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:
300% scheme tariff
Scheme rate is set by Sizwe
network Specialists:
300% scheme tariff
non-Network GPs:
100% scheme tariff
network GPs:
300% scheme tariff
Hospital Choice:
Choose any hospital
Day Hospitals:
Penalty for using other hospital:
n/a
You don't pay a penalty if admission was unavoidable due an emergency
Other Co-payments:
100% scheme rate, at DSP and from protocols
* 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)
100% scheme rate
No limits or co-payments for PMB level care and/or for emergency
Transplants:
Some minor procedures are only paid if done in day hospitals or doctor's rooms
Dialysis:
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:
There is a day-to-day limit for physiotherapy, radiology, pathology and acute medication
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:
R2,905 per family
Over-the-counter:
Consult:
1 test per person every 2 years
Frames:
R1,116 per person
Single lenses
R185 per lens
Bifocals:
R420 per lens
Multifocals
R745 per lens
Contacts
R1,884 with guidelines
Refractive Surgery:
R19,134 per family
Birth Control:
PMBs: 10+ consults, paid by scheme
R18,366 per family for psychologists and psychiatrists for mental health disorders
On Discharge:
21 days per person, including 6 in-hospital consults with psychiatrist
R48,300 per person per admission and R2,300 per day
Can be substituted with 10 consults in lieu of hospitalisation
Alcoholism/Drug Addiction: 3 days withdrawal treatment plus 21 days rehab at an appropriate facility
Biological:
7 days supply
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.
