Benefits


Consultations (out-of-hospital)

General Practitioners (GPs), Specialists and registered Homeopaths

  • Benefit is paid at 90% of Society Reference Price List (SRPL) rate.
  • Combined GP, specialist and homeopath limit of 15 consultations per beneficiary.
  • For elective non-emergency after hours consultations, the benefit shall be limited to the SRPL rate for a normal consultation. See page 77 in 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.

General Practitioner and Specialist in-rooms procedures

  • Benefit is paid at SRPL rate.
  • The following in-rooms procedures must be pre-authorised by the Society’s Managed-care department and will be reimbursed at the Scheme Rate:
    Gastroscopy, Colonoscopy, Vasectomy, Circumcision and Intravitreal Injection
  • The in-rooms procedure costs are unlimited but subject to the above 15 consultations limit per beneficiary.

Nursing Practitioner

  • Benefit is 100% of SRPL.
  • Unlimited.

Medicines

Acute medicine

  • Benefit is paid at 70% of the negotiated DSP rate, limited to R4 540 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 540 per beneficiary.
  • 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.
  • See page 40 in the Member Guide for more detail.

Chronic medicine

(CDL PMB and listed non-CDL chronic)

  • Benefit is paid at the negotiated DSP rate.
  • Benefit is limited to R37 780 for CDL and non-CDLs (cumulative) but remains unlimited for all PMBs once the chronic medicine limit is reached.
  • If a non-DSP (any supplier not on the DSP list) is voluntarily used, benefit will be 70% of the MRP or 70% of the FRP, whichever is less.
  • Subject to Mediscor approval for all chronic conditions.
  • Medicines used for the treatment of ADHD will only be funded from the chronic medicine benefit until the end of the year in which the beneficiary turns 18. Motivation by a psychiatrist will be considered by Mediscor, subject to their protocol, for chronic medicine benefit authorisation requests after the 18th birthday.
  • Note: The overall cumulative benefit limit for both CDL PMB and listed non-CDL chronic medicine is R37 780 per beneficiary per year. If this limit is reached before year-end, the CDL PMB chronic medicine will continue to be covered in terms of PMB protocols, provided a DSP is used to obtain the medicine and a valid authorisation exists.
  • The MRP will apply where a generic medicine exists and the additional cost of any medication obtained voluntarily at a value above this reference price will be the member’s liability.
  • See pages 35-36 in the Member Guide for more detail.

Mediscor share call number: 0860 119 553

For non-RSA members +27 12 674 8000

For further details with regards to Medicines, see Chapter 6 in the Member Guide.

Optometry

Composite consultation

(Including Refraction, Tonometry, Visual Field screening, Biometrics readings and Authenticate IT)

Frame and Lens Enhancements

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

Contact Lenses

Hard Contact Lenses

  • 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.

 

  • Composite consultation limit per 2-year cycle to a maximum of R675 at a PPN provider and R330 at a Non-PPN provider.
  • Composite consultation includes: Refraction, Tonometry and Visual Fields tests.
  • The PPN network consists of approximately 75% of all registered optometrists in RSA.
  • Visit the PPN website www.ppn.co.za to find your nearest PPN provider.

+

  1. Frame and Lens Enhancements – R1 550 for a PPN Network provider and R1 200 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
    1. Single vision – R370 OR
    2. Bifocal – R840 OR
    3. Multifocal – R1 490

OR

  1. Contact lenses
    1. Soft contact lenses- R1 500 per year OR
    2. 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

Cataract Removal

  • Benefit is the cost as approved by the Society.
  • Subject to pre-authorisation and managed care protocols.
  • The Society will pay for one post-operative cataract consultation per year.
  • In the event that an optometrist refers a beneficiary for a cataract examination by an Ophthalmologist, the prescription may not be completed until the outcome of the referral is known. Should the optometrist prescribe and dispense spectacles before any surgery that may subsequently be performed, then the beneficiary will not qualify for additional optical benefits post-surgery within the 24-month optical benefit cycle.
  • Preferred providers contracted specifically for cataract procedures are to be providers of first choice. Should a preferred provider not be within a 25km radius of the beneficiary’s residential address, then a DSP Network hospital is to be used.

