Onyx Benefit Guide Your 2018 - Passionate about your health - GEMS
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Your 2018
Onyx Benefit Guide
Passionate about your health
Working towards a healthier you
This guide shows you what benefits you have access to on the Onyx
option. Keep this guide handy for quick access to your benefits information.
Onyx is a top-of-the-range benefits option that offers extensive cover.
On the Onyx option you can claim for certain out-of-hospital expenses such
General Contraceptives Basic radiology
as General Practitioner (GP) and specialist visits, contraceptives or basic Practitioner (GP)
radiology from your day-to-day Block Benefit.
Important information to remember about the Onyx option
01 04
The Ruby, Emerald and Onyx (REO) Network is made Always get a referral from your nominated GP before you consult a specialist.
up of General Practitioners (GP), dental providers, Remember to ask for a specialist on the GEMS Specialist Network if you need to
specialists, renal dialysis providers, document-based consult a paediatrician, psychiatrist, obstetrician, gynecologist or a physician (which
care providers and pharmacies who have agreed also includes pulmonologists, gastroenterologists, neurologists, cardiologists and
to charge the contracted rate and follow GEMS rheumatologists). Network GPs and specialists have agreed to charge contracted
Network and managed care rules. rates so that you will not have to pay any out-of-pocket expenses for your
consultations. Your day-to-day benefits will also last longer if you use healthcare
providers that are on the GEMS network.
02
To find a GEMS Network provider in your area, visit
the GEMS website at www.gems.gov.za and click 05 Remember to call 0860 00 4367 to get pre-authorisation for all hospital visits, out-
on the GEMS Network logo or call the GEMS Call patient visits to a hospital, MRI scans, CT scans or radio-isotope studies, in-hospital
Centre on 0860 00 4367. physiotherapy, ambulance transportation and specialised dentistry.
03
We encourage you to nominate a GP on the GEMS REO GP Network, who you will consult for all your doctor visits. However, penalties will not apply
if you do not nominate a GP. Your nominated GP has the best understanding of your health and treatment history and will be in the best position to
determine whether a specialist referral is necessary. This will help to ensure that duplicate diagnostic tests are not done, medicine errors are reduced,
access to services is enhanced, and hospital admissions and re-admissions are reduced. In turn, you will receive the best possible healthcare from the
right healthcare provider, with the right skills, at the right time and have better control over how your benefits are managed.
Your health and wellness
With GEMS Fitness, you can expect support to:
Electronic Health Record (EHR)
• make healthier lifestyle choices
A record of your complete medical history, in one secure
• increase your physical activity
location. Sign in to Member Online to give your healthcare
• eat healthier foods
provider access to your medical history. This ensures that
• improve your sleeping habits
you receive the best treatment for your condition.
• reduce your stress level
• quit smoking
• manage your weight whether you want to lose or gain
GEMS Fitness • keep your heart healthy and reduce the risk of a heart attack
• stay motivated, and lots more
An exercise and health programme suited to your needs as a
valued GEMS member. GEMS Fitness facilitates a stimulating To benefit from GEMS Workplace Fitness Programme, your department
and supportive environment to help you improve your health needs to get on board and agree to the terms and conditions of the
and enhance the quality of your life. programme.
You can access GEMS Fitness via GEMS Member Online on You don’t have to do it alone. We are all in this together!
www.gems.gov.za.
Your health and wellness cont.
GEMS Fitness cont.
Join GEMS Fitness in a few easy steps Benefits of joining
1. You need to be a principal GEMS member or a dependant employed Group exercise sessions at work.
by government.
Access to on-site fitness tests, desk exercises, telephonic and
2. Your department needs to agree and sign the terms and conditions
on-site access to health coaches and dietitians.
(T&Cs) of the programme.
3. Once the department signs T&Cs and is on board, GEMS will come to
your department and host an activation event. This is the first step to Health tips via SMSs, brochures and emails.
becoming part of an experience like no other.
Access to the GEMS Fitness Portal to record and track your
4. You need to attend an activation event and complete a form to activate activity and health progress.
your GEMS Workplace Fitness membership.
Start your journey to better health today. Check the GEMS website > Member online > Fitness Journey, to see which departments have joined. You can also call
us on 0860 00 4367 where we will explain the process or email enquiries@gems.gov.za with the subject line “GEMS Fitness Programme” for more information.
Self-help tools
GEMS DotMobi
Quick and easy access to your benefit information, 24/7 Open your internet browser on your
WAP-enabled cell phone and type in m.gems.
SMS Benefit Check Service gov.za to view your claims, available benefits
and other benefits. Select ‘Member Online’ and
Check your benefits by sending an SMS to 33489 with the keyword log in using your membership number and PIN.
‘Benefit’, your membership number, the benefit category and the
dependant code (you find this on the back of your membership card).
For example: Benefit, 0001414, GP, 01 (each SMS will cost you R1.50).
Find a GEMS Network provider
Member Online
Visit www.gems.gov.za, click on the ‘Find a Network
Visit www.gems.gov.za, click on the ‘Sign in’ tab at the top of the page
Provider’ banner on the homepage. Once on the
and log in. If you are not registered to Member Online, you will need your
GEMS Network page, click ‘Find a Network Provider’
member number, identity number and a unique password to register.
on the left-hand menu. Now simply fill in the fields
provided. Alternatively, you can contact the GEMS
Call Centre on 0860 00 4367 or send an email to
enquiries@gems.gov.za.Glossary
Understand this frequently used medical scheme terminology to know your benefits better.
