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MEDXXI

Hospital plans allow you direct control over your medical spending and the management of your budget and offer core medical cover in case of an emergency.

The MEDXXI option is a hospital plan that offers you the following:

  • Unlimited hospital cover at any of the Scheme’s Designated Hospitals, paid at 100% of Agreed Tariff
  • 25 PMB Chronic Conditions
  • Ante-natal Classes and Foetal Scans R1,790.00
  • Contraceptive benefit to a maximum of R1,680.00
  • 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. Please refer to Sales Brochures for full details
  • Benefits for Non-Elective Maxilla-Facial and Oral Surgery
  • Maternity visits (subject to limit)
  • Out-Patient Treatment at Hospital Facility – Limited to R1,050.00 per family per annum for treatment at a hospital out-patient facility or emergency rooms

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 use whilst hospitalised100% of Agreed TariffNot Applicable
Outpatient treatment at hospital facilityNot ApplicableLimited to R 1,050.00 per family per annum for treatment at a hospitals outpatient facility or emergency rooms
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/ Visits100% of Medical Scheme Rate – UnlimitedTo be self funded
Radiology100% of Medical Scheme Rate – UnlimitedTo be self funded, except for 1 Mammogram per year, except for PMB
Pathology100% of Medical Scheme Rate – UnlimitedExcept if treatment part of Disease Management Programme and 1 Pap Smear per year by General Practitioner, except for PMB
ECHO-Tests100% of Medical Scheme Rate – UnlimitedTo be self funded
MRI- and CT-scans and Fadio-Isotope studies (Benefits subject to seperate pre-authorisation)100% 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 2,100.00 will apply100% 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 2,100.00 will apply
Clinical Procedures100% of Medical Scheme Rate – Unlimited.
Co-payments applicable to certain elective procedures, unless funded as PMB treatment. Please refer to Members’ Guide for details. No benefits for elective procedures, unless funded as PMB treatment:
– Joint Replacements
– Spinal Surgery
100% 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 ImplantsLimited to R 30,200.00 per implantNot Applicable
Material and injection material administered in doctor’s roomsNot ApplicableTo be self funded
MATERNITY
Ante-Natal Classes and Foetal scans100% 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
Ante-Natal ConsultationsNot Applicable100% of Medical Scheme Rate – Limited to 2 per year
Confinement100% of Agreed Tariff in respect of hospitalisation and 100% MSR in respect of Associated Provider services – Unlimited
AUXILIARY SERVICES
Physiotherapy and Biokinetics100% of Medical Scheme Rate – UnlimitedTo be self funded
Medical Technology100% of Medical Scheme Rate – UnlimitedTo be self funded
Clinical Technology100% of Medical Scheme Rate – UnlimitedTo be self funded
Speech Therapy and Occupational Therapy100% of Medical Scheme Rate – Unlimited Treatment must form part of Case Management ProgramTo 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 SurgeryNot ApplicableTo be self funded
SECONDARY FACILITIES
Treatment that forms part of a Case Management Programme
REHABILITATION
To be Self Funded. Only 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 a 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-authorisation
MEDICAL AND SURGICAL PROSTHESIS / APPLIANCES
Internal Prosthesis100% of Cost – Specific sub-categories with limits apply. Please refer to Member Guide for details
External Prosthesis100% of Cost – Limited to R 56,300.00 per family per year – subject to approval by Case Manager
Orthopaedic Appliances100% of Cost – Limited to R 8,000.00 per family per year – subject to Case Management
Medical AppliancesNot ApplicableTo be self funded
Hearing Aids
Not ApplicableTo be self funded
DENTISTRY
BasicTo be self fundedTo be self funded
SpecialisedTo be self fundedTo be self funded
MAXILLA-FACIAL AND ORAL SURGERY
ElectiveTo be self fundedTo be self funded
Non-elective (excluding extractions)100% of Medical Scheme Rate R 1,800.00 Co-payment applies, in the event of PMB, 100% of cost – Subject to PMB protocol100% of Medical Scheme Rate – Unlimited, In the event of a PMB 100% of Cost, Subject to PMB protocol
ImplantologyTo be self fundedTo be self funded
PRESCRIBED MEDICINE
Chronic (Member must apply for benefit)Not ApplicableTo be self funded – Except PMB
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 family 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, subject to R 44,800.00 for a live donor, and
R 26,800.00 for a cadaver (Annual Limit is applicable to in and out of hospital services). 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 FailureUnlimited - For Kidney Dialysis, incl. associated Radiology and Pathology tests
Oncology100% of Agreed Tariff - Benefit managed as part
of an Oncology Benefit Management Programme and subject to use of Preferred Provider Network. Subject to annual treatment limit of R 177,000.00 per family per year. No benefit for Biological drugs. Limit will not apply to PMB
Oxygen therapyFor Oxygen Therapy (cylinders included) - Subject to Case Management
AIDS AND HIVBenefits managed as part of a Disease Management Programme
FOREIGN CLAIMSNamibian claims only
MENTAL HEALTH
Clinical PsychologyUnlimited - Provided that treatment forms part of Case Management ProgrammeTo be self funded
PsychiatryProvided that treatment forms part of Case Management Programme. Treatment to be obtained in a mental health institution, as approved by the Scheme
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 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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