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 R8 030.
Audiology, chiropody, podiatry, acupuncture, dietician services, occupational therapy, and speech therapy
  • Paid at 90% of SRPL rate.
  • Combined limit of R3 590.
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 this table for more information.

  • Paid at 70% of the negotiated DSP rate, limited to R4 980, 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 980.
  • 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, glaucoma screening, visual field screening and artificial intelligence screening for retinopathy)
  • Benefit is provided at the PPN agreed tariffs.
  • The benefit applies over a two-year cycle (new cycle starts on 1 January 2022) for all beneficiaries and is subject to annual availability.
  • Benefits are limited to PPN tariffs when consulting a non-PPN provider. (A co-payment will apply if you use a non-PPN provider.)
Frame and lens enhancements

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

Contact lenses
Hard contact lenses

  • Composite consultation limited (per 2-year cycle) to a maximum of R730 at a PPN provider and R350 at a non-PPN provider.
  • Composite consultation includes refraction, glaucoma screening, visual field screening and artificial intelligence screening for retinopathy.
  • The PPN network consists of approximately 87% 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 600 for a PPN Network provider and R1 280 for a non-PPN 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. Per lens
a) Single vision – R210 OR
b) Bifocal – R445 OR
c) Multifocal – R770

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.
DENTAL
Conservative dentistry
  • Paid at SRPL rate.
  • Limited to R4 350, with a sub-limit of 1 check-up and scale and polish every 6 months.
  • Includes preventative and diagnostic consultations, fillings, extractions, cleanings 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 R8 300.
  • Includes crowns, dentures, bridges 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 R26 330 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 R15 110.
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 R56 130.
  • 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 R20 860.
  • 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 R22 880.
  • 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 630.
  • 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 R21 580.
  • 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 R11 460.
  • Quadriplegics and paraplegics/ONLY: limited to R33 030.
  • 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 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

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