A ACDL: DTP:
Additional Chronic Disease List. A list of chronic diseases the Scheme Diagnosis and Treatment Pairs are a list of the 270 PMB conditions in
covers in addition to the CDL conditions. the Medical Schemes Act linked to the broad treatment definition. A
list of these is available on www.gems.gov.za under the Member tab
B Benefit option: on the Prescribed Minimum Benefits page.
Each of the six GEMS benefit options – Sapphire, Beryl, Ruby,
Emerald Value, Emerald and Onyx – has a different range of G GP:
healthcare benefits. General Practitioner. A doctor based in the community who treats
patients with minor or chronic illnesses and refers those with serious
Benefit schedule: conditions to a hospital.
A listing of the benefits provided for by each benefit option.
I ICD-10 code:
C CDL: ICD-10 code stands for International Classification of Diseases and
Chronic Disease List. A list of the 26 specific chronic diseases Related Health Problems (10th revision). It is a coding system that
schemes need to provide a minimum level of cover for, as stated by translates the written description of medical and health information
law. into standard codes. These codes are used by the Scheme and
healthcare providers to identify your condition.
CT and MRI scans:
Specialised and more advanced type of X-rays. M MEL:
DMP: Medicine Exclusion List. A list of medicines that GEMS does not
D DMP: cover.
Disease Management Programme. Specific care programmes to help
members manage various chronic diseases and conditions. MPL:
Medicine Price List. A reference list we use to work out the prices of
DSP: groups of medicines.
Designated Service Provider. A healthcare provider the Scheme has
an agreement with to provide Prescribed Minimum Benefits (PMBs) to
members at specific prices.Glossary cont. Stay informed
P PDF: Please keep us updated with your latest contact details to make
Professional Dispensing Fee. A maximum fee that a pharmacist or sure that we can keep you informed at all times.
dispensing doctor may charge for their services, as set out in South
African law. Check that we have your current information by sending an email to
enquiries@gems.gov.za or signing in and updating your details via
PMBs: Member Online at www.gems.gov.za
Prescribed Minimum Benefits. Basic benefits that all medical
schemes in South Africa must cover according to the law.
Pre-authorisation request (PAR):
The process of informing GEMS of a planned procedure before
the event so that we can assess your benefit entitlement.
Pre-authorisation must be obtained at least 48 hours before the
event. In emergency cases, authorisation must be obtained within
one working day after the event. Failing to get authorisation will
incur a co-payment of R1 000 per admission to hospital.
S Scheme rate:
The price agreed to by the Scheme for the payment of healthcare
services provided by healthcare providers to members of the
Scheme. 100% Scheme rate means the full amount GEMS has
agreed to pay for the service.
SEP:
Single Exit Price. The one price that a medicine manufacturer or
importer charges for medicine to all its pharmacies. This price is set
out in South African law.
T TTO:
Treatment Taken Out. The medicine you receive when you are
discharged from hospital. Usually lasts for 7 days.Contact GEMS
Call: Email:
0860 00 4367 enquiries@gems.gov.za
Complaints:
complaints@gems.gov.za
Website: Compliments:
www.gems.gov.za compliments@gems.gov.za
Fax:
0861 00 4367
Postal address:
GEMS, Private Bag X782, Cape
Town, 8000
Or find us on
Facebook
The GEMS Member App is available for
free download from:
Disclaimer
This brochure contains a summary of medical benefits and contribution costs offered by GEMS for 2018. Should a dispute arise, the registered Rules of the Scheme will
apply. The registered Rules of the Scheme are available on the GEMS website at www.gems.gov.za, under About Us. You may also contact us directly to request a copy.
