MED Elite

The MED Elite option provides you the following benefits:

  • Unlimited hospital cover at any of the Scheme’s Designated Hospitals, paid at 100% of Agreed Tariff
  • Joint Replacements covered (co-payments may apply/individual sublimits apply)
  • Generous Oncology Benefits, cover for Biological drugs
  • 65 Chronic Conditions covered up to R 32,340.00
  • Ante-natal Classes and Foetal Scans R 1,790.00
  • Benefits for Mammogram and Pap Smear
  • Certain clinical procedures (Gastroscopy and Colonoscopy) covered in Doctor’s room
  • MRI-,CT scans in and out of hospital
  • Benefits for Non-Elective Maxilla-Facial and Oral Surgery

Benefits and Contributions

Description of Service/ TreatmentServices rendered as part of hospitalisation – subject to pre-authorisationServices rendered NOT as part of hospitalisation
HOSPITALISATION
Accommodation, theatre, medicine and material used whilst hospitalised100% of Agreed TariffNot Applicable
Outpatient treatment at hospital facilityNot ApplicableTo be self funded
Medicine received on discharge from hospital100% of Agreed Tariff (RP applies), if purchased on date of discharge, subject to a maximum of 7 days supply
MEDICAL PRACTITIONERS
Consultations/ Visits200% of Medical Scheme Rate – UnlimitedTo be self funded
Radiology200% of Medical Scheme Rate – UnlimitedTo be self funded, Except for 1 Mammogram per year. Limit will not apply to PMB
Pathology200% of Medical Scheme Rate – UnlimitedTo be self funded, Except for cases managed as part of a Case Management Program and 1 Pap Smear per year by General Practitioner. Limit will not apply to PMB
ECHO-Tests200% of Medical Scheme Rate – UnlimitedTo be self funded
MRI- and CT-scans and radio-isotope studies (Benefits subject to seperate pre-authorisation)200% of Medical Scheme Rate for MRI-scans, computed tomography and radio-isotope studies, subject to obtaining a PAR, additional to the PAR required for hospitalisation. Benefit is limited to 2 scans per beneficiary and an overall limit of R 15,000.00 per family. A co-payment of R 1,800.00 will apply200% of Medical Scheme Rate for MRI-scans, computed tomography and radio-isotope studies, subject to obtaining a PAR, additional to the PAR required for hospitalisation. Benefit is limited to 2 scans per beneficiary and an overall limit of R 15,000.00 per family. A co-payment of R1 800 will apply
Clinical Procedures200% of Medical Scheme Rate – Unlimited

Co-payments applicable to certain elective procedures, unless funded as PMB treatment

Refer to Members’ Guide for details for co-payments
200% of Medical Scheme Rate

Subject to pre-authorisation:
– Upper and lower gastro-intestinal endoscopy (excl. sigmoidoscopy and anoscopy)
– Laser tonsillectomy
– 24-hour oesophageal pH studies
– Oesophageal motility
– Yag laser
– Photoagulation therapy
– Photodynamic therapy
All other clinical procedures = To be self funded
Cochlear Implants200% of Medical Scheme Rate

