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:
PMB protocols
Scheme rate is set by Sizwe
network Specialists:
PMB protocols
non-Network GPs:
PMB protocols
network GPs:
PMB protocols
Hospital Choice:
Network Hospital
Day Hospitals:
PMBs conditions only :
Biopsy
Breast Biopsy
Cataract
Colonoscopy
Cone Biopsy/ Colposcopy
Cystoscopy
ERCP
Excision of Extensive/ Skin lesions
Repair Skin Graft
Gastroscopy or Colonoscopy or Oesophagoscopy
Haemorrhoidectomy
Hysteroscopy, D&C, Minor Gynaecological Procedures
Myringotomy / Grommets
Repair of Wounds
Termination of Pregnancy
Tonsillectomy and Adenoidectomy
Umbilical and Inguinal Hernia
Penalty for using other hospital:
non-DSP Hospital: 30% co-payment
You don't pay a penalty if admission was unavoidable due an emergency
Other Co-payments:
Joint Replacement: R5,000 co-payment
Umbilical Hernia Repair: R5,000 co-payment
Hysterectomy: R5,000 co-payment
Functional Nasal Surgery: R5,000 co-payment
Elective caesarean section: R5,000 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:
PMBs only
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
PMBs only
No limits or co-payments for PMB level care and/or for emergency
Transplants:
PMBs only
Dialysis:
PMBs only
Exclusions:
non-PMB procedures
* 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
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.
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.
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
From DSP GP:Unlimited
From Pharmacy:R1,767 per person and R4,927 per family
Over-the-counter:
R744 per family and R116 per script
Birth Control:
R882 per family
On Discharge:
7 days supply
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.
