BENEFIT GUIDE 2022 - #inthistogether - Anglo Medical Scheme
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#inthistogether BENEFIT GUIDE 2022
INTRO
Our promise
We promise you lifelong, quality products that are market-competitive and cost-effective in order to meet your
healthcare needs. In addition, we will strive to offer you exceptional administrative efficiency and sound financial
risk management.
Your guarantee
As a member of a medical scheme, you have access to Prescribed Minimum Benefits (PMBs). PMBs are a set of
defined benefits put in place to ensure all beneficiaries have access to certain minimum healthcare services,
regardless of the benefit option they have selected.
These 270 PMBs cover the most common conditions, ranging from fractured bones to various cancers, menopause
management, cardiac treatment, medical emergencies and Covid-19. Some of them are life-threatening
conditions for which cost-effective treatment would sustain and improve the member’s quality of life.
PMB diagnosis, treatment and care is not limited to hospitals. Treatment can be received wherever it is most
appropriate – in a clinic, an outpatient setting or even at home.
1The access to diagnosis, medical or surgical management and treatment of these conditions is not limited and is paid according to specific protocols per condition. If your doctor has diagnosed you with a chronic PMB condition, the doctor or the pharmacist needs to call us to verify if you meet the Scheme’s clinical entry criteria. If you do, your chronic condition will be registered with the Scheme so that your medicine and disease management will be funded from the correct benefit category and not from your day-to-day benefits. In addition to the 270 PMBs, you are also guaranteed treatment and medication for 26 chronic conditions. Members with these chronic conditions will need to visit their healthcare practitioner and may have to register the condition with a specialised chronic disease management programme. Some disease management programmes are obtained from a Designated Service Provider (DSP). Once registered, members will be entitled to treatment, including medication according to treatment protocols and reference pricing. PMB chronic conditions Addison's Disease Crohn's Disease Hypertension Asthma Diabetes Insipidus Hypothyroidism Bipolar Mood Disorder Diabetes Mellitus Type 1 Multiple Sclerosis Bronchiectasis Diabetes Mellitus Type 2 Parkinson’s Disease Cardiac Failure Dysrhythmias Rheumatoid Arthritis Cardiomyopathy Epilepsy Schizophrenia Chronic Renal Disease Glaucoma Systemic Lupus Erythematosus Chronic Obstructive Pulmonary Disease Haemophilia Ulcerative Colitis Coronary Artery Disease Hyperlipidaemia 2
Scheme website benefits The Anglo Medical Scheme App
As this Benefit Guide is a summary of the registered Scheme Rules only, in some instances, we will refer Download the Anglo Medical Scheme App on your Android or iPhone for a convenient way to access
you to the Scheme website www.angloms.co.za for more information. The Scheme website offers you a information about your membership, plan and benefits anywhere, anytime.
public and a member-only login area.
To use the App, you must be registered on the AMS website. You will use the same username and
The public area contains:
password for this App as for the AMS website. If you are not yet registered on the AMS website, register on
• The full set of registered Scheme Rules
www.angloms.co.za - you will find the link to register on the top right of the homepage.
• Information on how your Scheme works
• Detailed information on plans and products
The App will work on an iPhone or an iPod touch with iOS version 8.0 or later. Although the functionality will
• The Info Centre, containing an archive for MediBrief and news, as well as a glossary of medical
work on your iPad, it may not display properly. Your Android device needs to be version 2.3 or later. Android
scheme terms
devices include popular makes such as HTC, Samsung, LG, Sony and Huawei to name a few. The App has
• All contact details and more
been optimised for both smartphones and tablets.
In the member login area you can, after registration (depending on your plan):
• View all past interactions with the Scheme We are launching the App with the most frequently used functionality to start, but development will be
• Upload and track your claims ongoing with more content and functionality added as we go. Information and functionality might differ
• Check your chronic cover depending on your plan. Value Care Plan members will be able to access general membership information
• See your hospital authorisations and events and functionality only as this plan offers benefits via the Prime Cure network of providers.
• Update your personal details (including your banking details)
• Register your eligible dependants for AMS web access We have compiled a user guide for you which you will find in the Info Centre on the website.
• Change your communication preferences
• Check your available benefits Should you require any further assistance, please contact our administrator’s app & web team on
• Check your Medical Savings Account (Managed Care Plan only) webinfo@discovery.co.za or call them on 0860 100 696, Monday to Friday 7h00 – 18h00.
• Search for healthcare providers and accredited network facilities
• Access a library including all forms and information about procedures and medical scheme topics,
and more
We encourage you to register on the Scheme website and to make use of these administrative benefits.
4 5Your Scheme at a glance
High-level comparison
Please refer to more detailed benefit information in the relevant section of your plan and to the Scheme Rules.
VALUE CARE PLAN STANDARD CARE PLAN MANAGED CARE PLAN CATEGORY STANDARD CARE PLAN MANAGED CARE PLAN
PLAN COMPARISON
Type Network Traditional with certain Comprehensive with Medical Hospital services, incl. Radiology and
Unlimited Unlimited
Prime Cure providers network limitations Savings Account (MSA) Pathology
and facilities only Hospital Network Defined list of hospitals None
Tariff Prime Cure Tariff Scheme Reimbursement GP rate: 100% of SRR, or R68 470 per beneficiary subject to R145 235 per beneficiary subject to
Rate (SRR):100% GP network rate (negotiated Internal Surgical Prostheses
pre-authorisation pre-authorisation
Discovery Health Rate): no
Cancer (Oncology) Treatment R310 000 per beneficiary Unlimited subject to protocols
co-payments
Specialists excluding Pathology 21% of your contributions are
Medical Savings Account (MSA) No MSA
and Radiology: allocated to your MSA
– In hospital and in lieu of Specialised Medicine and Technology 20% co-payment Unlimited
hospitalisation: Top-Up rate up to Co-payments for non-DSP ambulance, Co-payments for non-DSP
230% (100% SRR + 130%) non-DSP hospitalisation, non-DSP dental ambulance, non-PMB hospitalisation,
– Out of hospital: Up to 125% of Co-payments services, non-network endoscopic and non-network endoscopic and
SRR cataract procedures, CDE de-registered cataract procedures, CDE de-
Benefits Primary healthcare See table on next page See table on next page members registered members
services Overall OH limit:
Out of Hospital (OH) Services MSA
Formulary medicine Limited Out of Hospital Medical Savings Account for Adult R5 500, Child R2 745
dispensed by network benefits Out of Hospital benefits Acute Medicine, GP and Specialist OH sublimit 2: Adult R5 165, Child R2 580 MSA
provider/pharmacy
Chronic Conditions Covered (non-PMB) 20 conditions 47 conditions
Chronic Medicine (non-PMB) R4 740 per beneficiary R18 300 per beneficiary
Hospital: Hospital Network: Hospital:
Family Hospital Limit: Unlimited Unlimited Medicine Management Strict protocol management Moderate protocol management
R173 000 (non-PMB) OH Pathology Adult R1 395, Child R500 Unlimited
Contribution rate* Main member: R1 075 Main member: R2 980 Total contributions OH Radiology Adult R1 820, Child R1 100 Unlimited
* Subject to Adult dependant: R1 075 Adult dependant: R2 980 Main member: R5 450 Basic Dentistry Basic services at DSP
underwriting Child dependant: R265 Child dependant: R895 Adult dependant: R5 450 Additional Basic and Specialised Adult R3 970; Child R1 500
Child dependant: R1 260 Adult R1 435, Child R360
Dentistry
When you consider switching plans (for reasons such as a change in income or
medical need), you may do so at the end of the year. We recommend you speak to Excluding MSA Eye Care Examinations R415 per beneficiary MSA
one of our Client Liaison Officers or your Paypoint Consultant for advice. Main member: R4 305 Eye Care Lenses and Frames R2 280 per family MSA
A plan change request form is included in the back of your Benefit Guide or on Adult dependant: R4 305
Frail Care None R73 040 per beneficiary
the website and has to be handed to your employer or pension fund administrator Child dependant: R995
as soon as possible, but not later than 10 December if you want to change your
plan for the next year. If you are a direct paying member, please submit the form Savings VALUE CARE PLAN
to the Scheme. Main member: R1 145
Healthcare services as per your plan benefits are fully covered, according to protocols, within network.