Working towards a healthier youONYX – In-Hospital Benefits Prescribed minimum benefits (PMBs) – Unlimited, subject to PMB legislation • Service provided by DSP • PMBs override all benefit limitations Yearly hospital benefit (public hospitals, GEMS-approved private hospitals, registered unattached theatres, day clinics and psychiatric facilities) – Unlimited • Services rendered by DSP • Includes accommodation in a general ward, high care ward and intensive care unit (ICU), theatre fees, medicines, materials and hospital equipment (includes bone cement for prostheses) and neonatal care • Accommodation in a private ward is subject to motivation by attending practitioner • Co-payment of R1 000 per admission if pre-authorisation not obtained Alcohol and drug dependencies – Subject to pre-authorisation and managed care Allied health services – Includes chiropractors, dieticians, homeopaths, podiatrists, phytotherapists, social workers, registered counsellors, orthoptists, acupuncturists and Chinese medicine practitioners • Subject to day-to-day block benefit • Services performed in hospital instead of hospitalisation will be paid from in-hospital benefit • Shared sub-limit of R1 117 per family for social workers and registered counsellors • Subject to services being related to admission diagnosis and managed care Alternatives to hospitalisation (sub-acute hospitals and private nursing) – Unlimited • Excludes frail care and recuperative holidays • Includes physical rehabilitation for approved conditions • Includes home nursing – Hospice • Unlimited, subject to PMB legislation Blood transfusion – Unlimited • Includes cost of blood, blood equivalents, blood products and the transport thereof • Includes erythropoietin Breast reduction – Unlimited Dental services (conservative, restorative and specialised) – Subject to list of approved services and use of day theatres • Professional fees shared with out-of-hospital dentistry benefit limit of R8 775 per beneficiary per year • General anaesthesia and conscious sedation subject to managed care rules • Only applicable to beneficiaries with severe trauma, impacted third molars or under the age of 6 years • Lingual and labial frenectomies under general anaesthesia for beneficiaries under the age of 8 years, subject to managed healthcare programme • Excludes osseo- integrated implants, all implant-related procedures and orthognathic surgery • Hospital cost included in in-hospital benefit Emergency services (casualty department) – Subject to use of facility as per in-hospital benefits or other registered emergency facility • Paid from out-of-hospital GP services if pre-authorisation is not obtained GP services – Consultations and visits • Unlimited • Reimbursement according to Scheme-approved tariff file Maternity (hospital, home birth and accredited birthing unit (public hospitals and designated private hospitals)) – Subject to registration on the Maternity Programme prior to admission • Hospital birth unlimited • Subject to PMB legislation • Elective caesarian may be subject to second opinion • Includes midwife services • Co-payment of R1 000 per admission if pre-authorisation not obtained Medical technologists – Unlimited Mental health – Accommodation, theatre fees, medicine, hospital equipment, professional fees of GPs, Psychiatrists and Psychologists • Limited to R37 042 per family per year • Limited to 1 individual psychologist consultation and 1 group psychologist consultation per day • Maximum of 3 days hospitalisation by GP • Educational and industrial psychologists excluded • All limits are subject to PMBs Oncology (chemo and radiotherapy) – In and out of hospital • Includes medicine and materials • Limit of R463 054 per family per year • Sub-limit of R312 979 per family for biological and similar specialised medicines • Includes cost of pathology, related basic radiology above advanced radiology benefit, medical technologist and oncology medicine • Erythropoietin included in blood transfusion benefit • Excludes new chemotherapeutic medicines that have not demonstrated a survival advantage of more than 3 months in advanced and metastatic solid organ malignant tumours unless pre-authorised • Subject to MPL Organ and tissue transplants – Subject to clinical guidelines used in public facilities • Includes materials • Limited to R587 996 per beneficiary per year • Sub-limit of R19 960 per beneficiary per year for corneal grafts (imported corneal grafts subject to managed care protocols) • Limit includes all costs associated with transplant, including immuno-suppressants • Authorised erythropoietin included in blood transfusion benefit • Organ harvesting limited to South Africa, except for corneal tissue Pathology – Unlimited • Subject to pathology tests being related to admission diagnosis • Managed care rules apply Physiotherapy – Limited to R4 757 per beneficiary per year – Post-hip, knee and shoulder replacement or revision surgery physiotherapy • 10 post-surgery physiotherapy visits (shared with out-of-hospital visits) up to a limit of R5 021 per beneficiary per event used within 60 days of surgery Prostheses – Covers prostheses and surgically implanted internal devices, including all temporary prostheses and all temporary or permanent devices used to assist with delivery of internal prostheses • Shared with medical and surgical appliances and prostheses benefit limit of R54 048 per family per year • Scheme may obtain competitive quotes and arrange supply of prosthesis • Bone cement paid from in-hospital benefits • Shared sub-limit