Benefits: Day-to-Day


What are day-to-day benefits?

Day-to-day benefits typically include (but are not limited to) consultations with doctors and other healthcare practitioners, dentist visits, acute medicines, and optometry benefits.


What day-to-day benefits are covered by the Society?

See the table below. Unless otherwise specified, limits in this table are per beneficiary per benefit year.

CONSULTATIONS
General Practitioners (GPs), specialists and registered homeopaths
  • Paid at 90% of Society Reference Price List (SRPL) rate.
  • Combined GP, specialist, and homeopath limit of 15 consultations.
  • For elective non-emergency after-hours consultations, the benefit is limited to the SRPL rate for a normal consultation. See page 69 of the MEMBER GUIDE on how to avoid additional co-payments in this regard.
  • Doctors’ house calls will be paid at normal consultation rates unless clinically assessed to be required due to a medical emergency.
Physiotherapy, biokinetics and chiropractic services
  • Paid at 90% of SRPL rate.
  • Combined limit of R7 690.
Audiology, chiropody, podiatry, acupuncture, dietician services, occupational therapy, and speech therapy
  • Paid at 90% of SRPL rate.
  • Combined limit of R3 440.
Nursing practitioner
  • Paid at SRPL rate.
  • Unlimited.
MEDICINE
Acute medicine (for chronic medicine benefits, see the separate chapter BENEFITS: CHRONIC MEDICINE)

Also see How to obtain acute medicine below the table for more information.

  • Paid at 70% of the negotiated DSP rate, limited to R4 770, per beneficiary per year.
  • Includes prescribed homeopathic medicine, contraceptive preparations and devices (pre- authorisation required for Mirena® device).
  • Benefit for self-medication (over the pharmacy counter) limited to a maximum of R145 per event with a sub-limit of a maximum of 6 fills per year, and subject to the acute medicine limit of R4 770.
  • MRP will apply and where a generic medicine exists and a beneficiary elects to receive the original medicine, the value above the reference price will be the member’s liability.
SIGHT
Composite consultation
(including refraction, tonometry and visual field screening)
  • Benefit is the Preferred Provider Negotiators (PPN) agreed tariffs.
  • The benefit applies over a two-year cycle (new cycle commenced on 1 January 2020) for all beneficiaries and is subject to annual availability.
  • Benefits are limited to DSP tariffs when consulting an out-of-network provider.
Frame and lens enhancements

Lenses
a. Single vision or
b. Bifocal or
c. Multifocal

Contact lenses
Hard contact lenses

  • Composite consultation limit per 2-year cycle to a maximum of R700 at a PPN provider and R350 at a non-PPN provider.
  • Composite consultation includes: Refraction, Tonometry and Visual Fields tests.
  • The PPN network consists of approximately 80% of all registered optometrists in RSA.
  • Visit the PPN website www.ppn.co.za to find your nearest PPN provider.

PLUS
1. Frame and lens enhancements – R1 550 for a PPN Network provider and R1 240 for a non- Network provider

This component of the optical benefit can be used to purchase a frame or for lens enhancements (tints and coatings), or a combination of both.

2. One pair of lenses
a) Single vision – R420 OR
b) Bifocal – R890 OR
c) Multifocal – R1 540

OR
Contact lenses

a. Soft contact lenses – R1 500 per year
OR
b. Hard contact lenses – R3 000 per 2-year cycle (Subject to pre-authorisation)

  • Prescriptions less than 0.50 dioptre will not be covered. No bi/multifocal lenses with a reading of less than 1.00 dioptre will be covered;
  • Bi/multifocal lenses for under 40-year-old beneficiaries must be motivated.
  • Contact lenses for children under 16 years of age must be motivated.
  • Beneficiaries can claim either spectacles or contact lenses (soft or hard) but not both in the 24-month cycle.
  • Fundus photography: R150 – Only payable by the Society in the event of positive pathology
  • Optical Coherent Tomography (OCT): R255 – Only payable by the Society in the event of positive pathology
DENTAL
Conservative dentistry
  • Paid at SRPL rate.
  • Limited to R4 170, with a sub-limit of 1 check-up and scale and polish every 6 months.
  • Includes preventative and diagnostic consultations, cleaning, fillings, extractions, and x-rays.
  • Managed-care protocols apply, and pre-authorisation is required in respect of:

