Benefits: Day-to-Day

• Paid at 90% of 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 70 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.

• Paid at 90% of SRPL rate.
• Combined limit of R8 510.

• Paid at 90% of SRPL rate.
• Combined limit of R4 010.

• Paid at 100% of SRPL rate.
• Limited to R2 250.
• This benefit is applicable to consultations and in-rooms procedures and does not include private nursing, wound care or palliative care.

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

• Paid at 70% of the negotiated rate, limited to R5 560.
• Includes prescribed homeopathic medicine, contraceptive preparations and devices (pre-authorisation required for Mirena® device procedure).
• Benefit for self-medication (OTC – 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 R5 560.

The MRP is a generic reference price that is the maximum amount that will be reimbursed for a list of generic medicines that cost less than the original brand name medicine. The member will be liable for the price difference should the beneficiary elect to receive medicine above the MRP price.

• Benefit is provided at 100% of the PPN agreed tariffs.
• The benefit applies over a two-year cycle (new cycle started on 1 January 2024) for all beneficiaries and is subject to annual availability.
• Benefits are limited to PPN tariffs when consulting a non-PPN provider and a co-payment may apply.
• When consulting a non-PPN provider, the member must pay the provider and the Society will reimburse the member.

Lenses (per lens)
a. Single vision or
b. Bifocal or
c. Multifocal

Contact lenses

Hard contact lenses

• 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.
• No liability for repairs of damage, or for loss of spectacles.

• Paid at 100% of SRPL rate.
• Limited to R4 850, with a sub-limit of 1 oral examination, scale and polish every 6 months, from date of last service.
• 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); and
  • 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.

• PRE-AUTHORISATION REQUIRED ONLY IF DONE IN HOSPITAL From the Society’s Hospital pre-authorisation department.
• Paid at 100% of SRPL rate.
• Limited to R9 270.
• Includes crowns, dentures, bridges and periodontal treatment.
• Managed-care protocols apply for procedures performed in-hospital.

• PRE-AUTHORISATION REQUIRED From the Society’s Claims department.
• Paid at 75% of SRPL rate.
• Limited to R27 910 per lifetime.
• Benefits are not provided for treatment starting after a beneficiary’s 18^th birthday.
• Managed-care protocols apply.

• Paid at 90% of SRPL rate.
• Limited to R16 870.

• Paid at 90% of SRPL rate, out of hospital.
• Unlimited, but subject to request by a medical practitioner.

• Paid at 90% of SRPL rate, out of hospital (except for one bone density scan every 2 years for all beneficiaries over the age of 50 which will be paid at 100% of SRPL rate).
• Unlimited, but subject to request by a medical practitioner.

• PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department.
• Paid at 90% of the cost as approved by the Society.
• Limited to R23 280.
• Repairs and maintenance are included in the limit, to a sub-limit of 15% of the limit.
• The benefit applies over a five-year cycle (starting from 1 January 2021).
• No benefit payable in respect of hearing aid batteries.
• Managed-care protocols apply.

• PRE-AUTHORISATION REQUIRED From Mediscor.
• Paid at 90% of the cost as approved by the Society.
• Limited to R24 250.
• Managed-care protocols apply.

• PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department.
• Paid at 50% of the cost as approved by the Society.
• Limited to R9 630.
• Includes insulin pumps, continuous glucose monitoring (CGM) devices including all test strips, orthopaedic boots, surgical collars, 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 limit.
• Managed-care protocols apply.

• PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department.
• Paid at 100% of cost as approved by the Society.
• Limited to R22 870.
• Portable Oxygen Concentrator subject to Society approval up to the limit.
• Managed-care protocols apply.

• PRE-AUTHORISATION REQUIRED From the Society’s Managed-care department.
• Paid at 90% of the cost as approved by the Society.
• Limited to R12 150.
• Quadriplegics and paraplegics only: limited to R36 870.
• No benefit for motorised carts / tricycles other than motorised wheelchairs in appropriate cases.
• Repairs and maintenance are included in the limit to a sub-limit of 20% of the limit.
• The benefit applies over a five-year cycle (starting from 1 January 2021).
• Managed-care protocols apply.