To calculate your individual contribution, use the Contribution Calculator on Adult dependant: R1 145
www.angloms.co.za > Plans & Products > Plan Comparison. Child dependant: R265
2022 benefits and contributions are subject to the approval of the Council for Medical Schemes
6 7Value Care Plan
Value Care Plan provides primary healthcare through a network of Prime Cure facilities and providers only.
In return for receiving quality, basic healthcare at the Scheme’s most affordable contribution rate, members of
this plan may only obtain healthcare services from a Prime Cure facility or network provider.
Value Care Plan Limits unless PMB
Family Hospital Limit R173 000 Consultations Nurse
R580 per family, maximum
practitioner at Prime
Sublimit Private Prime R290 per visit
VALUE CARE
R75 000 Cure network pharmacy
Cure hospital
Sublimit Blood
R17 110 Unlimited
transfusions
Consultations Prime Authorisation needed
R19 700 Cure network GPs after 6th consultation per
Sublimit Pathology
per family beneficiary
Sublimit Internal R30 000
surgical prostheses per family 3 815 per family,
R
Consultations
5 consultations per family,
R8 320 Specialist
Sublimit Psychiatric limited to 3 per beneficiary
per family
services
5 days
R2 905 per family with a
Sublimit Allied R8 320 Allied healthcare
maximum amount of
healthcare services per family services
R1 935 per beneficiary
Sublimit Specialised Radiology R19 700 per family
R105 per purchase limited
Pharmacist Advised
to three purchases up to
Therapy (PAT)
R315 per beneficiary
Contributions* Main member R1 075 Consultations GPs R1 100 per consultation
Adult dependant R1 075 out-of-network One consultation per
* Subject to underwriting Child dependant R265 beneficiary or two per family
9How it works
To call an ambulance To claim
Phone 0861 665 665 and press option 1. If deemed an emergency, Prime Cure will authorise and send an If you received emergency medical services outside the network which were authorised the next
ambulance. working day, please submit your claim to:
Email: refunds@primecure.co.za
In a medical emergency, where authorisation was not obtained, you need to provide details to Prime Cure by Send your claim with completed refund form, available on
calling 0861 665 665 the next working day following the incident. If deemed a non-emergency, you will be liable www.primecure.co.za/refund-request-form/
for the full cost. Post: Prime Cure Health, Private Bag 2108, Houghton, 2041
Third-party claims (for example, the Road Accident Fund) are not the responsibility of the Scheme.
To find a Prime Cure network doctor or facility Emergency treatments will be paid, but will need to be refunded.
Call 0861 665 665 or visit www.angloms.co.za > Plans & Products > Value Care Plan. You will not be responsible
to settle any account as Prime Cure is responsible for the payment of claims to network healthcare providers In order to be refunded, please ensure you provide the following information:
(unless you have not complied with the Rules). You may have to pay specialists for out of hospital consultations • A detailed account; and
and services upfront; you then submit the claim to Prime Cure. Prime Cure will reimburse costs for specialists at • Proof of payment
the Prime Cure agreed rate.
Your responsibilities
• Comply with Scheme Rules
To obtain authorisation • Obtain authorisation for services listed in the benefit table. It is your responsibility, not your healthcare
Authorisation is required for certain procedures, treatment and hospitalisation before the event, as provider’s
indicated in the benefit table, to ensure benefits are available and correctly paid. Authorisation to be • Be responsible for co-payments if you use out-of-network services
obtained by the member or beneficiary by calling Prime Cure on 0861 665 665. If you do not obtain • Obtain services and referrals from your Prime Cure network provider only. Use of a provider out of the
authorisation you will, in some instances, be liable for a co-payment as stated in the benefit table, or you Prime Cure network results in a co-payment, which can be the difference between the actual cost
will be liable for the full cost of the service, unless otherwise stipulated. and the network rate, or a specified value, as per the Rules
10 11Benefits
Prime Cure network providers only
Is
Is authorisation
Is a referral programme IH
In hospital
What you are entitled to (per annum) required? Limit** Co-payments and comments
required? *** registration 0H Out of hospital
0861 665 665*
required?
Alcohol and drug treatment programme, including Y 21 days Y Network providers only Y IH 0H
hospitalisation and medication
Allied healthcare services: Audiology, dietetics, R2 905 per family with a Co-payment of 50% of Prime Cure negotiated/
occupational therapy, podiatry, physiotherapy, Y maximum of R1 935 per Y agreed rates applies if you self-refer to any N 0H
psychology, social services and speech therapy beneficiary practitioner
Authorisation is required the next working day after
Subject to Family the emergency incident. Authorise inter-hospital
Ambulance services Y N N IH 0H
Hospital Limit unless PMB transfers before the event. Voluntary use of non-DSP
results in a 30% co-payment
Cancer treatment: Management Programme including Subject to Family
Y Y In Public Facilities only Y IH 0H
chemotherapy and radiotherapy Hospital Limit unless PMB
Consultations at a network pharmacy wellness clinic: N
R290 per visit subject N N 0H
Nurse practitioner to a Family Limit of R580
Authorisation required after 6 consultations
Consultations out of hospital: Network GP in rooms (PMB N N
per beneficiary. If you do not get authorisation, N 0H
and non-PMB) you will be liable for a co-payment of 30% of the
cost
A maximum of R1 100 per
consultation (including
Member liable for 20% of the cost per visit, subject
Consultations out of hospital: Non-network GP related expenses) per
Y N to authorisation obtained the next working day N 0H
(non-PMB) beneficiary, maximum
after the consultation. Facility fees not covered
of 1 consultation per
beneficiary or 2 per family
* Unless otherwise specified ** PMB rules apply *** Subject to referral by Prime Cure network healthcare practitioner
12 13Is
Is authorisation
Is a referral programme IH
In hospital
What you are entitled to (per annum) required? Limit** Co-payments and comments
required? *** registration 0H Out of hospital
0861 665 665*
required?
