Selfsure

The Selfsure option provides you the following benefits:

  • Unlimited hospital cover for any PMB at DSP (Designated Service Providers) at any of the Scheme’s designated hospitals. 100% of Agreed Tariff for elective hospitalisation
  • GP visits, Specialist visits, acute meds = R5,350.00 (principal member); R3,780.00 (adult dependant); R1,890.00 (minor dependant)
  • Basic Dentistry, Pathology, Radiology and Physiotherapy = R5,450.00 or R7,650.00 for family
  • Optometry: 100% of Scheme Tariff in respect of consultation and spectacles/ contact lenses limited to R5,100.00 per family per 24 month cycle
  • All Optical benefits are subject to Opticlear Network protocol
  • Medical appliances = R4,300.00
  • 25 Chronic PMB conditions
  • Unlimited Maternity visits
  • Ante-natal Classes and Foetal Scans R1,790.00
  • Contraceptive benefit to a maximum of R1,680.00
  • 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
  • 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

Annual Day-to-day Limit: Principal Member = R 5,350.00;
Additional per adult dependant = R 3,780.00;
Additional per minor dependant = R 1,890.00
• Radiology, Pathology, Basic Dentistry, Physiotherapy and Biokinetics = R 5,450.00 or R 7,650.00 for family
• Optometry = 100% of Scheme Tariff in repspect of consultation and spectacles/ contact lenses limited to R 5,100.00 per family per familty per 24 month cycle
• Medical appliances = R 4,300.00 per family
HOSPITALISATION
Accommodation, theatre, medicine and material used whilst hospitalised100% of Agreed TariffNot Applicable
Outpatient treatment at hospital facilityNot Applicable100% of Medical Scheme Rate, Subject to Annual Day-to-day Limit
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 – Unlimited100% of Medical Scheme Rate – Subject to Annual Day-to-day limit
Radiology and Pathology100% of Medical Scheme Rate – Unlimited100% of Medical Scheme Rate – Subject to joint limit for Basic Dentistry, Physiotherapy and Biokinetics
ECHO-Tests100% of Medical Scheme Rate – Unlimited100% of Medical Scheme Rate – limited to R3,150.00 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 15,000.00 per family. A co-payment of R2100.00 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 R2100.00 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 detail. No benefits for elective procedures unless funded as PMB treatment:
-Joint Replacements
– Spinal Surgery
100% of Medical Scheme Rate 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 limited to Annual Day-to-day limit
Cochlear Implants100% of Medical Scheme Tariff– Limited to R 30,200.00 per implantNot Applicable
Material and injection material administered in doctor’s roomsNot Applicable100% of Medical Scheme Rate – Subject to Annual Day-to-day Limit
MATERNITY
Ante-Natal Classes and Foetal scans100% of Medical Scheme Rate – Unlimited100% of Medical Scheme Rate. Foetal Scans limited to 2 per beneficiary per year and the cost of a 3D scan is limited to the cost of a 2D scan. Benefits allowed for additional pregnancy scans and/or pre-childbirth education at 100% of Cost to a maximum of R1,790.00 per Family per Year
Ante-Natal Consultations100% of Medical Scheme Rate – Unlimited100% of Medical Scheme Rate – Unlimited
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 – Unlimited100% of Medical Scheme Rate – Subject to joint limit for Radiology, Pathology and Basic Dentistry
Medical Technology100% of Medical Scheme Rate – Unlimited100% of Medical Scheme Rate – Subject to Annual Day-to-day Limit
Clinical Technology100% of Medical Scheme Rate – Unlimited100% of Medical Scheme Rate – Subject to Annual Day-to-day Limit
Speech Therapy and Occupational Therapy100% of Medical Scheme Rate – Unlimited (treatment to form part of a Case Management Programme)100% of Medical Scheme Rate – Subject to Annual Day-to-day Limit
Podiatry, Orthoptic treatment, Hearing Aid Acoustics, consultations with Dietitians, Chiropractors, Osteopaths, Homeopaths, Naturopaths and Herbalists100% of Medical Scheme Rate – Subject to Annual Day-to-day Limit100% of Medical Scheme Rate – Subject to Annual Day-to-day Limit
