Selfmed 80%

Comprehensive medical cover. Only 20% co-payments.
This option guarantees peace of mind.

The Selfmed 80% option provides you the following benefits:

  • Unlimited hospital cover at any private hospital in South Africa, paid at 100% of Agreed Tariff
  • Specialist covered at 80% of Cost in- and out- of hospital
  • Joint Replacements covered (co-payments may apply/ individual sub-limits apply)
  • Generous Oncology benefits, cover for Biological drugs
  • 65 Chronic Conditions covered up to R50,300.00 per family per year
  • Optometry: 100% of Scheme Tariff in respect of consultation and spectacles/ contact lenses limited to R10,900 per family per 24 month cycle
  • All optical benefits are subject to the Opticlear Network protocol
  • Ante-natal Classes paid at cost (R1,790.00)
  • Student dependants qualify for minor contributions up to the age of 25

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 Applicable80% of Cost. Subject to doctor’s visit and acute medication limit
Medicine received on discharge from hospital 100% of Agreed Tariff (RP applies), if purchased on date of discharge, subject to a maximum of 7 days supply
MEDICAL PRACTITIONERS
Consultations/ Visits80% of Cost or 100% of Medical Scheme Rate, whichever is greater – Unlimited80% of Cost – subject to the following limits:

Single member = max 15 visits
Member + 1 dependant = max 30 visits
Member + 2 or more dependants = max 45 visits
Radiology and Pathology100% of Medical Scheme Rate – Unlimited80% of Medical Scheme Rate – Unlimited
ECHO-Tests100% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate
– limited to R 3,500.00 per beneficiary per year
MRI- and CT-scans and radio-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 18,000.00 per family. A co-payment of R 1,800.00 will apply80% 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 18,000.00 per family. A co-payment of R 1,800.00 will apply
Clinical Procedures80% of Cost or 100% of Medical Scheme Rate, whichever is greater – Unlimited80% of cost for the following, 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
– Photocoagulation therapy
– Photodynamic therapy
All other clinical procedures are payable at 80% of Cost – Unlimited
Cochlear Implants100% of Medical Scheme Rate – limited to R 74,500.00 per implantNot Applicable
Material and injection material administered in doctor’s roomsNot Applicable80% of Agreed Tariff (RP applies) – Subject to Acute Medicine Limit
MATERNITY
Ante-Natal Classes and Foetal scans100% of Medical Scheme Rate – Unlimited80% of Cost – Benefits limited to 2 per beneficiary per year and the cost of a 3D-scan is limited to the cost of a 2D-scan, payable at 80% of Cost. Benefits allowed for additional pregnancy scans and/or prechildbirth education at 100% of Cost to a maximum of R 1,790.00 per family per year
Confinement100% of Agreed Tariff in respect of hospitalisation and 80% of Cost or 100% of Medical Scheme Rate in respect of Associated Provider Services – Unlimited
AUXILIARY SERVICES – Combined sub-limit may apply
Clinical Technology100% of Medical Scheme Rate – Unlimited80% of Medical Scheme Rate – Unlimited
Medical Technology100% of Medical Scheme Rate – Unlimited80% of Medical Scheme Rate – Unlimited
Physiotherapy & Biokinetics100% of Medical Scheme Rate – Unlimited80% of Medical Scheme Rate – Limited to
R 5,350 per beneficiary to a maximum of R 15,000 per family per year
Speech Therapy and Occupational Therapy100% of Medical Scheme Rate – Unlimited Treatment to form part of a Case Management Programme80% of Medical Scheme Rate – Limited to
R 5,350 per beneficiary to a maximum of R 15,000 per family per year
Podiatry, Orthoptic treatment, Hearing Aid Acoustics, consultations with Dietitians, Chiropractors, Osteopaths, Homeopaths, Naturopaths and Herbalists100% of Medical Scheme Rate – Benefits as described in respect of services rendered not as part of hospitalisation – Unlimited80% of Medical Scheme Rate – Limited to
R 5,350 per beneficiary to a maximum of R 15,000 per family per year
Aromatherapy, acupuncture and relexologyTo be self fundedTo be self funded
OPTICAL
ConsultationNot Applicable80% of Scheme Tariff for a standard eye examinaton per beneficiary per 24 month period – Subject to combined family limit per 24 month cycle
