Primary Care

The following benefit enhancements were approved by the Board of Trustees and will be implemented with effect from 1 January 2019.
  • Preventative Care Benefits - Screenings
    Out Of Hospital
    Cardiovascular screenings ( Blood pressure, Blood glucose, Cholesterol, Body mass index)

    Benefits are subject to Society's protocols and use of the Society's DSPs

    One per beneficiary per annum

    100% of Society rate
    Mammograms

    Age limit: 40 years (benefits for beneficiaries younger than 40 are subject to motivation and prior approval)

    One per beneficiary per annum

    100% of agreed tariff
    Pap smears

    Age limit: 50 years and older (benefits for beneficiaries younger than 50 are subject to motivation and prior approval)

    One per beneficiary per annum: 40 years and older

    100% of agreed tariff
    Prostate-specific antigen (PSA)

    Age limit: 50 years and older (benefits for beneficiaries younger than 50 are subject to motivation and prior approval)

    One per beneficiary per annum: 50 years and older

    100% of agreed tariff
    Faecal occult blood

    One per beneficiary per annum: 50 years and older

    100% of agreed tariff
    Elisa test (HIV Screening)

    One per beneficiary per annum

    100% of agreed tariff
    Bone density test

    Age limit: 50 years and older (benefits for beneficiaries younger than 50 are subject to motivation and prior approval)

    One per beneficiary per annum

    100% of agreed tariff
  • Preventative Care Benefits - Vaccinations
    Out Of Hospital
    Child and infant vaccinations
    100% of agreed tarif
    Human papillomavirus (HPV)

    Maximum of 3 per beneficiary depending on vaccination make:  male and female beneficiaries between the ages of 9 and 18

    Male and Female beneficiaries between ages of 9 and 18

    100% of agreed tarif
    Pneumococcal vaccination

    One per beneficiary per annum

    100% of agreed tariff
    Flu vaccination

    One per beneficiary per annum

    100% of agreed tariff
  • Preventative Care Benefits - Consultations
    Out Of Hospital
    Dental consultation

    In addition to the Dental Services benefit (Conservative and restorative dentistry, Special dentistry and Implants)

    One per beneficiary per annum

    100% of Society rate
    Eye test

    Acuity, pressure and other

    One per beneficiary every two-year cycle at DSP

    100% of Society rate
    Dietician consultation

    Age limit: 50 years and older (benefits for beneficiaries younger than 50 are subject to motivation and prior approval)

    One per beneficiary per annum

    100% of Society rate
  • Preventative Care Benefits - Other
    Out Of Hospital
    Male circumcision

    1 pbpa with a limit of R1 250 if done in a doctor's room

    100% of agreed tariff
    Contraceptives

    Subject to overall acute medication limit

    R1 600 pbpa and subject to Acute Medication limit

    100% of agreed tariff
  • General Practitioner and Specialist Services
    Out Of Hospital
    General Practitioner: Consultations, Services and visits

    Consultations in respect of a PMB condition are subject to a care plan

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year.

    Where the service 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

    Non-PMB limits

    Single: R6,840
    Family M+C: R9,140
    Family M+C+C: R11,400
    Family M+A: R9,140
    Family M+A+C: R11,400
    Family M+A+C+C: R13,720

    PMBs

    Unlimited, subject to the diagnoses, treatment and care cost of PMB conditions

    100%of agreed tariff if a network provider is used for Non-PMBs

    80% of Society rate if non-network provider is used for Non-PMBs

    100% of cost at a network provider for PMBs
    Specialist: . Consultations, Services and visits

    Consultations in respect of a PMB condition are subject to a care plan

    Includes consultations out of hospital (including, but not limited to, chiropractors, homeopaths, biokineticists, antenatal visits and midwifery, osteopaths, naturopaths, dieticians, podiatrists, chiropodists, ayurvedic and traditional healers, therapeutic massage therapists and outpatient facilities; subject to registration with the HPCSA and AHPCSA).

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year.

