General

The following benefits will be implemented with effect from 1 January 2024.
  • HIV/Aids
    And Related Illnesses
    Pathology, medication, consultations, and hospitalisations, and related services

    Medication 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 for medication

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

    Subject to pre-authorisation

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

    100% of cost
  • Infertility
    Infertility Treatment

    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 Treatment

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

    Medipost is the DSP for oncology medication.

    R676 110 per beneficiary per annum subject to PMBs and Appendix 1 of the Society's rules.

    These benefits apply to in- and out-of-hospital chemo- and radiotherapy.

    Medication to treat the side-effects of chemo and 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 for medication. 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