Limited to R3 815 per A 30% co-payment will apply where authorisation
family, 5 consultations per was not obtained. Services paid up to the Prime
Consultations out of hospital: Specialists (non-PMB) Y family and a maximum Y Cure agreed rate only. Medication prescribed and N 0H
of 3 consultations per obtained at a Prime Cure network pharmacy is
beneficiary included in this limit
Emergencies: A 30% co-payment will apply where
Consultations out of hospital: Specialists Y Y authorisation was not obtained the next working day. Y 0H
in rooms (PMB and emergencies)
Services paid up to the Prime Cure agreed rate only
Due to the changing nature of this benefit, please
Covid-19 N N visit the Scheme website or call the Call Centre for N IH 0H
more information
Dentistry: Conservative treatments including fillings, N
One consultation per N
Specific codes will be paid if clinically appropriate. N 0H
x-rays, extractions and consultations beneficiary Authorisation needed for 5 or more extractions
Dentistry: Emergency consultations – pain, sepsis and One event per
N N Paid at Prime Cure agreed rate N 0H
extractions (non-network provider) beneficiary
Dentistry: Hospital admissions for children under the age of Y
Subject to Family Y N IH
7 for the removal of impacted third molars and trauma (PMB) Hospital Limit
Dentistry: Preventative treatment – cleaning, scaling, N
One treatment per N
Authorisation needed for children over 12 years. N 0H
polishing and fluoride treatment beneficiary Paid at the Prime Cure agreed rate
One set of acrylic Benefit only for members over the age of 21 years
Dentistry: Specialised Y dentures per family N and subject to a co-payment, payable to the N 0H
every 2 years dentist, of 20% per set
Diabetes Y N Must authorise and adhere to Scheme protocols N 0H
One examination per
Eye care: Eye examination N N N 0H
beneficiary
One pair of spectacles
No contact lenses or sunglasses.
Eye care: Lenses and frames N per beneficiary every N N 0H
Spectacles: Prescription valid for one month
2 years
HIV/AIDS: Confidential management programme Y N
Must register and adhere to Scheme protocols. Y 0H
including medicine and related expenses Your status will at all times remain confidential
* Unless otherwise specified ** PMB rules apply *** Subject to referral by Prime Cure network healthcare practitioner
14 15Is
Is authorisation
Is a referral programme IH
In hospital
What you are entitled to (per annum) required? Limit** Co-payments and comments
required? *** registration 0H Out of hospital
0861 665 665*
required?
Hospitalisation: Allied healthcare services: dietetics,
Sublimit: R8 320, subject to
occupational and speech therapy, physiotherapy, Y Y N IH
the Family Hospital Limit
podiatry and social services
Sublimit: R17 110 subject
Hospitalisation: Blood transfusions (non-PMB) Y Y N IH
to the Family Hospital Limit
Family Hospital Limit: A R2 000 co-payment applies if no authorisation
Hospitalisation: Hospital services including GP and
R173 000 was obtained. Authorisation must be obtained
specialist consultations in hospital, day cases and 7 day Y Y N IH
Private Hospital sublimit: within 24 hours or first working day after admission.
supply of to-take-out medicines
R75 000 Obtain authorisation if admitted via casualty as well
Sublimit: R30 000 per
Hospitalisation: Internal surgical prostheses Y family, subject to the Y N IH
Family Hospital Limit
5 days per admission, with
a maximum of R8 320
Hospitalisation: Psychiatric services (non-PMB) Y Y In Public Psychiatric Facility N IH
per family, subject to the
Family Hospital Limit
Hospitalisation: Psychiatric services (PMB) Y 21 days Y In Public Psychiatric Facility N IH
Family Hospital Limit
Kidney disease: Dialysis (haemo, peritoneal) Y Y In Public Facilities only Y IH 0H
(unless PMB)
2 specialist consultations,
Paid at Prime Cure agreed rate. Register your
Maternity: Antenatal consultations, GP and specialists Y 2 ultrasound scans (2D) Y Y 0H
pregnancy between week 12 and 20 of the
per pregnancy
pregnancy to qualify for benefits
Maternity: Confinement in hospital Y Family Hospital Limit Y Y IH
Formulary medicine only; obtained at network GP,
Medicine: Acute, inclusive of dental medication N N N 0H
dentist or pharmacy
R315 per beneficiary
Formulary medicine only; obtained at network
Medicine: Pharmacist Advised Therapy (PAT) N (R105 per purchase) N N 0H
pharmacy
* Unless otherwise specified ** PMB rules apply *** Subject to referral by Prime Cure network healthcare practitioner
16 17Is
Is authorisation
Is a referral programme IH
In hospital
What you are entitled to (per annum) required? Limit** Co-payments and comments
required? *** registration 0H Out of hospital
0861 665 665*
required?
N One month's supply at a time; obtained only at a
Medicine (PMB chronic) Y Medicine formulary Y 0H
network GP or pharmacy
PMB chronic conditions
Addison’s Disease Chronic Obstructive Pulmonary Disease Epilepsy Parkinson’s Disease
Asthma Coronary Artery Disease Glaucoma Rheumatoid Arthritis
Bipolar Mood Disorder Crohn’s Disease Haemophilia Schizophrenia
Bronchiectasis Diabetes Insipidus Hyperlipidaemia Systemic Lupus Erythematosus
Cardiac Failure Diabetes Mellitus Type 1 Hypertension Ulcerative Colitis
Cardiomyopathy Diabetes Mellitus Type 2 Hypothyroidism
Chronic Renal Disease Dysrhythmias Multiple Sclerosis
Organ transplant: Harvesting of the organ,
post-operative care of the member and the donor, Y Y In Public Hospital facilities only Y IH 0H
anti-rejection medicine, professional services in hospital
and payment of donor
Sublimit: R19 700 per
Pathology: In hospital N family, subject to the N N IH
Family Hospital Limit
N Limited to approved tests. Must be requested by
Pathology: Out of hospital N network provider. Programme registration for PMB Y N 0H
conditions
N Limited to approved x-rays. Must be requested
Radiology: Basic (Out of hospital) N N 0H
by network provider
Family Hospital Limit N
Radiology: Basic (In hospital) N Subject to approved codes N IH
(unless PMB)
Radiology: Specialised radiology, MRI, CT scans and Y
R19 700 per family subject Y N IH 0H
mammograms to the Family Hospital Limit
Subject to age and protocols. Flu - cost of vaccine
Vaccines: Covid-19 and flu N N N 0H
only.
