MEDXXI 2017

Available with all our options

*Services rendered as part of hospitalisation are subject to pre-authorisation.

Description of Service/ Treatment Services rendered as part of hospitalisation – subject to pre-authorisation Services rendered NOT as part of hospitalisation
HOSPITALISATION
Accommodation, theatre, medicine and material use whilst hospitalised 100% of Agreed Tariff Not Applicable
Outpatient treatment at hospital facility Not Applicable Limited to R1,000.00 per family per annum for treatment at a hospital outpatient facility or emergency rooms.
Medicine received on discharge from hospital 100% of Agreed Tariff (RP applies), if purchased on date of discharge, subject to a maximum of 7 days supply
MEDICAL PRACTITIONERS
Consultations/ Visits 100% of Medical Scheme Rate – Unlimited To be self funded
Radiology 100% of Medical Scheme Rate – Unlimited Self Funded, except for 1 Mammogram per year, except for PMB
ECHO-Tests 100% of Medical Scheme Rate – Unlimited To be self funded
MRI- and CT-scans and radio-isotope studies (Benefits subject to seperate pre-authorisation) 100% of Medical Scheme Rate – R1,600.00 co-payment applies 100% of Medical Scheme Rate – R1,600.00 co-payment applies
Pathology 100% of Medical Scheme Rate – Unlimited Except if treatment part of Disease Management Programme and 1 Pap Smear per year by General Practitioner, except for PMB
Clinical Procedures 100% of Medical Scheme Rate – Unlimited. Co-payments applicable to certain elective procedures, unless funded as PMB treatment. Please refer to Members’ Guide for details. No benefits for elective procedures, unless funded as PMB treatment:
– Joint Replacements
– Spinal surgery
100% of Medical Scheme Rate Subject to pre-authorisation:
– Upper and lower gastro-intestinal endoscopy (excl. sigmoidoscopy and anoscopy)
– Laser tonsillectomy
– 24-hour oesophageal pH studies
– Oesophageal motility
– Yag laser -Photoagulation therapy
– Photodynamic therapy.

All other clinical procedures = To be self funded

Cochlear Implants Limited to R 30,200.00 per implant Not Applicable
Material and injection material administered in doctor’s rooms Not Applicable To be self funded
MATERNITY
Ante-natal Classes and Foetal scans 100% of Medical Scheme Rate – Unlimited Pre-childbirth Education paid at 100% of Cost and/ or Ultrasound Scans paid at 100% of Medical Scheme Rate per Year, subject to a combined limit of R 1,600.00 per Family per Year
Ante-natal Consultations Not Applicable 100% of Medical Scheme Rate – limited to 2 per year
Confinement Benefits as described in respect of Hospitalisation and Medical Practitioners
AUXILIARY SERVICES
Physiotherapy 100% of Medical Scheme Rate – Unlimited To be self funded
Medical Technology 100% of Medical Scheme Rate – Unlimited To be self funded
Clinical Technology 100% of Medical Scheme Rate – Unlimited To be self funded
Speech Therapy and Occupational Therapy 100% of Medical Scheme Rate – Unlimited To be self funded
Podiatry, orthoptic treatment, hearing aid acoustics, consultations with dietitians, chiropractors, osteopaths, homeopaths, naturopaths, herbalists and biokinetics To be self funded To be self funded
Aromatherapy, acupuncture and relexology To be self funded To be self funded
OPTICAL
Consultation Not Applicable To be self funded
Spectacles and Contact Lenses Not Applicable To be self funded
Refractive Surgery To be self funded To be self funded
SECONDARY FACILITIES
Treatment that forms part of a Case Management Programme 100% of Cost – Subject to approval by Case Manager
REHABILITATION
Treatment that forms part of a Case Management Programme Only for cases managed as part of a Case Management Programme, where a medical report was submitted by the attending physician.
AMBULANCE SERVICES
Preferred Provider (ER24) Not Applicable 100% of Agreed Tariff – For emergency transport to and from a hospital
Non-preferred Provider Not Applicable 100% of Medical Scheme Rate – Limited to R 2,700.00 per family per year, limit will not apply to PMB
BLOOD TRANSFUSIONS
Blood transfusions 100% of cost 100% of cost – subject to pre-authorisation
MEDICAL AND SURGICAL PROSTHESIS / APPLIANCES (CASE MANAGED)
Internal Prosthesis Specific sub-categories with limits apply. Please refer to Member Guide for details
External Prosthesis 100% of cost – Limited to R 56,300.00 per family per year – subject to approval by Case Manager
Orthopaedic Appliances 100% of cost – Limited to R 8000.00 per family per year – subject to Case Management
Medical Appliances Not Applicable To be self funded
Hearing Aids Not Applicable To be self funded
DENTISTRY
Basic To be self funded To be self funded
Specialised To be self funded To be self funded
MAXILLA-FACIAL AND ORAL SURGERY
Elective To be self funded To be self funded
Non-elective (excluding extractions) 100% of Medical Scheme Rate R 1,100.00 co-payment applies, PMB 100% of cost subject to PMB protocol 100% of Medical Scheme Rate – Unlimited, PMB 100% of Cost subject to PMB protocol
Implantology To be self funded To be self funded
PRESCRIBED MEDICINE
Chronic (Member must apply for benefit) Not Applicable To be self funded – Except PMB
Acute Not Applicable To be self funded
Immunisations Not Applicable To be self funded
Oral & Injectable contraceptives Not Applicable 100% of Medical Scheme Rate – Limited to R 1,500.00 per family per year
NON-PRESCRIBED MEDICINE(PAT)
Non-Prescribed Medicine (PAT) Not Applicable To be self funded
CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES
Organ Transplants The following benefits apply to organ donors in RSA: R 44,800.00 for a live donor, R 26,800.00 for a cadaver. Benefit in respect of donors only allowed if the recipient of the organ is a beneficiary of the Scheme. Specific radiology and pathology tests associated with the transplant procedure also qualify for benefit .Limit will not apply to PMB
Chronic Renal Failure 100% of Medical Scheme Rate for Kidney Dialysis, incl. associated Radiology and Pathology tests – Unlimited
Oncology Benefit managed as part of an Oncology Benefit Management Programme and subject to the use of Preferred Provider Network. Overall limit of R 176,600.00 per family per year. No benefit for biological drugs. Please refer to Member Guide for more details.
Asthma, Chronic Obstructive Airways Disease, Diabetes and Cardiocare Benefit managed by the Scheme and payable as per the applicable benefit described elsewhere in this summary
Oxygen therapy 100% of cost of oxygen therapy (cylinders included) subject to Case Management
Human Papillomavirus (HPV) Benefits subject to Authorisation on Disease Management Programme and provided that the condition forms part of Disease Management protocol. Further subject to member being registered on the Programme and member being compliant.
Mammogram and Pap Smears Benefit subject to Disease Management protocol.
AIDS AND HIV – Benefits management as part of a Disease Management Programme
FOREIGN CLAIMS – No benefit, except for Namibian claims
MENTAL HEALTH
Clinical Psychology 100% of Medical Scheme Rate – Unlimited – provided that treatment must form part of Case Management Programme To be self funded
Psychiatry Benefit as described elesewhere in this summary for Medical Practitioners and Hospitalisation. Treatment to be obtained in a mental health institution, as approved by the Scheme
PRESCRIBED MINIMUM BENEFITS (PMB) – Benefits subject to application and provided that the treatment and/ or chronic medicine is received from a designated service provider. If voluntarily obtained from any other service provider, a 40% co-payment will apply. Scheme protocol apply.

 

CONTRIBUTIONS – EFFECTIVE 1 JANUARY 2017
Contributions Principal member
R 1,599.00
Additional Adult Dependant
R 1,592.00
Additional Minor Dependant (payable up to maximum of 3)
R 818.00
ABBREVIATIONS: RP= Reference Pricing | PMB= Prescribed Minimum Benefits | MSR = Medical Scheme Rate
This is only a summary of the Benefits and Contributions.
In case of a dispute the Registered Scheme Rules apply. Reg. No: 1446