SelfNET Essential

Emergencies happen at any time, any place – to the best of us.

The SelfNET Essential entry-level option provides you the following benefits:

  • Hospital cover – Subject to a DSP network, limited to PMB conditions
  • 25 PMB Chronic Conditions
  • Unlimited MRI and CT scans in and out of hospital – 100% of the Network Rate for MRI and CT scans, performed in or out of hospital, subject to PMB regulation, obtaining a PAR, motivation and approval.
  • Confinement – Subject to pre-authorisation and Network Provider referral process.
  • Ambulance Services – 100% of Network Rate for emergency transport to and from hospital.

Benefits and Contributions

Description of Service/ TreatmentServices rendered as part of hospitalisation*Services rendered NOT as part of hospitalisation
HOSPITALISATION
Accommodation, theatre, medicine and material used whilst hospitalised100% of Negotiated Tariff at Scheme’s DSP, limited to PMBNot Applicable
Outpatient treatment at hospital facilityNot ApplicableTo be self funded
Medicine received on discharge from hospital100% of Network Rate (RP applies), if purchased on date of discharge, limited to a maximum of 7 days supply
MEDICAL PRACTITIONERS
General Consultations / Visits100% of Network Rate – Unlimited – Subject to PMB treatment and protocolTo be self funded
Specialist Practitioners Consultations / Visits100% of Network Rate – Unlimited – Subject to PMB treatment and protocolTo be self funded
Basic Radiology100% of Network Rate – Unlimited – Subject to PMB treatment and protocolTo be self funded
MRI- and CT-scans and radio-isotope studies (Benefits subject to seperate pre-authorisation)100% of the Network Rate for MRI-, CT scans, performed in or out of hospital, subject to PMB regulation, obtaining a PAR, motivation and approval
Basic Pathology100% of Network Rate – Unlimited – Subject to PMB treatment and protocolNo benefit unless treatment forms part of PMB treatment and protocol
Clinical Procedures100% of Network Rate – Unlimited – Subject to PMB treatment and protocolNo benefits will be allowed for elective Clinical Procedures, unless treatment forms part of PMB protocol
Material and injection material administered in doctor’s roomsNot ApplicableTo be self funded
MATERNITY
ConfinementSubject to pre-authorisation and Network Provider referral processNot Applicable
AUXILIARY SERVICES
Physiotherapy100% of Network Rate – Unlimited – Subject to PMB treatment protocolTo be self funded
Medical Technology100% of Network Rate – Unlimited – Subject to PMB treatment and protocolTo be self funded
Clinical Technology100% of Network Rate – Unlimited – Subject to PMB treatment protocolTo be self funded
Speech Therapy and Occupational Therapy100% of Network Rate – Unlimited – Subject to PMB treatment protocolTo be self funded
Podiatry, Orthoptic treatment, Hearing Aid Acoustics, consultations with Dietitians, Chiropractors, Osteopaths, Homeopaths, Naturopaths, Herbalists and BiokineticsTo 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 and PMB regulation
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. PMB regulation will apply
AMBULANCE SERVICES
Preferred Provider (ER24)Not Applicable100% of Newtork Rate – For emergency transport to and from a hospital
Non-preferred ProviderNot ApplicableTo be self funded
BLOOD TRANSFUSIONS
Blood transfusions100% of Cost, Subject to pre-authorisation – Limited to PMBTo be self funded
MEDICAL AND SURGICAL PROSTHESIS / APPLIANCES (CASE MANAGED)
Internal ProsthesisFunded as PMB treatment only
External ProsthesisFunded as PMB treatment only
Orthopaedic ApplicancesFunded as PMB treatment only
Medical AppliancesFunded as PMB treatment only
Hearing AidsNot 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-elective100% of Cost limited to PMB and subject to pre-authorisation and Network Clinical ProtocolTo be self funded
ImplantologyTo be self fundedTo be self funded
PRESCRIBED MEDICINE
Chronic (Member must apply for benefit)Not ApplicableBenefit is subject to approval and in accordance with the CDL Chronic Medicine Formulary. Medication to be supplied by Network Provider
AcuteNot ApplicableTo be self funded
ImmunisationsNot ApplicableTo be self funded
NON-PRESCRIBED MEDICINE(PAT)
Non-Prescribed Medicine (PAT)Not ApplicableTo be self funded
CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES
Organ TransplantsBenefits will only be allowed in respect of heart-, lung-, heart- and lung-, bone-marrow, kidney- and liver transplants. Benefits will apply in respect of a donor, provided that the donor is in RSA and further subject to the recipient being a beneficiary of the Scheme. Specific Radiology and Pathology tests associated with transplant procedure also qualify for benefit
Chronic Renal Failure100% of Network Rate for Kidney Dialysis, including associated Radiology and Pathology tests – subject to PMB protocol
OncologyBenefits are payable for PMB only. Benefit managed as part of a Disease Management Programme and use of the Scheme’s DSP network. No benefit for Biological drugs
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 Network Rate – For Oxygen Therapy (cylinders included) subject to Case Management
AIDS and HIV – Benefits managed as part of a Disease Management Programme
FOREIGN CLAIMS – Namibian claims only
MENTAL HEALTH
Clinical Psychology & PsychiatryBenefits for treatment out of hospital are subject to pre-authorisation, Case management through treatment plan and subject to PMB regulationBenefits for treatment in hospital are subject to pre-authorisation, Case management through treatment plan and subject to PMB regulation
PRESCRIBED MINIMUM BENEFITS (PMB) – Benefits subject to application and provided that the treatment and/ or chronic medicine is received from a Designated Service Provider. Please refer to the Member Guide for more detail. 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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