with out-of-hospital prosthetics and appliances of R4 394 for foot orthotics and prosthetics with a sub-limit of R1 255 for orthotic shoes, foot inserts and levelers per beneficiary per year • Foot orthotics and prosthetics subject to formulary • Subject to internal and external devices being related to admission diagnosis and procedure • R500 for crutches per beneficiary per year • R5 500 for wheelchairs per beneficiary per year • R8 000 per hearing aid per beneficiary per year • Subject to PMBs Radiology (advanced) – Shared with out-of-hospital advanced radiology limit of R26 461 per family per year • Specific authorisation required for angiography, CT scans, MDCT, coronary angiography, MUGA scans, PET scans, MRI scans and radio-isotope studies Radiology (basic) – Unlimited • Managed care rules apply Renal dialysis – Subject to clinical guideline used in public facilities • In hospital • Includes materials and related pathology tests • Limited to R251 993 per beneficiary per year for chronic dialysis • Acute dialysis included in the in-hospital benefit • Includes cost of pathology, radiology medical technologists, material and immuno-suppressants • Erythropoietin included in blood transfusion benefit Specialist services – Consultations and visits • Unlimited • Reimbursement according to Scheme approved tariff file • 100% of Scheme Rate for non-network providers • 130% of Scheme Rate for established network specialists Surgical procedures (including maxillo-facial surgery) – Unlimited • Excludes osseo-integrated implants, all implant related procedures and orthognathic surgery • Includes hospital procedures performed in practitioners’ rooms Key: Pre-authorisation is needed 100% of Scheme rate 100% of cost, subject to PMB legislation Subject to managed care rules Limited to PMBs
ONYX – Out-of-Hospital Benefits
Personal Medical Savings Account (PMSA) – No PMSA
Allied health services – Includes chiropractors, dieticians, homeopaths, podiatrists, phytotherapists, social workers, registered counsellors, orthoptists, acupuncturists and Chinese medicine practitioners • If offered as alternative to hospitalisation, then hospital benefits will apply • Shared
sub-limit of R1 117 per family for social workers and registered counsellors
Audiology, occupational
SAPPHIRE therapy and speech therapy – Benefits
– In-Hospital Subject to day-to-day block benefit • If offered in hospital or instead of hospitalisation will be paid from hospital benefits
Block benefit (day-to-day benefit) – Includes GP and specialist services, basic radiology, pathology, allied health services, physiotherapy, occupational therapy and speech therapy, mental health, maternity and contraceptives • Limited to R9 256 per beneficiary and R18 514 per family per
SAPPHIRE
SAPPHIRE –– In-Hospital
In-Hospital
Prescribed
year • Benefit is pro-rated fromminimum Benefits
Benefits
join date benefits (PMBs) – R208 237 per family per annum, subject to PMB legislation • Service provided by DSP • PMBs override all benefit limitations
Prescribed Yearlybenefits
Circumcision – Global feehospital benefit
of R1 (PMBs)
421 (public
per beneficiary, hospitals,
which GEMS-approved
includes all private
relatedsubject
costs hospitals, registered
oftopost-procedure care withinunattached
month of by theatres,
procedure dayoverride
clinics and
• Out-of-hospital psychiatric
benefit only facilities) – Includes accommodation in a general ward, high care ward and intensive care unit (ICU), theatre fees, medicines, materials
Prescribed minimum
minimum
and hospital (PMBs) ––(including
benefitsequipment R208
R208 237 per
per family
237bone family
cement
per
per annum,
forannum, subject
prostheses) andtoper
PMB
PMB legislation
neonatal legislation
careyear
•• Service
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• Service
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provided
provided byby
DSP
DSPDSP • PMBs
• •Chronic override all
PMBs medicine benefit
allprovided
benefit by limitations
limitations
chronic DSP • Subject to yearly hospital limit of R208 237 per family per year • TTO limited to 7 days • No limit per maternity confinement
Contraceptives
Yearly (oral, insertables, injectables and dermal) – Sub-limit of R3 356 family per
Yearly hospital
hospital benefit
benefit (public
event, but(public hospitals,
to yearlyGEMS-approved
hospitals,
subject hospital limit and private
GEMS-approved private hospitals,
hospitals,
registration registered
registered
on Scheme’s Maternityunattached
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Programme theatres,
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• Co-payment clinics
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Dental
and
and services
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equipment
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(including and
bone
bone restorative
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for dentistry including
prostheses)
prostheses) and
and acute
neonatal
neonatal medicine)
care
care •• Service
Service –provided
Shared limit
provided by
by with••in-hospital
DSP
DSP Chronic
Chronic dentistry provided
medicine
medicine of R8 775by
provided byper beneficiary
chronic
chronic DSP
DSP ••per year •to
Subject
Subject Excludes
to yearly
yearly osseo-integrated
hospital
hospital limit
limit of
of implants,
R208
R208 237
237 all implant-related
per
per family
family per
per year
year procedures
•• TTO
TTO andto
limited
limited orthognathic
to 77 days
days •• No
Nosurgery
limit
limit • General
per
per maternity
