Subject to DSPS, pre-authorisation and case management, clinical guidelines and
scheme rules. Emergency admissions must be notified to the Scheme within 48 hours
of admission
(Intensive Care, High Care, General Ward, Theatre and
Recovery Room)
All admissions (including PMBs) are subject to preauthorisation, case management,
clinical protocols and scheme rules.
A 30% penalty will be imposed for non-emergency late pre-authorisations.
Subject to PMB, clinical protocols and scheme rules. All procedures must be
preauthorised
Subject to PMB, preauthorisation, clinical protocols and scheme rules. Subject to
adherence to conservative treatment.
Department of Health Protocols apply.
Unlimited benefits for PMBs.
Subject to pre-authorisation, clinical guidelines, medicine formulary* and registration
on the Disease Management Programme
Subject to PMBs, preauthorisation, managed care protocols and scheme rules
Subject to pre-authorisation and PMBs at Day Clinic or as Day Case.
Subject to PMBs and preauthorisation at Day Clinic or as Day Case.
Subject to PMBs pre-authorisation, treatment protocols and the use of DSP.
General in-hospital benefit rules apply
Advanced dentistry benefits In-Hospital are limited to extensive conservative treatment
for children under the age of 7 years involving three (3) teeth.
General anaesthetic benefits are only available for children under the age of seven (7)
years for extensive dental treatment, limited to once per beneficiary per annum
Removal of symptomatic impacted wisdom teeth covered only as Day Case at a day
hospital
Subject to PMBs, pre-authorisation, treatment protocols and scheme rules.
Benefit for Temporo-Mandibular Joint (TMJ) therapy is limited to non-surgical
intervention/treatments.
Oral pathology procedures (cysts and biopsies, the surgical treatment of tumours
of the jaw and soft tissue tumours) will only be covered if supported by a laboratory
report that confirms diagnosis
Principal 
Adult 
Child 