Intra-ocular lenses

  • Benefit is the cost as approved by the Society, limited to single vision lenses and to a maximum of R2 330 per lens per lifetime.
  • Managed care protocols apply and pre-authorisation is required from the hospital pre-authorisation department.

Refractive Surgery

  • Benefit for hospital and associated provider costs is 50% of Scheme Rate (if pre-authorised and Network Hospital is used, or done in rooms) or 50% of SRPL rate (if pre-authorised and non-Network Hospital is used).
  • Limited to one procedure per eye per lifetime.
  • Lenses limited to single vision lenses.
  • Including but not limited to Excimer Laser and eye surgery required for Astigmatism, Hypermetropia, Presbyopia, Myopia and Hypermyopia.

PPN share call number: 0861 103 529

For non-RSA members +27 41 506 5900

In-hospital

Hospitalisation

(Including Day Cases, Fixed Fee Cases for Cataracts, In-rooms procedures in lieu of hospitalisation and alternative facilities)

  • Benefit is the Negotiated Rate where a Network Hospital has been authorised.
  • Subject to pre-authorisation and managed care protocols in a facility and manner which the Society deems appropriate.
  • Negotiated Rate applies to DSP Network Hospital authorisations, day clinics, fixed-fee cataract procedures and sub-acute facilities and Scheme Rate applies to all service providers providing their services at Network Hospitals.
  • The SRPL rate applies to all voluntary admissions to a non-Network Hospital and for facilities not deemed appropriate.
  • Pre-authorisation is required from the hospital pre-authorisation department at least 5 working days prior to admission.
  • A co-payment of R1 500 per procedure authorised will apply to all Colonoscopies, Gastroscopies, Circumcisions, Vasectomies and Intravitreal Injections authorised to take place in-hospital.

    • Where two or more of the above procedures are performed simultaneously in-hospital, only one co-payment will be applied.
    • No co-payment will be applied to the above procedures if pre-authorised and done in rooms out of hospital.
  • The Society in its discretion may waive any co-payment in respect of treatment and procedures associated with an approved hospital admission.
  • A co-payment of R1 500 will apply to all arthroscopic and laparoscopic procedures performed for diagnostic purposes.
  • The following laparoscopic procedures may be authorised in terms of the Society’s protocols but will be subject to a capped overall benefit limit (inclusive of all hospital costs):

    • Laparoscopic assisted Vaginal Hysterectomy (R37 650), Laparoscopic Unilateral Inguinal Hernia (R29 360). Laparoscopic Incisional/Ventral Hernia (R46 690). RALP (Robotic assisted laparoscopic procedure) capped overall at R138 050 being made up of the capped fee for the hospital procedure only, at R87 850, and this includes the anaesthetic time limited to a maximum of to 3 hours. All the associated provider costs are capped at a combined total of R50 200 for the RALP.

MSO toll free contact number: 0800 111 669

For non-RSA members: +27 11 259 5000

For further details with regards to Hospitalisation, see Chapter 4 in the Member Guide.

Professional fees charged by service providers in hospital

  • Scheme Rate applies to service providers where authorisation has been provided for a Network Hospital admission, as well as for day clinics and sub-acute facilities.
  • The SRPL rate applies to all voluntary non-Network Hospital admissions for hospital and service provider claims.
  • Subject to managed care protocols and limits where applicable.

Maxillofacial and oral surgery

  • Benefit for hospital and associated provider costs is paid at Scheme Rate (if pre-authorised and Network Hospital is used, or done in rooms) or SRPL rate (if pre-authorised and non-Network Hospital is used).
  • Pre-authorisation is required from hospital pre-authorisation department and managed care protocols will apply.
  • This excludes surgery in preparation for Osseo-integrated implants and Orthognathic surgery.

Blood transfusions

  • Benefit is paid at SRPL rate.
  • Unlimited.