maternityanaesthesia
confinement
confinement and
conscious
event, but sedation
subject Alcohol
tosubject
yearly and
to druglimit
hospital dependencies
pre-authorisation
and (only
registration– Subject
applicable
on to beneficiaries
to PMBs,
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Maternity with severe
Programme managed
trauma,
• care protocols
impacted
Co-payment third
of R1 andperthe
molars
000 or use ofthe
under
admission a DSP
age
if of 6 years)
pre-authorisation• No pre-authorisation
not obtained for metal base dentures • 200% of Scheme Rate for treatment of bony impactions of third molars under conscious
event, but subject to yearly hospital limit and registration on Scheme’s Maternity Programme • Co-payment of R1 000 per admission if pre-authorisation not obtained
sedation in doctors’
Alcohol and Allied
rooms health services
• Lingual – Includes
and labial frenectomies under general
chiropractors, anaesthesia
dieticians, homeopaths, for beneficiaries
podiatrists,theunder the age ofsocial
phytotherapists, 8 years, subjectorthoptists,
workers, to managed healthcare programme
acupuncturists and Chinese andmedicine
pre-authorisation
practitioners• Panoramic
• Limited X-rays
to PMBslimited to 1 X-ray
• Subject everyby3 network
to referral years perGPbeneficiary
and services• 4 being
bitewing X-rays
related to per
admission diagnosis
Alcohol andperdrug
beneficiary drug dependencies
yeardependencies
–– Subject
• Fluoride treatment Subject to
to PMBs,
excluded PMBs, pre-authorisation,
pre-authorisation,
for beneficiaries
managed
managed
older than 16 years
care
care protocols
protocols andand the use
use of
of aa DSP
DSP
Allied
Allied health services
healthassistance
Emergency services –– (road
Includes
and
Includes chiropractors, dieticians,
air) – Unlimited,
chiropractors, subjecthomeopaths,
dieticians, homeopaths, podiatrists,
podiatrists, phytotherapists,
phytotherapists, social workers,
social to
workers, orthoptists,
DSP limitacupuncturists
orthoptists, acupuncturists and Chinese
andR20
Chinese medicine
medicine practitioners
practitioners •• Limited
Limited to PMBs •• Subject to
to referral by
by network
network GP and
and services being related to
to admission diagnosis
Alternatives to hospitalisation (sub-acute to PMB legislation
hospitals and •private
Subject to use of–emergency
nursing) Subject services
yearly hospital and sub-limit of 823 per family per year • Excludes frailtocare
PMBs Subjecthome
• Includes referral
nursing GP
– Hospice services
• 100%beingof related admission
cost, subject to PMBdiagnosis
legislation
General Practitioner (GP) services – Consultation, visits and all other services • Limit is pro-rated from the join date • Reimbursement at 200% of Scheme Rate for procedures performed in doctors’ rooms instead of in hospital • Consultations and approved minor procedures at GP
Alternatives Blood transfusion – Includes cost of blood,private blood equivalents, blood products and transport thereof
Alternatives to to hospitalisation
hospitalisation (sub-acute (sub-acute hospitals hospitals and and private nursing) nursing) –– SubjectSubject to to yearly
yearly hospital
hospital limit
limit and
and sub-limit
sub-limit of of R20
R20 823823 per per family
family perper year
year •• Excludes
Excludes frail
frail care
care •• Includes
Includes home home nursing
nursing –– Hospice
Hospice •• 100% 100% of of cost,
cost, subject
subject to to PMB
PMB legislation
legislation
Blood
GP transfusion
network Breast
extender – reduction
benefit
Includes –
cost –beneficiaries
of No benefit
blood, blood equivalents, blood products and transport thereof
Blood transfusion – Includes cost of blood, blood equivalents, blood products and transport thereof
For with chronic conditions registered on disease management programme • 1 additional GP consultation at a network GP once block benefit is exhausted
HIV infection,
Breast reduction AIDS Dental
–– No services
andbenefit
related illness (conservative,
– Subject restorative
to PMBs andand managed specialised) – Only applicable
care • Pre-exposure to beneficiaries
prophylaxis included for withhigh
severerisk trauma,
beneficiariesimpacted third molars or under the age of 6 years • Subject to yearly hospital limit and out-of-hospital dentistry limit • Excludes osseo-integrated implants, all implant
Breast reduction No
related benefit
procedures, orthognathic surgery and specialised dentistry • Subject to list of approved services and use of day theatres and DSP hospitals
Infertility
Dental –
Dental services
services (conservative, restorative and
and specialised) –– Only
Subject to use of DSP applicable
(conservative,
Emergency restorative
services (casualty specialised)
department) –Only applicable to to beneficiaries
beneficiaries with with severe
severe trauma,
trauma, impacted
impacted third third molars
molars or or under
under thethe age
age ofof 66 years
years •• Subject
Subject to to yearly
yearly hospital
hospital limit
limit and
and out-of-hospital
out-of-hospital dentistry
dentistry limit
limit •• Excludes
Excludes osseo-integrated
osseo-integrated implants,implants, all all implant
implant
Maternity
related
related (ante- and
procedures,
procedures, post-natal
orthognathic
orthognathic care) and
surgery
surgery – 100%
and specialised
of Scheme
specialised dentistry
Rate paid
dentistry •• Subject
from risk,
Subject to
to list of
of approved
if registered
list approved onservices
Maternityand
services use
use of
Programme
and of day
day• theatres
Subject to:
theatres and
and DSP
DSP hospitals