Vitality check: Cholesterol, blood glucose, Vitality check done at Vitality Wellness network
N 1 per beneficiary per year N N 0H
BMI, blood pressure partners
* Unless otherwise specified ** PMB rules apply *** Subject to referral by Prime Cure network healthcare practitioner
18 19General exclusions General Rule reminders
The following are some of the Scheme exclusions (for a full list please refer to the Rules). These you would • This Benefit Guide is a summary of the 2022 AMS benefits, pending approval from the Council for
need to pay: Medical Schemes
• Frail care • Please refer to www.angloms.co.za (My Scheme, Scheme Rules) for the full set of registered Rules
• PET scans • The Anglo Medical Scheme Rules are binding on all beneficiaries, officers of the Scheme and on the
• Deep brain stimulator devices for Parkinson’s disease or epilepsy Scheme itself
• Implant devices for chronic pain management • The member, by joining the Scheme, consents on his or her own behalf and on behalf of any
• Polysomnogram and CPAP titrations registered dependants, that the Scheme may disclose any medical information to the administrators
• Facility fees and contracted third-parties for reporting or managed care purposes
• Medicine not found on the medicine list • A registered dependant can be a member’s spouse or partner, a biological or stepchild, legally
• Injury or illness that occur beyond the borders of the Republic of South Africa adopted child, grandchild or immediate family relation (first-degree blood relation) who is dependent
• Dental extractions for non-medical purposes on the member for family care and support
• All costs related to radial keratotomy and refractive surgery • To avoid underwriting, a member who gets married must register his or her spouse as a dependant
• Contact lenses, sunglasses and accessories within 30 days of the marriage. Newborn child dependants must be registered within 30 days of birth
to ensure benefits from the date of birth
The following medicines are specifically excluded unless authorised: • If your dependant reaches the age of 23 and you wish to keep him or her on the Scheme as an adult
• Erythropoietin (unless the beneficiary is eligible for renal transplantation) dependant, you may apply for continuation of membership
• Interferons • It is the member’s or dependant’s responsibility to notify the Scheme of any material changes, such
• Biologicals and biotechnological substances as marital status, banking details, home address or any other contact details and death of a member
• Immunoglobulins or dependant
20 21Standard Care Plan
Standard Care Plan is a traditional medical plan with defined benefits, Out of Hospital Family Limits and certain
network limitations.
Out of Hospital benefits are limited and grouped by service under individual limits. Unless it is a Prescribed
Minimum Benefit (PMB), all benefits are paid at 100% of the Scheme Reimbursement Rate (SRR):
• The SRR is based on the previously negotiated rate between medical schemes and providers
• Providers are entitled to charge above the SRR
• Members are encouraged to request the actual costs of services before purchasing them and to compare
with the SRR
• Obtain a quotation from your provider and call 0860 222 633 to receive an estimate of the SRR
• Members may negotiate a better rate with their provider
Hospital cover is unlimited and paid at 100% of SRR in network facilities.
STANDARD CARE
Contributions*: Main member R2 980, adult dependant R2 980, child dependant R895
* Subject to underwriting
22 23How it works
Standard Care Plan Limits unless PMB
To call an ambulance
EXAMPLE
How to calculate your Family Limit Adult R5 500 Phone our Designated Service Provider (DSP) Netcare 911 on 082 911. If deemed an emergency,
Overall Out of Hospital Family Limit
Child R2 745 Netcare 911 will authorise a road or air ambulance. If deemed a non-emergency, or services regarded
Sublimit 1: Alternative and allied Adult R3 550 as “home assessments” without transport to a casualty or hospital, you will be liable for the full cost. In a
Adult x 2 = R2 000
R1 000 healthcare Child R745 medical emergency where authorisation was not obtained, you need to provide details to Netcare 911
Sublimit 2: Consultations, acute the next working day after the incident.
Family Limit Adult R5 165
R2 200 medication and Pharmacist Advised
Child R2 580
Therapy (PAT) Voluntary use of a non-DSP results in a 20% co-payment.
Child
x 1 = R200
R200
Additional basic and specialised Adult R1 435
Dentistry Family Limit Child R360 To obtain authorisation
Use the combined available limit for one
or more family members Procedures, treatments, hospitalisation, external medical or surgical appliances, specialised radiology
Adult R1 820
Radiology Family Limit
Child R1 100 To access benefits and to ensure they are available and correctly paid, call 0860 222 633 to get
authorisation for procedures, treatments, hospitalisation, specialised radiology, internal surgical
Adult R1 395 prostheses and external medical appliances exceeding R3 000, before the event as indicated in
Pathology Family Limit
Child R500 the benefit table. Elective admissions need to be authorised 48 hours before the event. Emergency
General services in Unlimited
network hospitals Paid at admissions require authorisation the next working day after the event.
Radiology and Pathology 100% of SRR R9 795 per
Medical and surgical appliances Information required when calling for authorisation:
family
Internal surgical R68 470 per
• Membership number
prostheses beneficiary R4 740 per • Date of admission
Chronic medication (non-PMB)
beneficiary
• Name of the patient
Oncology: R310 000 per beneficiary per 12-month period. 20% co-payment
after depletion of limit, subject to protocols • Name of the hospital
• Type of procedure or operation, diagnosis with CPT code and the ICD-10 code
Specialised medicine 80% of SRR
and technology: (obtainable from the doctor)
• The name of your doctor or service provider and the practice number
24 25The authorisation number must be quoted on admission. It will be valid for a period of four months or To claim
until the end of the year, whichever comes first. Please phone 0860 222 633 if any of the details change
Ensure your claim is valid, you have received the treatment or services you have been charged for and
such as the date of operation, procedure, etc. If the admission is postponed or not taken up before it
that the following details are correct and complete:
becomes invalid, a new authorisation number will need to be obtained.
• Full name of main member
• Membership number
Chronic medicine • Name of patient (main member or dependant)
If you are diagnosed with a chronic condition (PMB or non-PMB), ask your doctor or pharmacist to • Name of provider and practice number
register the chronic condition by calling 0860 222 633. • Details of the service rendered (tariff code, CPT code and explanation)
• The diagnosis code (ICD-10)
We will then pay for your medicine from the relevant chronic medicine benefit and not from your day-to-
• The treatment date
day benefits. You can get a repeat of a month’s medication after 24 days (not before).