Psychiatric hospitalisation

Also alcohol and drug dependency in-hospital rehabilitation

  • Limited to 21 days per beneficiary per year provided that the treatment of PMB conditions is limited as per Annexure A of the Regulations.
  • Benefit is paid at Negotiated Rate (if pre-authorised and Network Hospital or registered mental health hospital is used), or SRPL rate (if pre-authorised and non-Network Hospital is used).
  • Limited to 24 days per beneficiary per year provided that the treatment of PMB conditions are limited as per Annexure A of the Regulations.
  • Benefit is paid at Negotiated Rate (if pre-authorised and Network Hospital or Rehabilition hospital is used), or SRPL rate (if pre-authorised and non-Network Hospital is used).

For both admissions above the following will apply:

  • Scheme Rate will apply to providers treating patients in Network and registered psychiatric hospitals.
  • For admissions to non-Network Hospitals, the SRPL rate will apply to the treating provider as well as the hospital.
  • Pre-authorisation is required from the hospital pre-authorisation department and managed care protocols will apply.
  • Internal prosthesis

    (such as bone cement, cages, plates, screws, stents and pacemakers, etc.)

    • Benefit is paid at the cost as approved by the Society.
    • Limited to an overall benefit of R48 540 per beneficiary (inclusive of bone cement, cages, screws, plates, coronary and vascular stents, pacemakers, aortic and valve replacements).
    • Managed care protocols will apply and pre-authorisation is required from the hospital pre-authorisation department.
    • The overall annual limit is cumulative for all the sub-limits below:

      • Joint replacements – R48 450;
      • Spinal prosthesis – R48 450;
      • Coronary and vascular stents, pacemakers, aortic and mitral valve replacements – R48 450; and
      • Mesh (Gortex slings and Permacol®) – R13 850.

    Cochlear implants

    • Benefit is paid at SRPL rate.
    • Managed care protocols will apply and pre-authorisation is required from the hospital pre-authorisation department.

    Hospital medicines

    • Benefit is Single Exit Price (SEP).
    • TTO medicine (take home medicine) up to a maximum of 7 days’ supply.

    Physiotherapy

    • Benefit is paid at Scheme Rate (if pre-authorised and Network Hospital is used), or SRPL rate (if pre-authorised and non-Network Hospital is used).
    • Subject to pre-authorisation and managed care protocols.

    Occupational, Speech Therapy and Dietician

    • Benefit is paid at Scheme Rate (if pre-authorised and Network Hospital is used), or SRPL rate (if pre-authorised and non-Network Hospital is used).
    • Subject to pre-authorisation and managed care protocols.

    Pathology

    • Benefit is paid at Scheme Rate (if pre-authorised and Network Hospital is used), or SRPL rate (if pre-authorised and non-Network Hospital is used).
    • Subject to a request by a medical practitioner.

    Radiology

    • Benefit is paid at SRPL rate.
    • Subject to a request by a medical practitioner.
    • Pre-authorisation is required from the hospital pre-authorisation department for all MRI (Magnetic Resonance Imaging) and CT (Computed Tomography) scans.
    • Limited to 3 scans per year in and out of hospital.
    • No benefit for Bone Density scans in hospital.

    Maternity

    • Benefit is Scheme Rate (if pre-authorised and Network Hospital is used), or SRPL rate (if pre-authorised and non-Network Hospital is used).
    • Subject to pre-authorisation and manged care protocols.
    • Limited to 2 days hospitalisation for normal delivery and 3 days for hospitalisation for a caesarean delivery.

    Prescribed Minimum Benefits (PMBs)

    • Benefit is diagnosis, treatment and care costs of the prescribed treatment.
    • Benefits are subject to the provisions set out in paragraph 2 of Annexure B of the Rules and shall, insofar as may be applicable, override any restrictions or limitations imposed in respect of benefits set out below.
    • Notwithstanding any provisions to the contrary in this schedule, the Society will fund:

      • diagnosis, treatment and care costs of the PMBs subject to PMB regulations, if those services are obtained from a DSP; or
      • the relevant SRPL for the diagnosis, treatment and care costs of the PMBs if a beneficiary voluntarily accesses PMBs via a non-DSP, subject to PMB regulations; or
      • the cost for involuntary use of a non-DSP, subject to PMB regulations.
    • When annual limits are specified in this schedule, the limit will first be utilised for the payment of the relevant claims, and thereafter continued funding will apply for PMB claims only, subject to PMB regulations.
    • Diagnosis costs are only regarded as a PMB if the result of the diagnostic investigations confirms a PMB diagnosis.
    • In terms of the PMB regulations, protocols and treatment plans may be applied.