Maternity Programme protocols, Managed Care Protocols and processes and PMBs
hospitals OR 100% of Scheme Rate paid from day-to-day block benefit,
if not registered onGP
Emergency theservices
Maternity–Programme
Consultations and visits
• Subject • Subject to yearly
to PMBs • (Kindly hospital
contact limitGEMS• Reimbursement
to obtain moreaccording
detail on the to Scheme-approved
consultations and benefits tariff filethat
for may
maternity confinement,
be funded under theapplicable
GEMS Maternityto bothProgramme)
caesarian and non-caesarian delivery
Emergency servicesservices (casualty
(casualty department)
department) ––
GPMedical and
services surgical
Maternity
–– Consultations appliances(hospital,
and visits and prostheses
home birth –
and accredited
Includes hearing birthing
aids, unit (public
wheelchairs, hospitals
mobility and
scooters, designated
oxygen private
cylinders, hospitals))
nebulisers, –
glucometers,
Subject colostomy
to kits,
registration diabetic
on the equipment,
Maternity foot
Programmeorthotics • and external
Elective prostheses
caesarian may be• Insubject
and outtoofsecond
hospitalopinion
• Shared with in-hospitalinprostheses
• Hospitalisation designatedlimit private hospitals for
GP services
of R54 048 per Consultations
family per yearand
post-discharge visits •• Subject
• complications
Sub-limit Subject
of R18
to yearly
forto069
yearly hospital
hospital
for medical
newborns limitedand
limit
limit • Reimbursement
6• weeks
Reimbursement
to surgical appliances
according to
• Includesaccording
per to Scheme-approved tariff
perScheme-approved
familyservices
midwife year••Co-payment tariff
Diabetic accessories
of R1
file for
file000
forandmaternity
maternity
perappliances,
admission
confinement,
confinement,
except
applicable to
forapplicable
glucometers,
if pre-authorisation to both
not both caesarian and
to becaesarian
obtained claimed from and non-caesarian
non-caesarian
the chronic medicine
delivery
deliverybenefit • Shared sub-limit with in-hospital prosthetics and appliances of
Maternity
R4 394 for (hospital,
Maternity (hospital, home
home and birth
birth and
and accredited
accredited birthing
of R1unit
birthing 255 (public
unit (public hospitals
hospitals andinserts
designated private perhospitals)) –– Subject
year • to registration on
on the Maternity Programme •• Elective caesarian may be
be subject to
to second
per yearopinion •• Hospitalisation
for wheelchairsin designated private hospitals for
• and designated private hospitals))
foot orthotics prosthetics with a sub-limit for orthotic shoes, foot and levelers beneficiary per Subject Foot
to orthotics and
registration prosthetics
the Maternity subject to formulary
Programme • R500
Elective for crutches
caesarian may per beneficiary
subject second • R5 500
opinion Hospitalisation in per beneficiary
designated per year
private • R8 000
hospitals for
post-discharge
post-discharge perMedical
per hearing aid complicationsbeneficiary
complications
technologists
for
pernewborns
for
–limited
year • Bilateral
newborns
Includes to
limitedhearing
materials
to 66 weeks •••Includes
aids every
weeks
Limited
Includes36 months to PMBs
midwife
midwife • SubjectSubject
services
servicesto••PMBs
to event pre-authorisation
Co-payment
Co-payment of of R1
R1 000
000 per per admission
admission ifif pre-authorisation
pre-authorisation not not obtained
obtained
Mental health
Medical Mental– health
(Consultations,
technologists – materials
Accommodation,
assessments, theatre
treatment fees,• medicine,
and/or counselling hospital equipment,
bypre-authorisation
GP, Psychiatrist professional fees of General
and Psychologist) Practitioners,assessments,
– Consultations, Psychiatrists and Psychologists
treatments • Subject tobypre-authorisation
and/or counselling GPs, psychiatristsand andmanaged care •protocols
psychologists If offered•asEducational
alternativeand industrial psychologists
to hospitalisation, then hospital excluded
benefits• Limited to PMBs
Medical technologists – Includes
Includes materials •• LimitedLimited to
to PMBs
PMBs • Subject
Subject to
to event
event pre-authorisation
will apply • Limited to 1 individual psychologist consultation and 1 group psychologist consultation per day • Educational and industrial psychologists excluded • Subject to PMBs
Mental
Mental health
health –– Accommodation,
Accommodation, theatre
theatre fees,
fees, medicine,
medicine, hospital
hospital equipment, professional fees
fees of of General Practitioners, Psychiatrists and Psychologists •• Subject to
to pre-authorisation and
and managed care protocols •• Educational
Educational and and industrial psychologists excluded
excluded •• Limited
Limited to PMBs
Optical servicesOncology (eye examinations,(chemo and radiotherapy)
frames, lenses, contact– In andequipment,
lenses
professional
out of (permanent
hospital or disposable)
• Includes Generaland
medicine Practitioners,
and acute
materials Psychiatrists
medicine)
• Subject to and
– Sub-limit
Psychologists
clinical ofguidelines
R2 608 perused
Subject pre-authorisation
in public
beneficiary facilities
every and MPL
two benefit
managed
years•and Excludes carenew
yearly limit
protocols
ofchemotherapeutic
R5 229 per familymedicines
industrial psychologists
that have
• Frames limited to R2not085demonstrated
• Limited toa1 survival
toadvantage
PMBs
eye examination of more than
3 months in advanced and metastatic solid organ malignant tumours unless pre-authorised
per beneficiary per year • 1 frame and 1 pair of lenses per beneficiary every second year • No limit will be applied to the number of contact lenses that may be rendered to a beneficiary, aside from the indicated financial benefit limits • Either spectacles or contact lenses will be funded in a
Oncology
benefit year,(chemo
Oncology (chemo and
and radiotherapy)
radiotherapy) –– In
In •and
and out ofof hospital •• Includes medicine and materials •• Subject ato clinical guidelines used in
in public facilities and
lensMPL •• Excludes with anew chemotherapeutic medicines that have not
not demonstrated
up to 35% tintaaforsurvival
albinismadvantage of more
more than
33subject
months
not both Organ • Benefit
and is not pro-rated
tissue transplants –out
Post-cataract
Subject hospital
tosurgery, Includes
optical PMB
pre-authorisation medicine
andentitlement
clinicaland guidelines
materials
limited to the Subject
usedcostin of tobifocal
public clinical lens
facilities guidelines
•and not more
Subject used than
to PMBs public
R1 061 facilities
• Includes for both and
materials MPL
and frame, Excludes new chemotherapeutic
sub-limit of R210 for frame medicines
• Includesthattinted
havelenses demonstrated survival advantage
and proven ofphotophobia,
than
months to in
in advanced
advanced and
pre-authorisation and metastatic
• Excludessolid
metastatic solid
variableorgan
organ tintmalignant
malignant tumours
tumours lenses
and photochromic unless
unless pre-authorised
pre-authorised
Organ and Pathology – Subject to yearly hospital limit and clinical guidelines used in public facilities • Subject to PMBs • Includes materials
Organ and tissue
Orthopedic Disease
tissue transplants
Management
transplants –– Subject
SubjectProgramme
to – Negotiated
to pre-authorisation
pre-authorisation and rate • Subject
clinical to managed
guidelines used incare publicprotocols and• processes
facilities Subject to PMBs • Includes materials
Pathology
Pathology ––– Subject Physiotherapy
Includesto yearly – Post-hip, knee and shoulder replacement or revision surgery physiotherapy • 10 post-surgery physiotherapy visits (shared with out-of-hospital visits) up to a limit of R5 021 per beneficiary per event used within 60 days of surgery
Pathology Subject yearly hospital
toliquid-based hospital limit
cytology
limit pap smears
Physiotherapy –––Prostheses
Physiotherapy
Physiotherapy If offered in
Post-hip, knee – Covers
hospital
and orprostheses of and
instead replacement
shoulder surgically
hospitalisation or implanted
will be paid
or revision
internal devices,benefits
from hospital
surgery physiotherapy including all temporary
•• 10 – Post-hip,
10 post-surgery
prostheses
knee andand
physiotherapy allvisits
shoulderaccompanying
replacement
visits (shared withtemporary
with out-of-hospital
or permanent
or revision surgery
visits)
visits) up
devices
physiotherapy
to
to aa394
used R5
limit
limitforof
to•assist
10 with the guidance,
021post-surgery
021 per
per beneficiary
alignment
physiotherapy
per
per event visitsand
used delivery
(shared
within 60with ofin-hospital
days internal
of surgeryprostheses
visits) up to• aSubject
limit oftoR5the021
yearly
per hospital limit and
beneficiary per event aPost-hip,
sub-limit
used within
knee
of R23 and 790
60 days
shoulder
per family
of surgery
replacement
per year • Bone revision
cementsurgery paid from physiotherapy
in-hospital benefits post-surgery
• Shared sub-limitsphysiotherapy
with out-of-hospital (shared out-of-hospital
prosthetics and appliances up
of R4 offoot
R5 orthotics beneficiary
and prosthetics event
with aused within
sub-limit of60R1days
255offorsurgery
orthotic shoes, foot inserts and levelers per beneficiary
Prostheses
Prostheses –– Covers Covers prostheses
per year. and
and surgically
Foot orthotics
prostheses implanted
and prosthetics
surgically implantedsubjectinternal
internaltodevices,formulary
devices, including
• R500all
including allfortemporary
crutches prostheses
temporary per beneficiary
prostheses and all
and perall accompanying
year • R5 500temporary
accompanying for wheelchairs
temporary or
or permanent devices
per beneficiary
permanent devicesper used
usedyear to
to assist
•assist
R4 500with
withperthe guidance,
thehearing
guidance, aidalignment and
and delivery
per beneficiary
alignment per yearof
delivery of•internal
Subjectprostheses
internal to internal ••and
prostheses Subject
external
Subject to
to the yearly
devices
the hospital
yearlybeing limit
limittoand
related
hospital admission diagnosis
and
aaPrescribed
sub-limit
sub-limit of
medicine
of R23
R23 and 790 and injection
per
per family
790procedure family •perper
material
year
year ••toBone
Subject PMBs
Bone
– Prescribed
cement
cement paid
and administered
paid fromfrom in-hospital
by a professional
in-hospital benefits
benefits •• Shared
legally entitled
Shared sub-limits
sub-limits with
to do so • Subjectprosthetics
with out-of-hospital
to MPL and MELappliances
out-of-hospital prosthetics and
– Acute medical
and appliances of of R4
R4 394
conditions
394 for
for foot
• Subject to prosthetics
foot orthotics
orthotics and
formulary • Limita ofsub-limit
and prosthetics with
R5 947 perR1beneficiary
with a sub-limit of of R1 255
255 for
and R16 657 foot
for orthotic
orthotic shoes,
per family per
shoes, foot inserts
inserts and
year, subject
and levelers
levelers per
to a sub-limit
per beneficiary
beneficiary
of R527 per
per family per year for homeopathic medicine • 30%• co-payment on out-of-formulary medicine – Chronic medical conditions •beneficiary
CDL and DTP year PMB chronic conditions • Subject to prior application and approvaltoand use of chronic medicine pharmacy DSP • Includes benefit for life
per year.
year. Foot
Foot orthotics
orthotics
Radiology
and
and prosthetics
prosthetics
(advanced)
subject
subject to
to formulary
– Subject formulary R500
R500 for
to list of•approved for crutches
crutches per per beneficiary
beneficiary per per year
year •• R5R5 500500 for for wheelchairs
wheelchairs per per beneficiary per per year •• R4 R4 500
500 per
per hearing
hearing aid aid per
per beneficiary
beneficiary per per year
year •• Subject
Subject to internal
internal andand external
external devices
devices being
being related
related to to admission
admission diagnosis
diagnosis
threatening allergies
and payablePMBs from risk and subject to managed care and servicesformulary • Limit of R18 072 per beneficiary and R37 042 per family per year • Unlimted for PMBs, subject to PMB legislation • 30% co-payment on out-of formulary medicine and voluntary use of non-DSP • Once limit
and procedure
procedure •• Subject
Subject to to PMBs
is depleted, CDL benefit Radiology will be limited
(basic) –
– Subject Prescribed
to yearly medicine from hospital stay (TTO)
hospital limit • Includes 2 x 2D ultrasound scans per pregnancy • Payable from risk once acute medicine benefit is exhausted • Included in acute medicine benefit limit • TTO limited to 7 days and must be related to admission diagnosis and procedure –
Radiology
Radiology
Self-medicine (advanced)
(advanced)
(OTC) • Only –– Subject
Subject
schedule to
to list0, of
list of approved
approved
1 and 2 covered services
services
• Subject to acute medicine benefit limit and sub-limit of R1 795 per family per year, R1 084 per beneficiary per year and R296 per beneficiary per event
Radiology (basic) Renal dialysisyearly – In hospital •limit Includes materials andultrasound
related pathologypertests • Subject to clinical guidelines used in public facilities
Preventative
Radiology care––services
(basic) Subject
Subject to – Payable
to yearly hospital
from risk
hospital limit •• Includes
• Includes
Includes 22 xx 2D
Influenza ultrasound scans
2D vaccination, per pregnancy
HPV vaccination
scans pregnancy and Pneumococcal vaccination • Influenza vaccination and HPV vaccination (for female beneficiaries) limited to 1 per year unless indicated otherwise • Pneumococcal vaccination once every
5
Renalyears for Specialist
beneficiaries
dialysis – at risk services
• Subject – toConsultations
managed and
care visits
protocols • 100%
and of
processesScheme • Rate
Includes for non-network
screening providers
services provided • 130% of Scheme
by network pharmaciesRate for established network specialists • Subject to yearly hospital limit • Reimbursement according to Scheme-approved tariff file
Renal dialysis – In hospital • Includes materials and related pathology tests • Subject to clinical guidelines used
In hospital • Includes materials and related pathology tests • Subject to clinical guidelines used in in public
public facilities
facilities
Screening
Specialist services
services Surgical– Serum procedures
–– Consultations cholesterol, (including
and visitsbone maxillo-facial
density scan, pap smearsurgery) –
(including liquid-based
Subject to yearly cytology),
hospital prostate
limit • specific
Subject antigen,
to case glaucoma
management screening, serum glucose,
• Maxillo-facial surgery occult blood
subjectyearly test, Thyrotropin
to yearly (TSH)
sub-limit•ofReimbursement
R20 823 practice • Neonatal
per family Hypothyroidism
• Excludes screeningimplants,
osseo-integrated test – TSH all (Thyrotropin)
implant-related tariffprocedures
4507 only and orthognathic
Specialist services
• Includes screening Consultations
services
surgery providedand visits •• 100%
by network 100% of
of Scheme
pharmacies Scheme Rate Rate for for non-network
non-network providers providers •• 130% 130% of of Scheme
Scheme Rate Rate for for established
established networknetwork specialists
specialists •• Subject
Subject to to yearly hospital
hospital limit
limit • Reimbursement according according to to Scheme-approved
Scheme-approved tariff tariff file
file
Surgical
Surgical procedures
procedures (including maxillo-facial surgery) –– Subject to
to yearly hospital limit •• Subject to
to •case management •• Maxillo-facial surgery
surgery subject to yearly sub-limit of
of R20 823
823 perper family • Excludes osseo-integrated implants, all
all implant-related procedures and orthognathic
Radiology (advanced)(including – Shared maxillo-facial
limit with in-hospital surgery)
advanced Subject
radiology yearly
of R26 hospital
461 per limit
family Subject
per year case management
Specific authorisation Maxillo-facial
required for angiography, subject CT to yearlyMDCT,
scans, sub-limit
coronary R20angiography, family
MUGA• scans,
Excludes PETosseo-integrated
scans, MRI scansimplants, implant-related
and radio-isotope studies procedures and orthognathic
surgery
surgery
Radiology (basic) – X-rays and soft tissue ultrasound scans • 2 x 2D ultrasound scans per pregnancy provided for by maternity benefit
Renal dialysis – Out of hospital • Includes materials and related pathology tests • Subject to pre-authorisation, managed care protocols and processes • Limited to PMBs • Subject to use of a Renal Dialysis Network DSP • If a non-network provider is voluntarily used, a co-payment of 15%
will be applied per event in accordance with network rules
Specialist services – Consultation, visits and all other services • 100% of Scheme Rate for non-network providers • 130% of Scheme Rate for established network specialists • Specialist consultations subject to GP referral • Limit is pro-rated from the join date • Reimbursement at 200%
of Scheme Rate for procedures specified by managed care done in doctors’ rooms instead of in hospital • Reimbursement at 200% of Scheme Rate for cataract procedures performed by ophthalmologists in their rooms
Key:
Key:
Key: Pre-authorisation is needed 100% of Scheme rate 100% of cost, subject to PMB legislation Subject to managed care rules Limited to PMBsYou can also read
