  • R1,740, subject to preventative care benefit sublimit of R2,886
On Discharge:
  • 7 days supply
Biological:
  • R230,423

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OPTOMETRY:
Optimum
Scheme Benefits: Notes and Links:
Optometry:
  • From day-to-day benefit, up to R2,633 per person, every 2 years
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here

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MENTAL HEALTH:
Optimum
Scheme Benefits Notes and Links:
In-hospital:
  • PMB: Unlimited, per protocol
  • non-PMB: R20,299 per family
Out-of-hospital:
  • From day-to-day benefit, unless PMB
  • Sublimit: R6,035
Trauma: 2020 benefits coming soon

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OTHER BENEFITS:
Optimum
Scheme Benefits Notes and Links:
General Appliances:
  • From day-to-day benefit
1.1. Hearing Aids:
  • See above
1.2. Wheelchairs:
  • See above
Dialysis:
  • PMB only
International Insurance: 2020 benefits coming soon
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Optimum
Scheme Benefits: Notes and Links:
Flu vaccination:
  • From day-to-day benefit (savings), subject to preventative care benefit sublimit of R2,897 per family
  • This sublimit is shared with most of the preventative care benefits
Pneumonia vaccines:
  • No benefit
Biometric Screening:
  • From day-to-day benefit (fund), subject to preventative care benefit sublimit of R2,897 per family AND the benefit booster sublimit of R1,646
  • This sublimit is shared with most of the preventative care benefits
Child Immunisation:
  • From day-to-day benefit (savings), subject to preventative care benefit sublimit of R2,897 per family
  • This sublimit is shared with most of the preventative care benefits
Pap Smear:
  • From day-to-day benefit (fund), subject to preventative care benefit sublimit of R2,897 per family AND the benefit booster sublimit of R1,646
  • This sublimit is shared with most of the preventative care benefits
Mammogram:
  • From day-to-day benefit (fund), subject to preventative care benefit sublimit of R2,897 per family AND the benefit booster sublimit of R1,646
  • This sublimit is shared with most of the preventative care benefits
PAS Test:
  • From day-to-day benefit (savings), subject to preventative care benefit sublimit of R2,897 per family
  • This sublimit is shared with most of the preventative care benefits
HIV Test:
  • From day-to-day benefit (fund), subject to preventative care benefit sublimit of R2,897 per family AND the benefit booster sublimit of R1,646
  • This sublimit is shared with most of the preventative care benefits
Other:
  • HPV vaccine, subject to R2,886 sublimit for preventative care

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PROSTHETICS:
Optimum
Scheme Benefits: Notes and Links:
Overal Limit:
  • Overall limit: R131,670
Sub-limits:
  • Speak to us about specific sub-limits

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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised