Selfmed 80% 2017

Available with all our options

Below is a summary of the benefits and contributions. In case of dispute, the registered scheme rules apply.

*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 used whilst hospitalised 100% of Agreed Tariff Not Applicable
Outpatient treatment at hospital facility Not Applicable Benefits as described in respect of doctor visits and acute medicine
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 80% of cost – Unlimited 80% of Cost – subject to the following limits:

Single member = max 15 visits

Member + 1 dependant = max 30 visits

Member + 2 or more dependants = max 45 visits
Radiology and Pathology 100% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate – Unlimited
ECHO-Tests 100% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate

– limited to R 2,800.00 per beneficiary per year
MRI- and CT-scans and radio-isotope studies (Benefits subject to seperate pre-authorisation) 100% of Medical Scheme Rate – R1,100.00 co-payment applies 80% of Medical Scheme Rate R 1,100.00 co-payment applies
Clinical Procedures 80% of cost – Unlimited 80% of cost for the following, 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

• Photocoagulation therapy

• Photodynamic therapy

All other clinical procedures are payable at 80% of Cost – Unlimited
Cochlear Implants 100% of Medical Scheme Rate – limited to R 74,500.00 per implant Not Applicable
Material and injection material administered in doctor’s rooms Not Applicable 80% of Agreed Tariff (RP applies) – subject to Acute Medicine Limit
MATERNITY
Ante-natal Classes and Foetal Scans 100% of Medical Scheme Rate – Unlimited 80% of Cost – Benefits limited to 2 per beneficiary per year and the cost of a 3D-scan is limited to the cost of a 2D-scan Benefits allowed for additional pregnancy scans and/or prechildbirth education at 100% of Cost to a maximum of R 1,400.00 per Family per Year
Confinement Benefits as described in respect of Hospitalisation and Medical Practitioners
AUXILIARY SERVICES – Combined sub-limits may apply: limited to R 4,500.00 per
beneficiary to a maximum of R 12,700.00 per family per year
Clinical Technology 100% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate – Unlimited
Medical Technology 100% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate – Unlimited
Physiotherapy 100% of Medical Scheme Rate – Unlimited 80% of Medical Scheme Rate – Combined sub-limit applies
Speech Therapy and Occupational Therapy 100% of Medical Scheme Rate – Unlimited Treatment to form part of a Case Management Programme 80% of Medical Scheme Rate – limited to R 4,800.00 per beneficiary to a maximum of R 13,600.00 per family per year. Combined sub-limit applies.
Podiatry, orthoptic treatment, hearing aid acoustics, consultations with dietitians, chiropractors, osteopaths, homeopaths, naturopaths, herbalists and biokinetics 100% of Medical Scheme Rate – Benefits as described in respect of services rendered not as part of hospitalisation 80% of Medical Scheme Rate – limited to R 4,800.00 per beneficiary to a maximum of R 13,600.00 per family per year. Combined sub-limit applies.
Aromatherapy, acupuncture and relexology To be self funded To be self funded
OPTICAL Limited to R 5,500.00 per beneficiary to a maximum of R 10,900.00 per family over two years
Consultation Not Applicable 80% of Cost
Spectacles and Contact Lenses Not Applicable 80% of Cost
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 – 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 hospital
Non-preferred Provider Not Applicable 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 63,700.00 per family per year – subject to approval by Case Manager
Orthopaedic Applicances 100% of Cost, limited to R 9,400.00 per family per year – subject to Case Management
Medical Appliances Not Applicable 80% of Cost – limited to R 5,300.00 per family per year. This maximum may be exceeded, subject to a maximum limit of R 15,900.00, in respect of certain appliances, provided that the treatment forms part of a Case Management Programme
Hearing Aids Not Applicable 80% of Cost, limited to R16,200.00 per family per year
DENTISTRY
Basic 80% of Medical Scheme Rate 80% of Medical Scheme Rate
Specialised 80% of Medical Scheme Rate – limited to R 7,700.00 per beneficiary to a maximum of R 23,600.00 per family per year
MAXILLA-FACIAL AND ORAL SURGERY
Elective 80% of Medical Scheme Rate 80% of Medical Scheme Rate

Non-elective (excluding extractions)

100% of Medical Scheme Rate – Unlimited, PMB 100% of Cost subject to PMB protocol Unlimited, PMB 100% of Cost subject to PMB protocol
Implantology 80% of Medical Scheme Rate – implants (prosthesis) limited to R 5,600.00 per beneficiary per year
PRESCRIBED MEDICINE – Combined sub-limits may apply: limited to R 5,400.00 per beneficiary to a maximum of R 16,100.00 per family per year
Chronic (Member must apply for benefit) Not Applicable 80% of Agreed Tariff (RP applies), limited to R 23,300.00 per beneficiary per year with a maximum of R 45,400.00 per family per year
Acute Not Applicable 80% of Agreed Tariff (RP applies) – 80% of Agreed Tariff (RP applies) limited to R 5,800.00 per beneficiary to a maximum of R 17,200.00 per family per year
Combined sub-limit applies
Immunisations Not Applicable 80% of Agreed Tariff (RP applies) – 80% of Agreed Tariff (RP applies) limited to R 5,800.00 per beneficiary to a maximum of R 17,200.00 per family per year
Combined sub-limit applies
Oral & Injectable Contraceptives Not Applicable 80% of Agreed Tariff (RP applies) – 80% of Agreed Tariff (RP applies) limited to R 5,800.00 per beneficiary to a maximum of R 17,200.00 per family per year
Combined sub-limit applies
NON-PRESCRIBED MEDICINE (PAT)
Non-Prescribed Medicine (PAT) Not Applicable 80% of Agreed Tariff (RP applies) – limited to R 1,500.00 per family per year and subject to the Acute Medicine maximum
CASE MANAGED / DISEASE MANAGED CONDITIONS / PROCEDURES
Organ Transplants The following benefits apply to organ donors in RSA: R 51,000.00 for a live donor, R 30,200.00 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 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 Management Programme. Overall limit of R 408,500.00 per family per year applies with a sub-limit of R 157,600.00 for Biological Drugs, if approved by the Scheme. Please refer to Member Guide for detail
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 managed 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 80% of Medical Scheme Rate – subject to R 8,800.00 Clinical Psychology limit
Psychiatry 100% of Medical Scheme Rate – Unlimited – provided that treatment must form part of Case Management Programme 80% of Medical Scheme Rate – subject to R 8,800.00 Clinical Psychology limit
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 6,335.00
Additional Adult Dependant
R 5,485.00
Additional Minor Dependant
(payable up to maximum of 3)
R 1,100.00
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