Value

Hospital and related

• No overall annual limit (100% scheme rate)
• Private hospitals (CORE plan network hospitals)
• Specialists cover a 100% medical aid rate
• To-Take-Out medication (TTO): seven (7) days PMB medication (Non-PMB limit applies) • Maternity cover within medical protocols (100% Scheme rate)
• Internal and external prosthesis, R55 026 per family, sub-limits apply
• Deductibles may apply for certain non-PMB procedures, please consult the benefit guide
• Oncology: unlimited for PMB and 80% scheme rate cover above R573 300
• Specialised radiology: MRI/PET/CT, two (2) scans per beneficiary per annum. 10% co-pay for non PMB.
• Ambulance and Emergency Services – Europe Assist (0860 117 799) 24-hour access. Authorisation is required within 72 hours of an emergency event

Out-of-hospital benefits other than GP & Specialists consultations, Pathology, Radiology and Chronic Medicine collective limit per family per annum

• M – R11 356
• M+1 – R23 980
• M+2 – R26 090
• M+3 + – R29 722
• Note that sub-limits apply

GP Consultations

• Ten (10) visits per beneficiary subject to an overall family limit of 20 visits
• A 30% co-payment will apply after the 7th GP visit per beneficiary
• Value Core – Unlimited GP visits. Acute medication from any GP within the DSP network. A 30% co-payment will apply for GP consultations outside the DSP* Network

Specialist Consultations

• M – three (3) visits
• M+1 – five (5) visits
• M+2 + – seven (7) visits

Combined radiology and pathology

• R4 106 per beneficiary per annum, subject to sub-limits

Dental care – Benefit managed by Dental Risk Company

• Consultations, fillings and extractions
• Preventative scale and polish
• Infection control
• Conscious sedation: limited to beneficiaries below the age of 16 years, managed care protocol applies
• Advanced dentistry: crowns and bridgework, dentures, orthodontics R5 115 per beneficiary, family limit of R7 303

Optical – Benefit managed by Isoleso

• 24-month treatment cycle
• One (1) eye test per beneficiary
• Frame: R902 per beneficiary
• Lenses: Single vision – R239 per lens. Bifocal vision – R504 per lens. Multifocal vision – R504 per lens.
• Or choose contact lenses -R2 053 per beneficiary

Maternity benefits – Register on the Bambino programme

• Ten (10) antenatal visits per pregnancy, six (6) either with a GP, Midwife and four (4) with a Specialist Obstetrician
• Two (2) x 2D scans
• Childhood Immunisation, as per the Department of Health, is for children up to 12 years of age. One (1) heart, hearing and vision screening for babies under two (2) years of age

Appliances

• Appliances are limited to R16 063 per family per annum. Sub-limits and treatment cycles apply

Cover for 26 PMB chronic conditions, subject to registration and approval. Covered medication, bloods and GP within PMB protocols and authorisations.

• Addison’s disease
• Asthma
• Bipolar Mood Disorder
• Bronchiectasis
• Cardiac failure
• Cardiomyopathy
• Chronic obstructive pulmonary disease
• Chronic renal disease
• Coronary artery disease
• Crohn’s disease
• Diabetes insipidus
• Diabetes mellitus types 1 & 2
• Dysrhythmias
• Epilepsy
• Glaucoma
• Haemophilia
• HIV/AIDS
• Hyperlipidaemia
• Hypertension
• Hypothyroidism
• Multiple sclerosis
• Parkinson’s disease
• Rheumatoid arthritis
• Schizophrenia
• Systemic Lupus Erythematosus
• Ulcerative colitis

Other Chronic (Non-CDL) Medicine, Subject to pre-authorisation clinical protocol and medicine formulary. R 16 008 per family per annum and limited to R7 938 per beneficiary per annum.

• Attention Deficit Hyperactivity Disorder (ADHD)
• Allergic Rhinitis
• Benign Prostatic Hypertrophy (BPH)
• Cushing’s Disease
• Cystic Fibrosis • Depression
• Endometriosis
• Gout
• Hyperthyroidism
• Hypoparathyroidism
• Menopause/Hormone Replacement Therapy (HRT)
• Myasthenia gravis
• Osteoarthritis
• Osteoporosis
• Paget’s Disease
• Pituitary Microadenomas
• Psoriasis
• Stroke (Cerebrovascular accident)

Health screening is an essential part of preventative healthcare and is vital to maintaining overall well-being and improving outcomes by providing care at the earliest possible stage.

Preventative Care and Screening Benefits include

• Wellness Consultation limit, R1 870 per family per annum
• One (1) Pap Smear for females over 18 years per beneficiary annually
• One (1) Mammogram for females over 40 years per beneficiary annually
• One (1) PSA for males over 40 years per beneficiary annually
• Blood sugar, cholesterol, blood pressure, Body Mass Index (BMI), HIV
• One (1) skin cancer screening per beneficiary above 55 years of age, annually

Vaccinations Benefit

• Covid-19 vaccination per beneficiary
• One (1) flu vaccination per beneficiary
• One (1) HPV vaccination for beneficiaries between nine (9) and 12 years of age
• One (1) Pneumococcal vaccine per beneficiary above 65 years of age

Female Contraceptive Benefit

• R1 604 per family per annum