Aromatherapy, acupuncture and relexologyTo be self fundedTo be self funded
OPTICAL
ConsultationNot Applicable100% of Medical Scheme Rate. For a standard eye examination per beneficiary per 24 month period – Subject to combined family limit per 24 month cycle
Spectacles and Contact LensesNot Applicable100% of Medical Scheme Rate – For a pair of generic standard lenses
100% of Medical Scheme Rate – For a frame limited to R500 per beneficiary per 24 month period – OR
100% of Medical Scheme Rate – For clear contact lenses limited to R900 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 benefits 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 R2,950.00 per family per year, limit will not apply to PMB
BLOOD TRANSFUSIONS – 100% 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 details
External Prosthesis100% of Cost, limited to R 56,300.00 per family per year – subject to approval by Case Manager
Orthopaedic Applicances100% of cost limited to R 8,000.00 per family per year – subject to Case Management
Medical AppliancesNot Applicable100% of Cost, limited to R 4,300.00 per family per year. This maximum may be exceeded, subject to a maximum of R12,900.00, in respect of certain appliances, provided that the treatment forms part of a Case Management Programme
Hearing AidsNot ApplicableTo be self funded
DENTISTRY
Basic 100% Medical Scheme Rate – R1,800.00 co-payment applies and subject to joint limit for Radiology, Pathology, Physiotherapy and Biokinetics100% Medical Scheme Rate – Subject to joint limit for Radiology, Pathology, Physiotherapy and Biokinetics
Specialised100% Medical Scheme Rate – R1,800.00 co-payment applies and subject to Annual Day-to-day Limit100% Medical Scheme Rate –Subject to Annual Day-to-day Limit
MAXILLA-FACIAL AND ORAL SURGERY
Elective
100% Medical Scheme Rate – R1,800.00 co-payment applies and subject to Annual Day-to-day Limit100% Medical Scheme Rate – Subject to Annual Day-to-day Limit
Non-elective (excluding extractions) 100% Medical Scheme Rate – R1,800.00 co-payment applies. In the event of PMB 100% of Cost – Subject to PMB protocol100% Medical Scheme Rate – Unlimited _ In the event of PMB 100% of Cost – Subject to PMB protocol
Implantology100% Medical Scheme Rate – R 1,800.00 co-payment applies, PMB 100% of Cost -Subject to PMB protocol100% Medical Scheme Rate – Subject to Annual Day-to-day Limit
PRESCRIBED MEDICINE
Chronic (Member must apply for benefit)Not ApplicableNo benefit, except PMB
AcuteNot Applicable100% of Agreed Tariff (RP applies) – subject to Annual Day-to-day Limit
ImmunisationsNot Applicable100% of Agreed Tariff (RP applies) – subject to Annual Day-to-day Limit
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 Applicable100% of Agreed Tariff (RP applies) – limited to R 280.00 per day and subject to Annual Day-to-day Limit
CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES
Organ TransplantsThe following benefits apply to organ donors in RSA. R 44,900.00 for a live donor, R 26,800.00 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 Benefit Management Programme and subject to use of Preferred Provider. Overall limit R 242,400.00 per family per year. Limit will not apply to PMB. 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 of Oxygen Therapy (cylinders included) subject to Case Management
Human Papillomavirus (HPV)Benefits 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.
FOREIGN CLAIMS – Namibian claims only
AIDS AND HIVS – Benefits managed as part of a Disease Management Programme
MENTAL HEALTH
Clinical Psychology100% Medical Scheme Rate – Unlimited – provided that treatment forms part of Case Management Programme100% Medical Scheme Rate – Subject to Annual Day-to-day Limit
Psychiatry100% Medical Scheme Rate – Provided that treatment forms part of Case Management Programme. Treatment to be obtained in a mental health instituion, as approved by the Scheme100% Medical Scheme Rate – Subject to Annual Day-to-day 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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