    Where the service 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

    Non-PMB Limits

    Single: R6,840
    Family M+C: R9,140
    Family M+C+C: R11,400
    Family M+A: R9,140
    Family M+A+C: R11,400
    Family M+A+C+C: R13,720
    Limited to combined limit for specialist and general practitioner services

    PMB's: Non-DSPs 100% of COST           DSPs 100% of negotiated rate

    Non-PMB's: Non DSP 100% of MSR for the first 2 consultations pbpa thereafter 80% of MSR

    DSP 100% of negotiated rate    
  • Maternity
    Maternity Related Services

    Subject to Enrolling on the Maternity Programme

    Subject to overall annual limit and the Society's protocols

    Care Plan 10 obstetric consultations
    10 antenatal visits
    2 ultrasound scans, limited to 2D

    basic pathology tests
    Additional services, such as tococardiography, external cephalic version, lecithin-sphingomyelin ratio tests and amniocentesis may be granted where clinically appropriate and medically necessary.
  • Auxiliary services
    Out Of Hospital
    Audiology

    Only treatment or procedures to be paid from this benefit

    Consultations will be paid from the Consulation Benefit.

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    Where the service 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.

    R8 340 per family per annum for all Out of Hospital Auxiliary Services

    80% of Society rate
    Audiometry

    Only treatment or procedures to be paid from this benefit

    Consultations will be paid from the Consulation Benefit.

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    Where the service 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.

    R8 340 per family per annum for all Out of Hospital Auxiliary Services

    80% of Society rate
    Occupational therapy

    Only treatment or procedures to be paid from this benefit

    Consultations will be paid from the Consulation Benefit.

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    Where the service 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.

    R8 340 per family per annum for all Out of Hospital Auxiliary Services

    80% of Society rate
    Speech therapy

    Only treatment or procedures to be paid from this benefit

    Consultations will be paid from the Consulation Benefit.

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    Where the service 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.

    R8 340 per family per annum for all Out of Hospital Auxiliary Services

    80% of Society rate
    Orthoptic services

    Only treatment or procedures to be paid from this benefit

    Consultations will be paid from the Consulation Benefit.

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    Where the service 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.

    R8 340 per family per annum for all Out of Hospital Auxiliary Services

    80% of Society rate
    Physiotherapy

    Only treatment or procedures to be paid from this benefit

    Consultations will be paid from the Consulation Benefit.

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    Where the service 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.

    R8 340 per family per annum for all Out of Hospital Auxiliary Services

    80% of Society rate
    Biokinetics

    Only treatment or procedures to be paid from this benefit

    Consultations will be paid from the Consulation Benefit.

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    Where the service 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.

    R8 340 per family per annum for all Out of Hospital Auxiliary Services

    80% of Society rate
  • Appliances and Consumables - Chronic
    Relating to Chronic Diseases and Other Medical Conditions
    Wheelchairs, crutches, braces, walking frames and similar equipment

    Subject to pre-authorisation

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    R11 390 per beneficiary per annum

    100% of cost
    Appliances relating to chronic diseases and other medical conditions

    e.g. oxygen cylinders and nebulisers (includes either hire or purchase)

    Subject to pre-authorisation, except for nebulisers

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    R11 390 per beneficiary per annum

    100% of cost
    Consumables relating to chronic diseases and other medical conditions.

    e.g. colostomy kits and other incontinence materials or equipment

    Subject to pre-authorisation

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    R22 360 per beneficiary per annum

    100% of cost
    Diabetic consumables and appliances

    including needles, strips and glucometers

    Subject to pre-authorisation

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    R4 490 per beneficiary per annum

    100% of cost
  • Appliances and Consumables - Acute
    For Acute Conditions

    Examples of appliances for acute conditions include, but are not limited to:

    Braces, slings, splints and corsets; cervical collars; thermomoulded shoes and post-operative sandals, including bunionectomy Arcopedico shoes; air casts; pressure garments; compression hoses; cushions; mastectomy breast prostheses; TED compression stockings; the hiring of sleep apnoea monitors for infants; and the hiring of wheelchairs, walking frames, crutches, traction equipment, toilet and bath raisers and bath swivel stools

    Benefit is adjusted in proportion to the number of months of membership if member joins during benefit year

    R7 680 per family per annum

    80% of cost
  • Appliances and Consumables - Hearing Aids
    Includes repairs to hearing aids
    Hearing Aids and their repairs

    Consultations in respect of a PMB condition are subject to a care plan

    Benefit is adjusted in proportion to the number of months of membership if a member joins during benefit year

    R19 990 per beneficiary per 2 year cycle

    100% of cost
  • Psychological and Psychiatric Treatment
    Psychological and Psychiatric Treatment

    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.