    For further details with regards to PMBs, see Chapter 03 in the Member Guide.

    Diagnostic testing

    Pathology

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

    Radiology

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

    CT and MRI Scans

    (In- and out-of-Hospital)

    • Benefit is paid at SRPL rate.
    • Limited to 3 scans per beneficiary per year.
    • Subject to managed care protocols and pre-authorisation from the hospital pre-authorisation department.

    Bone density scans

    • Benefit is paid at 90% of SRPL rate, out of hospital.
    • No benefit in-hospital.

    Oncology

    Treatment in and out of hospital

    • Benefit is according to the ICON Advanced Option.
    • Benefit is limited to R275 360 per beneficiary.
    • In-hospital treatment – ICON protocols apply and pre-authorisation is required from the hospital pre-authorisation department.
    • Out-of-hospital treatment – ICON protocols apply and pre-authorisation is required from Mediscor and the Society’s Managed-care department.
    • Should an ICON provider not be used, the consultation benefit will be limited to 75% of the SPRL rate and accrue to the Oncology benefit.
    • If you do not obtain your oncology medicine from one of the Society’s DSPs, a 30% out-of-network co-payment will be applied.
    • All parenteral medicine for oncology treatment must be obtained from Dis-Chem Direct and comply with normal MRP and Formulary rules.
    • 6 follow-up visits are provided for at an ICON provider.

    PET and related CT planning scans

    • Benefit is paid at SRPL rate.
    • Accrues to Oncology benefit limit.
    • Subject to ICON protocols and must be pre-authorised by the Society’s Managed-care department.

    Dental

    Conservative dentistry

    • Benefit is paid at SRPL rate.
    • Limited to R3 970 per beneficiary 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 for dentistry on children under the age of nine (limited to one admission per year), the 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

    • Benefit is paid at SRPL rate.
    • Limited to R6 580 per beneficiary.
    • Includes crowns, dentures, bridges, implants and periodontal treatment.
    • Managed care protocols apply and where hospitalisation is required contact the Society’s hospital preauthorisation department for authorisation.

    Orthodontic treatment

    • Benefit is paid at 75% of SRPL rate.
    • Limited to R24 000 per beneficiary per lifetime.
    • Benefits are not provided for treatment starting after a beneficiary’s 18th birthday.
    • Pre-authorisation is required from the Society’s Claims department.

    Medical equipment

    Aids and appliances

    • Benefit is paid at 50% of the cost as approved by the Society.
    • Limited to R7 870 per beneficiary.
    • Includes, but is not limited to: insulin pumps, continuous glucose monitoring (CGM) devices including test strips, CPAP machines, orthopedic 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 for medical equipment are included in the limit.
    • Managed care protocols apply and pre-authorisation is required from the Society’s Managed-care department.

    Colostomy bags and catheters

    • Benefit is paid at 90% of the cost as approved by the Society.
    • Limited to R20 860 per beneficiary.
    • Mediscor protocols apply and pre-authorisation is required from Mediscor.

    Continuous Oxygen Supply machine rental and/or oxygen

    • Benefit is paid at cost as approved by the Society.
    • Limited to R19 680 per beneficiary.
    • Portable Oxygen Concentrator subject to Society approval up to the annual limit.
    • Managed care protocols apply and pre-authorisation is required from the Society’s Managed-care department.

    Artificial limbs

    (including prosthetic eyes)

    • Benefit is paid at 90% of the cost as approved by the Society.
    • Limited to R51 160 per beneficiary per five-year cycle from date of first supply.
    • Managed care protocols apply and pre-authorisation is required from the Society’s Managed-care department.
    • No benefit is payable in respect of repairs to artificial limbs.
    • Where a rolling five-year benefit limit is applicable, the benefit limit due will remain fixed at the benefit limit that applied at the time of initial utilisation of the benefit. The benefit limit will only increase to the increased benefit limit in place at the time of the commencement of the next rolling five-year benefit cycle.