    • Elective procedures where general anaesthesia is required
    • Children under the age of nine (limited to one admission per year)
    • Removal of impacted wisdom teeth, apicectomies, removal of teeth and roots or exposure of teeth for orthodontic reasons.
  • No limit applies in respect of dentistry required as a result of trauma.
Specialised dentistry
  • PRE-AUTHORISATION REQUIRED ONLY IF DONE IN HOSPITAL From the Society’s Hospital pre-authorisation department
  • Paid at SRPL rate.
  • Limited to R6 910.
  • Includes crowns, dentures, bridges, implants, and periodontal treatment.
  • Managed-care protocols apply.
Orthodontic treatment
  • PRE-AUTHORISATION REQUIRED From the Society’s Claims department
  • Paid at 75% of SRPL rate.
  • Limited to R25 200 per beneficiary per lifetime.
  • Benefits are not provided for treatment starting after a beneficiary’s 18th birthday.
MENTAL
Mental health
  • Paid at 90% of SRPL rate.
  • Limited to R14 460.
PROSTHESIS
Artificial limbs (including prosthetic eyes)
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at 90% of the cost as approved by the Society.
  • Limited to R53 720.
  • Repairs and maintenance are included in the limit, to a sub-limit of 15% of the annual limit per category.
  • The benefit applies over a five-year cycle (starting from 1 January 2021).
  • Managed-care protocols apply.
TESTS
Pathology
  • Paid at 90% of SRPL rate, out of hospital.
  • Unlimited, but subject to request by a medical practitioner.
Radiology
  • Paid at 90% of SRPL rate, out of hospital.
  • Unlimited, but subject to request by a medical practitioner.
  • No benefit in respect of bone density scans in hospital.
HEARING
Hearing aids
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at 90% of the cost as approved by the Society.
  • Limited to R19 970.
  • Repairs and maintenance are included in the limit, to a sub-limit of 15% of the annual limit per category.
  • The benefit applies over a five-year cycle (starting from 1 January 2021),
  • Managed-care protocols apply.
MEDICAL EQUIPMENT
Colostomy bags and catheters
  • PRE-AUTHORISATION REQUIRED From Mediscor
  • Paid at 90% of the cost as approved by the Society.
  • Limited to R21 900.
  • Mediscor protocols apply.
Aids and appliances
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at 50% of the cost as approved by the Society.
  • Limited to R8 260.
  • Includes, but is not limited to, insulin pumps, continuous glucose monitoring (CGM) devices including test strips, CPAP machines, orthopaedic boots, surgical collars, external breast prosthesis, nebulisers and hiring of equipment.
  • The type of appliance covered by this benefit will be at the discretion of the Society and all repairs and maintenance are included in the limit, to a sub-limit of 15% of the annual limit per category.
  • Managed-care protocols apply.
Continuous Oxygen Supply machine or Oxygen
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at cost as approved by the Society.
  • Limited to R20 660.
  • Portable Oxygen Concentrator subject to Society approval up to the annual limit.
  • Managed-care protocols apply.
Wheelchairs
  • PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department
  • Paid at 90% of the cost as approved by the Society.
  • Limited to R10 970.
  • Quadriplegics and paraplegics/ONLY: limited to R31 610.
  • No benefit for motorised carts / tricycles other than motorised wheelchairs in appropriate quadriplegic cases.
  • Repairs and maintenance are included in the limit to a sub-limit of 20% of the annual limit per category.
  • The benefit applies over a five-year cycle (starting from 1 January 2021).
  • Managed-care protocols apply.

 

Where to obtain acute medicine

You can obtain your acute medicine from any registered pharmacy, but the Society has an agreement with its DSPs (Dis-Chem Pharmacies) to ensure that the agreed Society rate is charged, so that you would not have an out-of- pocket expense other than the standard 30% co-payment that applies to acute medicine.

If you have a Dis-Chem Pharmacy in your area, or live in the vicinity of Lime Acres Pharmacy, Cullinan Health & Home Pharmacy, or the Namaqualand Pharmacy in Springbok*, you may collect your acute medicine from these pharmacies. (*Members in the Northern Cape can also collect acute medicine from Dr HA Burger in Springbok.)

If this is not convenient, you may also collect your acute medicine from any other retail pharmacy in RSA. However, keep in mind that if you do not obtain your acute medicine from a DSP, you could have additional out-of-pocket expenses, over and above the standard 30% co-payment that applies to acute medicine, if such a pharmacy charges a higher dispensing fee than the one negotiated with DSPs and covered by the Society.

Other Benefits

Back to Top