General

The following benefit enhancements were approved by the Board of Trustees and will be implemented with effect from 1 January 2019.
  • Hiv/Aids
    And Related Illnesses
    Pathology, medication, consultations, and hospitalisations, and related services

    Medicine and hospital pre-authorisation is required

    Use of a DSP and formulary medication is required, failing which a co-payment for the voluntary use of a non-DSP and non-formulary medication will apply

    Pathology, medication, consultations, and hospitalisations, and related services are subject to PMBs

    Post-exposure prophylactics: Members will be covered for 28 days on triple therapy

    Read about the HIV Programme

    100% of single exit price, plus the lower of the agreed upon or regulated dispensing fee at DSP

    100% of agreed tariff at DSP or 90% of cost at other providers
  • Alcoholism and Drug Dependency
    Alcoholism and Drug Dependency Services

    Subject to preauthorisation

    Subject to PMBs and Appendix 1 of the Society's rules

    ADD Prescribed Minimum Benefits Only.

    100% of cost
  • Infertility
    Infertility Treatement

    Only if a PMB

    Will be paid in respect of services obtained at the DSP and from State and public hospitals

    100% of cost
  • Oncology Programme/ Chemo- and Radiotherapy
    Oncology Treatement

    Subject to preauthorisation, once-off registration on the programme and use of a specialist affiliated with ICON

    R560 000 (2019) per beneficiary per annum subject to PMB

    These benefits apply to in- and out-of-hospital chemo- and radiotherapy Medication to treat the side-effects of chemoand radiotherapy are to be paid from this benefit

    Not subject to chronic medication limits

    Includes all treatment in terms of the care plans

    Consultations are subject to authorised treatment plans and not the limits for Specialist Consultations

    Where the treatment is deemed to be clinically appropriate and medically necessary by the Society's designated agent, an additional benefit may be granted by the Trustees in excess of the limit, provided that application is made for the additional benefit prior to the service being rendered

    Read about the Oncology Programme

    100% of agreed tariff at DSP Claims in respect of medication obtained from a non-DSP will be paid at the single exit price, plus the lower of the dispensing fee, as set out in medicine pricing regulations or agreed upon with DSP