    Benefit is adjusted in proportion to the number of months of membership if a member joins during benefit year

    R7 680 per family per annum

    80% of Society rate for Non-PMB

    PMB: 100% of cost
  • Clinical and Technical Technologists
    In-hospital services

    Subject to pre-authorisation

    100% of cost, to a maximum of twice the Society rate
    Out-of-hospital services
    100% of Society rate
  • Dental Services
    Conservative and restorative dentistry

    Includes plastic dentures and extractions under conscious sedation; General anaesthetic and hospitalization for conservative dental work excluded, except in the case of trauma and impacted molars

    All orthodontic services are subject to prior approval

    General anaesthetic and hospitalisation for conservative dental work excluded, except in the case of trauma and impacted third molars In-hospital dentistry subject to preauthorisation by Society's designated agent or hospital DSP Benefit is adjusted in proportion to the number of months of membership if a member joins during benefit year

    All Dental Services Limited to:
    M: R10 740
    M+1: R16 030
    M+2: R19 860
    M+3: R21 450

    100% of Society rate or agreed tariff
    Special dentistry

    including metal based dentures

    All orthodontic services are subject to prior approval

    General anaesthetic and hospitalisation for conservative dental work excluded, except in the case of trauma and impacted third molars In-hospital dentistry subject to preauthorisation by Society's designated agent or hospital DSP Benefit is adjusted in proportion to the number of months of membership if a member joins during benefit year

    All Dental Services Limited to:
    M: R10 740
    M+1: R16 030
    M+2: R19 860
    M+3: R21 450

    100% of Society rate or agreed tariff
    Implants

    In-hospital dentistry subject to pre-authorisation by Society's designated agent or hospital DSP

    All orthodontic services are subject to prior approval

    General anaesthetic and hospitalisation for conservative dental work excluded, except in the case of trauma and impacted third molars In-hospital dentistry subject to preauthorisation by Society's designated agent or hospital DSP Benefit is adjusted in proportion to the number of months of membership if a member joins during benefit year

    All Dental Services Limited to:
    M: R10 740
    M+1: R16 030
    M+2: R19 860
    M+3: R21 450

    100% of Society rate or agreed tariff
  • Optical Services
    1 per beneficiary per cycle. Consultations outside the network limited to R370 per beneficairy per cycle
    Comprehensive consultation (inclusive of tonometry, glaucoma screening and visual screening)

    1 pair of clear single vision lenses limited to R180 per lens per beneficairy per cycle when obtained outside the network
    OR
    1 pair of clear bifocal lenses limited to R395 per lens per beneficairy per cycle when obtained outside the network
    OR
    1 pair of clear multifocal lenses limited to R840 per lens of any prescription per beneficairy per cycle when obtained outside the network

    100% of cost if obtained from Iso Leso
    Spectacle lenses

    Limited to R840 per beneciary per cycle

    100% of cost if obtained from Iso Leso
    Frames and/or prescription lens enhancements

    Limited to R1 630 per beneciary per cycle

    100% of cost if obtained from Iso Leso
    Contact lenses

    R530 per beneficairy per cycle

    100% of cost if obtained from Iso Leso
    Contact lenses instead of spectacles

    Either the Spectacle or Contact lenses benefit, may be used

    R530 per beneficairy per cycle

    100% of cost if obtained from Iso Leso
    Lens enhancements

    100% of cost available to Iso Leso members only
    Lens enhancement of R530 per beneficiary per cycle
    LensXtend benefit of R500 for EITHER lens extras such as tints OR for an upgrade to a more expensive frame OR to buy contact lenses 

    100% of cost if obtained from Iso Leso
    Refractive surgey
    Provided for under the hospitalization benefit and is subject to pre-authorisation and the guidelines of the Society’s designated agent