• Proof of payment if you have settled your account
Diabetes, HIV/AIDS and oxygen therapy management
Send your completed claim to:
Register on the programme to ensure maximum benefits: Email: claims@angloms.co.za
• Diabetes – call the Centre for Diabetes and Endocrinology (CDE) on 011 053 4400 Post: Anglo Medical Scheme, PO Box 746, Rivonia, 2128
• HIV/AIDS management – call 0860 222 633 Call: 0860 222 633 for further assistance
• Oxygen therapy management – call 0860 222 633 to receive services from VitalAire Upload: www.angloms.co.za after logging in as a member or
upload on the Anglo Medical Scheme App
To reduce your medicine costs
We can only process your claims if all details are legible. Fax submissions are therefore not
Visit www.angloms.co.za > Standard Care Plan > Medicine to find a Scheme Preferred Pharmacy near recommended. If you still prefer to fax the claims, please send them to 011 539 1008.
you for lower medicine prices and reduced co-payments.
26 27Third-party claims (for example, the Road Accident Fund) are not the responsibility of the Scheme. International claims
Emergency treatments will be paid, but will need to be refunded. You will need to provide a letter
Emergency and acute medical treatment received when travelling or residing overseas
of undertaking to refund the Scheme for any amounts paid on your behalf where a third party is
responsible for payment. The Scheme will consider, in accordance with the Rules and necessary authorisations, making a payment
towards your overseas healthcare cost.
You or your service provider have up to four months from the treatment date to submit a claim for • The Scheme will not pay a doctor or service provider outside RSA borders directly. You must pay for the
services at the time of the treatment and the Scheme may refund you
payment. After four months, it will be considered ‘stale’ and the Scheme will no longer be responsible
• If you are entitled to benefits from another insurer you must claim from that insurer first. Any shortfall
for payment.
or uncovered cost may be submitted to the Scheme, which will be considered based on your benefit
entitlements and the Scheme Rules
Keep all receipts so you can claim back from your personal tax and keep a copy in case the originals
• Complete the international claim form and submit a fully specified account, in English, with your
get lost.
proof of payment to the Scheme
• The account must give details of the service rendered and the relevant healthcare provider
After submission of your claim, the Scheme will: • Any payment made towards the cost of a claim will be made in South African Rands into your
• Notify you by SMS or email once your claim has been processed (if you have subscribed to this service) South African bank account. The amount paid will be at the SRR had the service been obtained in
• Pay all amounts according to the Scheme Rules and at the Scheme Reimbursement Rate (SRR) South Africa in the Scheme’s absolute discretion. If the service is not available in South Africa, the
• Pay this amount directly into your bank account (or the provider’s account) amount paid will be for a similar or equivalent service if it exists. Remember that, except in the case of
• Send you a statement by email or post showing amounts paid, to whom, rejections and amounts for a medical emergency, the normal authorisation procedure needs to be followed before undergoing
you to settle any routine or specialised treatment overseas
Repatriation and social transfers will not be covered. We suggest you take out adequate medical
travel insurance to cover any major medical emergency.
Your responsibility
• Check the statement if payments have been made correctly Chronic medicine advanced supply
• Check rejections on your statements. If a mistake has been made on the claim, correct it For an advanced supply of chronic medicine, please submit:
and resubmit within 60 days • A completed advanced supply form (available on www.angloms.co.za)
• A prescription covering the period
• Settle any outstanding amounts with your service provider
• A copy of your ticket or itinerary
• Obtain authorisation for services listed in the benefit table. It is your responsibility to get an authorisation,
not your healthcare provider’s The Scheme will only approve advanced supplies within the current benefit year. Call 0860 222 633 for
further assistance.
28 29Preventative Care Benefits
The following preventative care measures are recommended, and will be paid from your Out of
Hospital Family Limit or other relevant benefit limit at the Scheme Reimbursement Rate or negotiated
rate or cost if PMB. Please discuss your individual need with your doctor. Refer to the benefit table for
more detail.
To support you in managing your health proactively, we encourage you to take preventative measures.
Detecting health risks or a disease early could prevent a disease or at least improve the success rate of
the treatment. Description Sex of Age* Paid from Purpose
Eyesight check Early detection of eye
F/M 40+ Eye Care Benefit
The below preventative care benefits are paid by the Scheme (not from your normal benefits) at the Including Glaucoma screening disease or deterioration
Scheme Reimbursement Rate. Refer to the benefit table for more detail. Early detection of dental disease and
Dental check-up at DSP F/M All Basic Dental Benefit
preservation of dentine
Early detection of
Description Sex Age* Benefit Category Purpose Out of Hospital Services
Gynaecological check-up F All cancer and gynaecological
Benefit, Sublimit 2
Detection of osteopaenia or osteoporosis (fragile problems
Bone density scan F 65+ Specialised Radiology
bones)
Out of Hospital Services Early detection of medical
Colonoscopy F/M 50+ Endoscopy** Early detection of colorectal or colon cancer Hearing test F/M All
Benefit, Sublimit 1 conditions and hearing dysfunction
As per Pathology Out of Hospital
Immunisation HIV test F/M All Early detection of HIV/AIDS
F/M DoH# Vaccines Prevention of severe illness and death Benefit (non-PMB)
Covid-19 Vaccine
schedule
Immunisation children
Influenza prevention; particularly important for As recommended by the As per Out of Hospital Services Prevention and reduction of
people who are at risk of serious complications F/M
Flu Vaccine F/M All Vaccines Department of Health, GP schedule Benefit, Sublimit 2 complications of childhood diseases
from influenza (chronic conditions, pregnant, or paediatrician
HIV patients or ageing members)
Baby and child Baby/ Out of Hospital Services Early detection of developmental
Human Papillomavirus (HPV): F/M
F/M 9-26 Vaccines Prevention of cervical cancer caused by HPV Paediatric assessment Child Benefit, Sublimit 2 problems
Cervarix/Gardasil
Pathology screening
Prevention of serious lung infections; particularly • Cholesterol Pathology Out of Hospital
important for people who are at high risk F/M All Early detection of chronic illness
Pneumococcal Vaccine F/M 55+ Vaccines • Glucose Benefit (non-PMB)
for serious complications (certain chronic • Thyroid
conditions, HIV patients or ageing members)
Prostate check-up Out of Hospital Services
M 50+ Early detection of prostate cancer
Mammogram F 40+ Specialised Radiology Early detection of breast cancer (examination) Benefit, Sublimit 2
Maternity
F Maternity Monitoring of your pregnancy and prevention Senior members
Consultation
of complications Home nursing assessment on F/M 65+ Detection of complications or
Ultrasound F Maternity Doctor or Scheme request Out of Hospital Services
mobility problems negatively
Benefit, Sublimit 1
Pap smear F 21-65 Pathology: Pap smear Early detection of cervical cancer impacting on wellbeing or illness
Podiatry care F/M All
Prostate check
M 50+ Pathology Early detection of prostate cancer
(blood test) Out of Hospital Services
Skin health F/M All Detection of skin cancer
Vitality check Benefit, Sublimit 2
• Cholesterol
Stool test (cancer and other Pathology Out of Hospital Detection of cancer and other
• Blood glucose (sugar) F/M All Vitality check Early detection of chronic illness F/M 50+
screening) Benefit (non-PMB) diseases
• BMI
• Blood pressure
* recommended age unless you have specific risk factors **co-payments may apply in hospital *recommended age unless you have specific risk factors
#
Department of Health
30 31Benefits
All benefits paid at 100% of SRR*, or negotiated rate or at cost if PMB
Is authorisation Is programme Designated IH
What you are entitled to (per annum) required? Limit*** registration service provider In hospital Comments and co-payments
0860 222 633** required? (DSP) 0H Out of hospital
If you do not register with SANCA, you may
SANCA and continue using your existing provider, but you
Alcohol and drug treatment: Admission and Y 21 days N SANCA IH will be responsible for the difference between
medication in SANCA facility (subject to PMB)
approved facilities the amount charged and the amount the
Scheme would have paid to SANCA
Overall Out of Hospital Family SANCA and
Alcohol and drug treatment: Consultations and Y Limit and Sublimits: N SANCA 0H
medication upon discharge
Adult R5 500, Child R2 745 approved facilities
Notify Netcare 911 at the time of
Ambulance services: Life-threatening medical Y emergency or the next working day.