– limited to R 74,500.00 per implant
Not Applicable
Material and injection material administered in doctor’s roomsNot ApplicableTo be self funded
MATERNITY
Ante-natal Classes and Foetal scans200% of Medical Scheme Rate – UnlimitedPre-childbirth Education paid at 100% of Cost and/or Ultrasound Scans paid at 100% of Medical Scheme Rate per year, subject to a combined limit of R 1,790.00 per family per year
Confinement100% of Agreed Tariff in respect of hospitalisation and 100% MSR in respect of Associated Provider services – Unlimited
AUXILIARY SERVICES
Physiotherapy and Biokinetics200% of Medical Scheme Rate – UnlimitedTo be self funded
Medical Technology200% of Medical Scheme Rate – UnlimitedTo be self funded
Clinical Technology200% of Medical Scheme Rate – UnlimitedTo be self funded
Speech Therapy and Occupational Therapy200% of Medical Scheme Rate – Unlimited (Treatment must form part of the Disease Management Program)To be self funded
Podiatry, Orthoptic treatment, Hearing Aid Acoustics, consultations with Dietitians, Chiropractors, Osteopaths, Homeopaths, Naturopaths and HerbalistsTo be self fundedTo be self funded
Aromatherapy, Acupuncture and RelexologyTo be self fundedTo be self funded
OPTICAL
ConsultationNot ApplicableTo be self funded
Spectacles and Contact LensesNot ApplicableTo be self funded
Refractive SurgeryTo be self fundedTo be self funded
SECONDARY FACILITIES
Treatment that forms part of a Case Management Programme100% of Cost, subject to approval by Case Manager
REHABILITATION – To be self-funded, except for cases managed as part of a Case Management Programme, where a medical report was submitted by the attending Physician.
AMBULANCE SERVICES
Preferred Provider (ER24)Not Applicable100% of Agreed Tariff for emergency transport to and from hospital
Non-preferred ProviderNot Applicable100% of Medical Scheme Rate – Limited to R 2,950.00 per family per year, limit will not apply to PMB
BLOOD TRANSFUSIONS
Blood transfusions100% of Cost – Subject to pre-authorisation100% of Cost – Subject to pre-authorisation
MEDICAL AND SURGICAL PROSTHESIS / APPLIANCES (CASE MANAGED)
Internal Prosthesis100% of Cost. Specific sub-categories with limits apply. Please refer to Member Guide for detail
External Prosthesis100% of Cost, limited to R 58,400.00 per family per year – Subject to approval by Case Manager
Orthopaedic Applicances100% of cost limited to R 8,800.00 per family per year – Subject to Case Management
Medical AppliancesNot ApplicableTo be self funded
Hearing AidsNot ApplicableTo be self funded
DENTISTRY
BasicTo be self fundedTo be self funded
Specialised
To be self fundedTo be self funded
MAXILLA-FACIAL AND ORAL SURGERY
ElectiveTo be self fundedTo be self funded
Non-elective (excluding extractions)200% of Medical Scheme Rate R 1,800.00 co-payment applies. In the event of PMB, 100% of Cost Subject to PMB protocol200% of Medical Scheme Rate – Unlimited – In the event of PMB, 100% of Cost Subject to PMB protocol
ImplantologyTo be self fundedTo be self funded
PRESCRIBED MEDICINE
Chronic (Member must apply for benefit)Not Applicable100% of Agreed Tariff (RP), limited to R32,400.00 per family per year
AcuteNot ApplicableTo be self funded
ImmunisationsNot ApplicableTo be self funded
Oral & Injectable ContraceptivesNot Applicable100% of Medical Scheme Rate – Limited to R 1,680.00 per year
NON-PRESCRIBED MEDICINE (PAT)
Non-Prescribed Medicine (PAT)Not ApplicableTo be self funded
CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES
Organ TransplantsThe following benefits apply to organ donors in RSA. R 46,200.00 for a live donor, R 27,500.00 for a cadaver. Benefit in respect of donors only allowed if the recipient of the organ is a beneficiary of the Scheme. Specific Radiology and Pathology tests associated with transplant procedure also qualify for benefit. Limit will not apply to PMB
Chronic Renal Failure100% Medical Scheme Rate for Kidney Dialysis, incl. associated Radiology and Pathology tests – Unlimited
Oncology100% of Agreed Tariff – Benefit managed as part of an Oncology Benefit Management Programme. Overall limit R 327,100.00 per family per year with a sub-limit of
R 157,600.00 for Biological drugs, if approved by Scheme. Limit will not apply to PMB
Asthma, Chronic Obstructive Airways Disease, Diabetes and CardiocareBenefit managed by the Scheme and payable as per the applicable benefit described elsewhere in this summary
Oxygen Therapy100% of Cost of Oxygen Therapy (cylinders included) subject to Case Management
Human Papillomavirus (HPV), Prostate Test, Pneumococcal Conjugate Vaccine (PVC) and Annual Influenza Type B Single DoseBenefits subject to Authorisation on Disease Management Programme and provided that the condition forms part of Disease Management protocol. Further subject to member being registered on the Programme and member being compliant
FOREIGN CLAIMS – Namibian claims only
AIDS AND HIVS – Benefits managed as part of a Disease Management Programme
MENTAL HEALTH
Clinical Psychology100% of Medical Scheme Rate – Provided that treatment must form part of Case Management ProgrammeTo be self funded
Psychiatry100% of Medical Scheme Rate – Provided that treatment forms part of Case Management Programme. Treatment to be obtained in a mental health institution, as approved by the SchemeProvided that treatment forms part of Case Management Programme
PRESCRIBED MINIMUM BENEFITS (PMB) – Benefits subject to application and provided that the treatment and/ or chronic medicine is received from a Designated Service Provider. If voluntarily obtained from any other service provider, a 40% co-payment will apply. Scheme protocol apply.
*Services rendered as part of hospitalisation are subject to pre-authorisation.

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