Spectacles and Contact LensesNot Applicable100% Medical Scheme Rate for a pair of generic standard lenses – 100% Medical Scheme Rate for a frame limited to R1,400 per beneficiary per 24 month period – OR – 100% Medical Scheme Rate for clear contact lenses limited to R1,800 per beneficiary per 24 month period – Subject to combined family limit per 24 month cycle
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 – 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 hospital
Non-preferred ProviderNot Applicable 100% 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 (CASE MANAGED)
Internal Prosthesis 100% of Cost. Specific sub-categories with limits apply. Please refer to Member Guide for detail
External Prosthesis100% of Cost -Limited to R 63,700.00 per family per year – Subject to approval by Case Manager
Orthopaedic Applicances100% of Cost, limited to R 9,400.00 per family per year – Subject to Case Management
Medical AppliancesNot Applicable80% of Cost – limited to R 5,300.00 per family per year. This maximum may be exceeded, subject to a maximum limit of
R 15,900.00, in respect of certain appliances, provided that the treatment forms part of a Case Management Programme
Hearing AidsNot Applicable80% of Cost – Limited to R16,200.00 per family per year
DENTISTRY
Basic80% of Medical Scheme Rate – Unlimited80% of Medical Scheme Rate – Unlimited
Specialised
80% of Medical Scheme Rate – limited to R 8,500.00 per beneficiary to a maximum of R 26,140.00 per family per year
MAXILLA-FACIAL AND ORAL SURGERY
Elective80% of Medical Scheme Rate – Unlimited80% of Medical Scheme Rate – Unlimited
Non-elective (excluding extractions)100% of Medical Scheme Rate – Unlimited. In the event of PMB, 100% of Cost, Subject to PMB protocol100% of Medical Scheme Rate – Unlimited. In the event of PMB, 100% of Cost, Subject to PMB protocol
Implantology80% of Medical Scheme Rate – implants (prosthesis) limited to R 5,600.00 per beneficiary per year
PRESCRIBED MEDICINE
Chronic (Member must apply for benefit)Not Applicable80% of Agreed Tariff (RP applies), limited to R 25,800.00 per beneficiary per year with a maximum of R 50,300.00 per family per year
AcuteNot Applicable80% of Agreed Tariff (RP applies) – 80% of Agreed Tariff (RP applies) limited to R 6,400.00 per beneficiary to a maximum of R 19,000.00 per family per year
Combined sub-limit applies
ImmunisationsNot Applicable 80% of Agreed Tariff (RP applies) – 80% of Agreed Tariff (RP applies) limited to R 6,400.00 per beneficiary to a maximum of R 19,000.00 per family per year
Combined sub-limit applies
Oral & Injectable ContraceptivesNot Applicable80% of Agreed Tariff (RP applies) – 80% of Agreed Tariff (RP applies) limited to R 6,400.00 per beneficiary to a maximum of R 19,000.00 per family per year
Combined sub-limit applies
NON-PRESCRIBED MEDICINE (PAT)
Non-Prescribed Medicine (PAT)Not Applicable80% of Agreed Tariff (RP applies) – limited to R 1,680.00 per family per year and subject to the Acute Medicine maximum
CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES
Organ TransplantsThe following benefits apply to organ donors in RSA. R 51,000.00 for a live donor, R 30,200.00 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% of Medical Scheme Rate for Kidney Dialysis, incl. associated Radiology and Pathology tests – Unlimited
Oncology100% of Agreed Tariff - Benefit managed as part of an Oncology Management Programme. Overall limit of R 408,500.00 per family per year applies with a sub-limit of R 158,000.00 for Biological Drugs, if approved by the Scheme
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
Mammogram and Pap SmearsBenefit subject to Disease Management protocol
AIDS AND HIV – Benefits managed as part of a Disease Management Programme
FOREIGN CLAIMS – Namibian claims only
MENTAL HEALTH
Clinical Psychology100% of Medical Scheme Rate – Unlimited – provided that treatment must form part of Case Management Programme80% of Medical Scheme Rate – subject to R 8,800.00 Clinical Psychology limit
Psychiatry100% of Medical Scheme Rate provided that treatment must form part of Case Management Programme. Treatment to be obtained in a mental health institution as approved by the Scheme80% of Medical Scheme Rate – subject to R 8,800.00 Clinical Psychology limit
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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