N Netcare 911 IH 0H
Authorise inter-hospital transfers before
emergency transport 082 911 the event. Voluntary use of non-DSP
results in 20% co-payment
100% of SRR for in and out of hospital
services subject to protocols. After the
depletion of the Oncology Limit, a
Oncology Limit Oncology facility co-payment of 20% applies. Innovation
Cancer treatment: Oncology management Y R310 000 per beneficiary, Y or accredited IH 0H
drugs will incur a co-payment of 20% from
programme
per 12-month period hospital commencement of treatment. Post-
oncology treatment will be recognised as
part of your oncology treatment which
needs to be registered separately
Due to the changing nature of this
Covid-19 N N N IH 0H
benefit, please visit the Scheme
website or call the Call Centre for more
information.
* Scheme Reimbursement Rate and Tariffs available from the Call Centre ** unless otherwise specified *** PMB rules apply
32 33Is authorisation Is programme Designated IH
What you are entitled to (per annum) required? Limit*** registration service provider In hospital Comments and co-payments
0860 222 633** required? (DSP) 0H Out of hospital
Dental hospitalisation (including medicine and
related products): In the case of trauma
Day clinic or
or patients under the age of 7 years requiring Y N IH
Hospital Network
anaesthetic, the removal of impacted molars,
maxillo-facial and oral surgery (PMB conditions)
Basic Dental Services Limit per Subject to DRC protocols
beneficiary: Every 180 days: 1 For a list of DRC network providers,
consultation, 1 scaling, polishing, call the Call Centre or visit
and fluoride treatment, 2 www.angloms.co.za
intra-oral radiographs per visit, Dental Risk
Dentistry: Basic dental services provided by the N 1 local anaesthetic per visit, N Company 0H
DRC network
4 extractions, 5 restorations (DRC)
(amalgam or resin), one pair of Authorisation required for more than
plastic dentures every 4 years 4 extractions. Authorisation required for
incl. 1 relining and repair per more than 5 resin restorations
year
Subject to DRC protocols. Use of
Dentistry: Basic dentistry provided by non-network N
Limited to basic dental services N N 0H
non-network provider results in a
provider listed above co-payment (the difference between
80% of SRR and the claimed amount)
Family Limit: Limit applies to both, network and
Dentistry: Additional basic and specialised dentistry N N N IH 0H
Adult R1 435, Child R360 non-network providers
Register on the Diabetes Programme
with the Centre for Diabetes and
Endocrinology (CDE) to receive
medicine, testing equipment and related
treatments according to the programme.
Diabetes management programme: Consultation Y If you choose not to register with CDE,
with doctors, dietitians, ophthalmologists, pathology Y CDE§ IH 0H
011 053 4400 you may continue using your existing
tests, podiatrists, medicine and related products
doctor, but you will be responsible for
the difference between the SRR and the
claimed amount on all diabetic-related
services including diabetic-related
hospitalisation
* Scheme Reimbursement Rate and Tariffs available from the Call Centre ** unless otherwise specified *** PMB rules apply §
If condition results in hospital admission, the Hospital Network applies
34 35Is authorisation Is programme Designated IH
What you are entitled to (per annum) required? Limit*** registration service provider In hospital Comments and co-payments
0860 222 633** required? (DSP) 0H Out of hospital
No co-payment if performed in a day
clinic or an accredited network facility,
or in case of emergency treatment. For
Endoscopy: Gastroscopy, colonoscopy, Day clinic or
Y N IH 0H a list of accredited facilities, call the Call
sigmoidoscopy and proctoscopy accredited facility
Centre or visit www.angloms.co.za.
Co-payment of R3 200 if admitted to
hospital specifically for an endoscopy
Eye care: Eye examinations N R415 per beneficiary N N 0H
20% discount on frames and eyeglass lenses
Eye care: Lenses, frames N R2 280 per family N N 0H at optometrists in the Discovery Health
Optometry Network
No co-payment when performed out of N
N
Intra-ocular lens subject to the hospital. For a list of accredited facilities, o
Eye care: Cataract surgery with intra-ocular lens o Day clinic or
Y Internal Surgical Prostheses N IH 0H please call the Call Centre or visit t
replacement t accredited facility
Limit www.angloms.co.za. Co-payment e
e
of R1 000 when performed in hospital
Once registered on the HIV/AIDS
§ management programme, members
HIV/AIDS: Confidential management programme Y Y N 0H
must adhere to Scheme protocols. Your
status will at all times remain confidential
After registration, phone Dis-Chem Direct
Dis-Chem
HIV/AIDS: Medicines Y Y 0H (011 589 2788) to confirm how you want
Direct
to receive your medication
Hospice: Instead of hospitalisation (in-patient care Y N IH 0H Subject to Scheme protocols
facility and out-patient home care)
* Scheme Reimbursement Rate and Tariffs available from the Call Centre ** unless otherwise specified *** PMB rules apply §
If condition results in hospital admission, the Hospital Network applies
36 37Is authorisation Is programme Designated IH
What you are entitled to (per annum) required? Limit*** registration service provider In hospital Comments and co-payments
0860 222 633** required? (DSP) 0H Out of hospital
Hospital services covered in network
hospitals. Co-payment of R3 200 for
Hospitalisation: Hospital services including allied
voluntary admission to a non-network
healthcare services (as determined by the Scheme),
hospital. No co-payment if medical
day cases, blood transfusions, radiology, pathology, Y Unlimited N Hospital Network IH
emergency. List of hospitals available
professional services and 7 day supply of to-take-out
from the Call Centre or Scheme website.
medication
Authorisation procedure, see page 25.
