SelfNET

Get the peace of mind that you and your family are covered.

The SelfNET entry option provides you the following benefits:

  • Hospital cover – Subject to a DSP network, limited to PMB conditions.
  • 25 PMB Chronic Conditions
  • 3 Non PMB Conditions – Adenoidectomy, Tonsillectomy, Grommets
  • General Practitioners Consultations – Unlimited, 100% of Network Rate via the Network GP for all medically necessary consultations per beneficiary. Cover includes basic primary care services. Minor trauma treatment subject to the listed tariffs.
  • Specialist Practitioners Consultations – 100% of Network Rate via the Network Provider, subject to a combined limit of R1,185.00 per Beneficiary per year for cost of consultation, medication, procedures and Radiology and Pathology related to the authorised out of hospital specialised visit, limited to a maximum of R2,370.00 per family per year subject to Pre-Authorisation.
  • Spectacles and Contact Lenses – One pair of clear standard mono-focal, bi-focal or multi-focal lenses plus standard frame from a selection OR one set of approved contact lenses to the value of R480.00 per Beneficiary per 24 months at the Network Optometrist. Frames other than the pre -selection of frames limited to R185.00.
  • Basic dentistry – 100% of the Network Rate, subject to the Network protocol and the use of the Network Dentist.
  • Basic Radiology – 100% of Network Rate, subject to the Network protocol, formulary and referral by a Network GP.
  • Basic Pathology – 100% of Network Rate, subject to the Network protocol, formulary and referral by a Network GP.
  • MRI-, CT scans in and out of hospital – 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. MRI and CT scans will be covered to a maximum of R500.00, should scan confirm non-PMB condition, subject to the General Practitioner – Out of Network/ Emergency visits limit of R1,050.00 per annum.
  • Maternity – Subject to pre-authorisation and Network Provider referral process.
  • Outpatient treatment at hospital facility/Out of Network Consultations – Benefits as described in respect of Medical Practitioners, limited to three consultations, subject to R1,050.00 limit. Account payable upfront by member and submitted to Network for refund in accordance with the Network protocol and benefit limit.

 

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 Tarriff at Scheme’s DSP, limited to PMBNot Applicable
Outpatient treatment at hospital facilityNot ApplicableBenefits as described in respect of Medical Practitioners, limited to three consultations, subject to R 1,050.00 limit. Account payable upfront by member and submitted to Network for refund in accordance with the Network protocol and benefit limit
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
MAJOR MEDICAL BENEFITS – NON-PMB
Adenoidectomy, Tonsillectomy and Grommets100% of Network Rate – Maximum benefit limit of R12,000.00 per family per year, subject to pre-authorisation and procedure being performed in a day hospitalNot Applicable
MEDICAL PRACTITIONERS
General Consultations / Visits100% of Network Rate – Unlimited – Subject to PMB protocol100% of Network Rate- Via the Network GP for all medically necessary consultations per beneficiary. Cover includes basic primary care services. Minor trauma treatment subject to the listed tariffs
Specialist Practitioners Consultations / Visits100% of Network Rate – Unlimited – Subject to PMB protocol100% of Network Rate – Via the Network provider, subject to a combined limit of R 1,185.00 per Beneficiary per year for cost of consultation, medication, procedures and radiology and pathology related to the authorised out of hospital specialised visit, limited to a maximum of R 2,370.00 per family per year
Basic Radiology100% of Network Rate – Unlimited – subject to PMB protocol100% of Network Rate, subject to the Network protocol, formulary and referral by a Network GP
MRI- and CT-scans and radio-isotope studies (Benefits subject to seperate pre-authorisation)100% of Network Rate – for MRI-, CT scans, performed in or out of hospital, subject to PMB regulation, obtaining a PAR, motivation and approval. MRI and CT scans will be covered to a maximum of R500.00, should scan confirm non-PMB condition subject to General Practitioners – Out of Network/ Emergency visits limit of R1,050.00 per annum
Basic Pathology100% of Network Rate – Unlimited – Subject to PMB protocol100% of Network Rate, Subject to the Network protocol, formulary and referral by a Network GP
Clinical Procedures100% of Network Rate – Unlimited but subject to PMB treatment and protocolNo benefits will be allowed for elective Clinical Procedures, unless treatment forms part of PMB
Material and injection material administered in doctor’s roomsNot Applicable100% of Network Rate, subject to the Network protocols, formulary and referral by a Network GP
MATERNITY
Foetal scans100% of Network Rate – Unlimited – Subject to PMB protocol100% of Network Rate, subject to the Network protocols, formulary and referral by a Network GP
Ante-Natal Specialist ConsultationsNot ApplicableSubject to combined Specialist Practitioners Consultations/ Visits benefit
ConfinementSubject to pre-authorisation and Network Provider referral process, limited to PMBNot Applicable
AUXILIARY SERVICES
Physiotherapy100% of Network Rate – Unlimited – Subject to PMB protocolTo be self funded
Medical Technology100% of Network Rate – Unlimited – Subject to PMB protocolTo be self funded
Clinical Technology100% of Network Rate – Unlimited – Subject to PMB protocolTo be self funded
Speech Therapy and Occupational Therapy100% of Network Rate – Unlimited – Subject to PMB 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 Applicable100% of the Network Rate – For one examination per beneficiary per 24 months at the Network Optometrist
Spectacles and Contact LensesNot ApplicableOne pair of clear standard mono-, bi- or multi-focal lenses plus standard frame from a selection OR One set of approved contact lenses to the value of R480.00 per Beneficiary per 24 months at the Network Optometrist. Frames other than the pre-selection of frames limited to R185.00
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 Cost100% of Network Rate – subject to pre-authorisation – Limited to PMB
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 funded100% of Network Rate, Subject to the Network protocol, list of codes and the use of a Network dentist
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-autorisation and Network Clinical Protocol
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 Applicable100% of the Network Rate (Subject to Reference Pricing) for Medicine, provided that it is prescribed or supplied by a Network GP and is subject to the Network formulary
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 this donor is in RSA and further subject to the recipient being a beneficiary of the Scheme. Specific radiology and pathology tests associated with the transplant will also qualify for benefit
Chronic Renal Failure100% of Network Rate for Kidney Dialysis, including associated Radiology and Pathology tests – Unlimited
OncologyBenefits are payable for PMB only. Benefit managed as part of 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 Cost – 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 during hospitalisation are subject to pre-authorisation and referral by Network GPBenefits for treatment out of hospital are subject to pre-authorisation and referral by network GP (DSP). 100% of Network Rate for consultations and treatment by a General Practitioner, Psychiatrist, Psychologist, Psychiatric Nurse Practitioner or Social Worker
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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