    Hearing aids

    • Benefit is paid at 90% of the cost as approved by the Society.
    • Limited to R19 020 per beneficiary per five-year cycle from date of last supply.
    • Managed care protocols apply and pre-authorisation is required from the Society’s Managed-care department.
    • No benefit is payable in respect of hearing aid repairs or batteries.
    • Where a rolling five-year benefit limit is applicable, the benefit limit due will remain fixed at the benefit limit that applied at the time of initial utilisation of the benefit. The benefit limit will only increase at the beginning of the next rolling five-year benefit cycle.

    Wheelchairs

    • Benefit is paid at 90% of the cost as approved by the Society.
    • Limited to R10 450 per beneficiary per rolling five-year cycle from date of last supply.
    • Quadriplegics and Paraplegics ONLY: limited to R30 100 per rolling five-year cycle from date of last supply.
    • Managed care protocols apply and pre-authorisation is required from the Society’s Managed-care department.
    • No benefit for motorised carts / tricycles other than motorised wheelchairs in appropriate quadriplegic cases.
    • No benefit for repairs to any wheelchairs.
    • Where a rolling five-year benefit limit is applicable, the benefit limit due will remain fixed at the benefit limit that applied at the time of initial utilisation of the benefit. The benefit limit will only increase at the beginning of the next rolling five-year benefit cycle.

    Care not in-hospital

    Audiology, Chiropody, Podiatry, Acupuncture, Dietician services, Occupational and Speech Therapy

    • Benefit is paid at 90% of SRPL rate.
    • Combined limit of R3 280 per beneficiary.

    Physiotherapy including Biokinetics and Chiropractic Services

    • Benefit is paid at 90% of SRPL rate.
    • Combined limit of R7 320 per beneficiary.

    Private Nursing, Hospice and Wound Care

    • Benefit is paid at 90% of SRPL rate.
    • Limited to R10 500 per beneficiary.
    • Pre-authorisation is required from the Society’s Managed-care department and the provider must have a registered practice number.

    Mental health

    • Benefit is paid at 90% of SRPL rate.
    • Limited to R13 770 per beneficiary.

    Home confinement/Natural birth delivery

    • Benefit is paid at SRPL rate.
    • Limited to the in-hospital maternity benefit costs.
    • Subject to pre-authorisation and managed care protocols.

    Emergency road and air transport

    • Benefit is paid at cost for emergency transport to hospital and for inter-hospital transfers, if pre-authorised by ER24.
    • ER24 is the DSP for all emergency and ambulance services.
    • No benefit for use of any other unauthorised ambulance services or when declined by ER24.
    • Coverage only in RSA, Lesotho and Swaziland and limited to qualifying residents in Botswana and Namibia subject to conditions as outlined on page 29 in the Member Guide.
    • Although members are covered for emergency evacuation within Lesotho and Swaziland, no hospital or other benefits apply in these countries.

    Other

    Dialysis

    (applicable only to PMB confirmed cases)

    • Benefit is paid at Scheme Rate (if pre-authorised and Network Hospital is used or done out of hospital, or SRPL rate (if pre-authorised and non-Network Hospital is used).
    • Managed care protocols will apply and pre-authorisation required from the Society’s Managed-care department.

    Organ transplants

    (applicable only to PMB confirmed cases)

    • Benefit is paid at Scheme Rate (if pre-authorised and Network Hospital is used), or SRPL rate (if pre-authorised and non-Network Hospital is used).
    • Managed care protocols will apply and pre-authorisation required from the hospital pre-authorisation department.

    Corneal transplants

    • Benefit is paid at Scheme Rate (if pre-authorised and Network Hospital is used), or SRPL rate (if pre-authorised and non-Network Hospital is used).
    • Graft benefit limited to R11 010 per beneficiary.
    • Harvesting cost limited to a maximum of R14 320.
    • Managed care protocols will apply and pre-authorisation required from the hospital pre-authorisation department.

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