Subject to Scheme protocols
Hospitalisation: Internal surgical prostheses Y R68 470 per beneficiary N N IH
Hospitalisation: Step-down instead of hospitalisation Y N N 0H Subject to Scheme protocols
Hospitalisation: Professional services for a defined
list of minor procedures performed by specialists in Y N N 0H
doctor’s rooms instead of hospital
Co-payment of R3 200 per admission for N
Accredited facility
voluntary admission to a non-network e
Hospitalisation: Psychiatric admission Y 21 days N or IH
hospital. Authorisation procedure, see w
Hospital Network
page 25. Subject to Scheme protocols
§
Infertility: Treatment subject to PMB Y N N IH 0H
Kidney (renal) disease management programme: Y Y N IH 0H Subject to Scheme protocols
Dialysis (haemo or peritoneal)
Maternity management programme: Consultations Y
8 consultations, 2 ultrasound N N IH 0H
Register between weeks 12 and 20 of the
and ultrasound scans scans (2D) per pregnancy pregnancy to qualify for benefits
* Scheme Reimbursement Rate and Tariffs available from the Call Centre ** unless otherwise specified *** PMB rules apply §
If condition results in hospital admission, the Hospital Network applies
38 39Is authorisation Is programme Designated IH
What you are entitled to (per annum) required? Limit*** registration service provider In hospital Comments and co-payments
0860 222 633** required? (DSP) 0H Out of hospital
Confinement in network hospital or
in a low-risk maternity unit provided
by a registered midwife if preferred.
Maternity: Confinement Y N Hospital Network IH
Co-payment of R3 200 for voluntary
admission to a non-network hospital.
No co-payment if medical emergency
Discovery Health Authorisation required for appliances
Medical appliances: External appliances provided Y
Medical and Surgical N
network of 0H
over R3 000 each. You are responsible
by orthotists and prosthetists Appliance Family Limit: R9 795 orthotists and for the difference in cost when using
prosthetists a non-DSP
Medical appliances: External appliances provided Y
Medical and Surgical N N IH 0H
Authorisation required for appliances
by providers other than orthotists and prosthetists Appliance Family Limit over R3 000 each, paid at network rate
Medical appliances: Hearing aids Y
Medical and Surgical N N 0H
Clinical motivation by ENT required for
(1 pair every 2 years per beneficiary) Appliance Family Limit beneficiaries younger than 60 years
Medical appliances: Wheelchair Y
Medical and Surgical N N 0H
(1 wheelchair every 2 years per beneficiary) Appliance Family Limit
* Scheme Reimbursement Rate and Tariffs available from the Call Centre ** unless otherwise specified *** PMB rules apply
40 41Is authorisation Is programme Designated IH
What you are entitled to (per annum) required? Limit*** registration service provider In hospital Comments and co-payments
0860 222 633** required? (DSP) 0H Out of hospital
One month’s supply at a time. 100% of
SEP and dispensing fee, subject to the
Medicine Reference Price List. Generic
N medicine, where appropriate, will prevent
Medicine management programme: Chronic Y Y
Except HIV/AIDS
0H co-payments. Check generic alternatives
conditions (PMB)
and diabetes and co-payments on www.angloms.co.za
> My Plan > SCP > Medicine. Subject
to Scheme protocols. Registration by
pharmacist or doctor
PMB chronic conditions
§
Addison’s Disease Chronic Obstructive Pulmonary Disease Epilepsy Parkinson’s Disease
Asthma Coronary Artery Disease Glaucoma Rheumatoid Arthritis
Bipolar Mood Disorder Crohn’s Disease Haemophilia Schizophrenia
Bronchiectasis Diabetes Insipidus Hyperlipidaemia Systemic Lupus Erythematosus
Cardiac Failure Diabetes Mellitus Type 1 Hypertension Ulcerative Colitis
Cardiomyopathy Diabetes Mellitus Type 2 Hypothyroidism
Chronic Renal Disease Dysrhythmias Multiple Sclerosis
* Scheme Reimbursement Rate and Tariffs available from the Call Centre ** unless otherwise specified *** PMB rules apply §
when recognised as chronic according to Scheme protocol
42 43Is authorisation Is programme Designated IH
What you are entitled to (per annum) required? Limit*** registration service provider In hospital Comments and co-payments
0860 222 633** required? (DSP) 0H Out of hospital
One month’s supply at a time. 100% of
SEP and dispensing fee, subject to the
Medicine Reference Price List. Generic
medicine, where appropriate, will prevent
Medicine management programme: Chronic Y R4 740 per beneficiary N N 0H co-payments. Check generic alternatives
conditions (non-PMB)
and co-payments on www.angloms.
co.za > My Plan > SCP > Medicine. Subject
to Scheme protocols. Registration by
pharmacist or doctor
Non-PMB chronic conditions
§
Acne Atopic Dermatitis (Eczema) Gastro-oesophageal Reflux Disease (GORD) Osteoporosis
Other Venous Embolism
Allergy Management Attention Deficit Disorder Gout (chronic)
and Thrombosis
Alzheimer’s Disease Benign Prostatic Hyperplasia Ménière’s Disease Peptic Ulcer
Anaemia Degeneration of the Macula Migraine Psoriasis Vulgaris
Ankylosing Spondylitis Depression Osteoarthritis Pulmonary Embolism
In accordance with the organ transplant
Organ transplant: Harvesting of the organ, management programme. All costs for
post-operative care of the member Y Y N IH 0H organ donations for any person other
and the donor and anti-rejection medicine than a member or registered dependant
of the Scheme are excluded
* Scheme Reimbursement Rate and Tariffs available from the Call Centre ** unless otherwise specified *** PMB rules apply § when recognised as chronic according to Scheme protocol
44 45Is authorisation Is programme Designated IH
What you are entitled to (per annum) required? Limit*** registration service provider In hospital Comments and co-payments
0860 222 633** required? (DSP) 0H Out of hospital
Sublimits to Overall Limit: Sublimit 1:
Out of hospital services (non-PMB): Including Alternative and allied healthcare
Overall Out of Hospital Family services. Sublimit 2: Consultations, acute
consultations, visits, procedures, alternative and allied N Limit: Adult R5 500 N N 0H
medicine out of hospital and PAT. The
healthcare services, acute medicine and Pharmacist
Child R2 745 two OH sublimits do not add up, to allow
Advised Therapy (PAT)
member benefit flexibility within the
overall OH Limit
Sublimit 1
Alternative and allied healthcare services
Acupuncture, audiology, chiropody, chiropractic Family Limit also includes homeopathic,
services (including x-rays), dietetics, homeopathy, N Family Limit for alternative and N N 0H NAPPI coded compounded medicine,
naturopathy, occupational therapy, orthoptics, allied healthcare: dispensed by a registered homeopath
physiotherapy, podiatry, psychology, registered nurse Adult R3 550, Child R745 and
services, social services, speech therapy Overall Out of Hospital Family
Limit
Discovery Health
Orthotists and prosthetists consultations N N network of orthotists 0H
and prosthetists
Private nursing instead of hospitalisation Y N N 0H
Sublimit 2
GP and specialist in rooms (non-PMB), consultations,
visits, procedures and treatments in rooms and acute N N N 0H
medicine and injection material relevant to the Family Limit for consultations,
treatmentl acute medicine and PAT
Medicine: NAPPI coded acute medicine and Adult R5 165, Child R2 580
injection material prescribed or dispensed by and Overall Out of Hospital
N Family Limit N N 0H
a registered homeopath, GP, specialist or dispensed
by a pharmacy
PAT medicine: R115 per purchase, 5 purchases N N N 0H
per family every 3 months
Subject to Scheme protocols and
registration of chronic condition
Out of hospital services (PMB): Specialist and GP N N N 0H (registration on management
consultations for chronic PMB conditions
programme required for cancer, renal,
HIV and diabetes)
* Scheme Reimbursement Rate and Tariffs available from the Call Centre ** unless otherwise specified *** PMB rules apply
46 47Is authorisation Is programme Designated IH
What you are entitled to (per annum) required? Limit*** registration service provider In hospital Comments and co-payments
0860 222 633** required? (DSP) 0H Out of hospital
Oxygen therapy management programme: Subject to the Scheme clinical entry
At home, cylinder, concentrator (rental only) and Y N VitalAire 0H criteria. You are responsible for the
consumables difference in cost when using a non-DSP
Pathology: Out of hospital chronic disease N N N 0H Subject to Scheme protocols and
conditions (PMB) registration of the chronic condition
Cervical cancer screening:
beneficiaries from 21-65 years, one pap
Pathology: Pap smear/prostate check N N N IH 0H
smear test. Prostate screening: one PSA
test
Pathology: In hospital N N N IH
The Scheme will not pay for DNA testing
Family Limit
Pathology: Out of hospital (non-PMB) N N N 0H and investigations, including genetic testing
Adult R1 395, Child R500
for familial cancers and paternal testing
Radiology: In hospital N N N IH
Family Limit
Radiology: Out of hospital, x-rays (non-PMB) N N N 0H
Adult R1 820, Child R1 100
Radiology: Specialised radiology, isotope therapy,
Referral required. 1 scan for bone
MRI and CT scans, bone densitometry and Y N N IH 0H
densitometry per beneficiary
mammogram
* Scheme Reimbursement Rate and Tariffs available from the Call Centre ** unless otherwise specified *** PMB rules apply
48 49Is authorisation Is programme Designated IH
What you are entitled to (per annum) required? Limit*** registration service provider In hospital Comments and co-payments
0860 222 633** required? (DSP) 0H Out of hospital
Specialised medicine and technology:
This benefit applies to a specified list of specialised Paid at 80% of SRR, subject to Scheme
medicine (excluding oncology medicine) in excess Y N N IH 0H protocols. 20% to be paid as co-payment
of R5 000 per month and specialised technology in by member
excess of R5 000 per item as a once-off purchase
Frequency of vaccine(s) and
Vaccine: Covid-19 N administration according to N N 0H
DoH# guideline.
Recommended for high-risk patients
1 vaccine and 1 consultation
Vaccine: Influenza (Flu) N N N 0H (chronic conditions, HIV patients,
per beneficiary
pregnant or ageing members)
1 vaccine and 1 consultation Recommended for high-risk patients
Vaccine: Pneumococcal N per beneficiary over the age N N 0H (chronic conditions, HIV patients or
of 55 per lifetime ageing members)
1 lifetime vaccination per For beneficiaries from age 9-26, unless
Vaccine: Human Papillomavirus (HPV) N N N 0H
beneficiary motivated by your doctor
Vitality check: Cholesterol, blood glucose, Vitality check done at Vitality
N 1 per beneficiary per year N N 0H
BMI, blood pressure Wellness network partners
* Scheme Reimbursement Rate and Tariffs available from the Call Centre ** unless otherwise specified *** PMB rules apply #
Department of Health
50 51Ex gratia General exclusions
Members may apply for benefits in addition to those provided in the Rules. An application will be The following are some of the Scheme exclusions (for a full list please refer to the Rules). These you would
considered by the Scheme which may assist members by awarding additional funding. need to pay:
• Services rendered by any person who is not registered to provide healthcare services, as well as
These cases will be considered on the basis of financial hardship and/or in cases of exceptional clinical medicine that have been prescribed by someone who is not registered to prescribe
circumstances. Decisions do not set precedent or determine future policy as each case is dealt with on • Experimental or unproven services, treatments, devices or pharmacological regimes
its own merits. • Patent and proprietary medicines and foods, including anabolic steroids, baby food and baby milk,
mineral and nutritional supplements, tonics and vitamins except where clinically indicated in the
Call 0860 222 633 or download the ex gratia application form at www.angloms.co.za Scheme’s managed care protocols
• Cosmetic operations, treatments and procedures, cosmetic and toiletry preparations, medicated or
Submit the completed application form: otherwise
Email: ex-gratia@angloms.co.za or • Obesity treatment, including slimming preparations and appetite suppressants
Fax: 011 539 1021 or • Examinations for insurance, school camps, visas, employment or similar
Post: The Ex Gratia Department, P.O. Box 746, Rivonia 2128 • Holidays for recuperative purposes, regardless of medical necessity
• Interest or legal fees relating to overdue medical accounts
Upon approval, submit your claims: • Stale claims, which are claims submitted more than four months after the date of treatment
Email: ex-gratiaclaims@angloms.co.za or • Claims for appointments that a member fails to keep
Fax: 011 539 1021 or • Costs that exceed any annual maximum benefit and costs that exceed any specified limit to the
Post: Anglo Medical Scheme, P.O. Box 746, Rivonia 2128 benefits to which members are entitled in terms of the Rules
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