Primary Care

The following benefits will be implemented with effect from 1 January 2024.
  • 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

    One per beneficiary per annum

    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

    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 cost
    Vaccinations (Child and infant)

    State protocols apply

    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 tariff
    Human papillomavirus (HPV)

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

    100% of agreed tariff
    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

    One per beneficiary per annum

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

    One per beneficiary per annum, subject to a limit of R1 490 if performed in a doctor's room

    100% of agreed tariff
    Contraceptives

    Limited to R1 890 per beneficiary per annum and subject to overall acute medication limit

    100% of agreed tariff
  • General Practitioner and Specialist Services
    Combined Limit:

    M R8 040
    M+1 R10 780
    M+2 R13 430
    M+3+ R16 170

    General Practitioner: Consultations, Services and visits

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

    Includes consultations and treatment out of hospital, including outpatient facilities.

    Consultations in respect of a PMB condition are subject to the Care Plan and Appendix 1 of the Society's rules.

    Once the limit is reached, only services in respect of PMB conditions will be paid.

    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.

    Benefit is pro-rated if member joins during benefit year.

    PMBs

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

    PMB   100%of Agreed Tariff if a network or non-network GP is used

    Non-PMB   100%of Agreed Tariff if a network GP is used

    or

    80% of Agreed Tariff if a non-network GP is used
    Specialist: Consultations, Services and visits

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

    Includes consultations and treatment out of hospital, including outpatient facilities.

    Consultations in respect of a PMB condition are subject to the Care Plan and Appendix 1 of the Society's rules.

    Once the limit is reached, only services in respect of PMB conditions will be paid.

    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.

    Benefit is pro-rated if member joins during benefit year.

    PMBs

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

    PMB   100%of Agreed Tariff if a network or non-network Specialist is used

    Non-PMB   100% of Agreed Tariff if a network Specialist is used

    or

    80% of Society Rate if a non-network Specialist is used
  • Maternity
    Maternity Related Services

    Subject to registration, pre-authorisation and Society protocols

    Additional services, such a Toco-Cardiography, External Cephalic Version, Lecithin-Sphingomyelin and Amniocentesis may be granted where clinically appropriate and medically necessary.

    The following benefits will be paid from the overall annual in-hospital benefit as part of the maternity treatment plan. Any other costs incurred at the time of the visit will be paid from your benefits, as specified in the rules of the Society. Once the maternity treatment plan benefit limits have been reached, tests will be paid from the applicable benefit limit:
    Pathology test out-of-hospital Per Year Tarriff Code
    Full blood count 1 3755
    Blood test: Blood group 1 3764
    Blood test: Rhesus antigen 1 3765
    Urine culture 1 3893
    HIV Elisa or other screening 1 3932
    Rubella antibody 1 3948
    VDRL(Venereal Disease Research Laboratory) 1 3949
    Glucose strip 1 4050
    Urine analysis dipstick 13 4188
    HIV antibody rapid 1 4614
    Obstetric/GP/MIDwife consultations per pregnancy 10
    Ultrasound scans, limited to 2D 2
    100% of Society rate
  • Auxiliary services
    Out Of Hospital
    Benefits include: Audiology, Audiometry, Occupational Therapy, Speech Therapy, Orthoptic Services, Physiotherapy, Biokinetics, Psychological Treatment: Social Workers and Registered Councilors, Clinical and Technical Technologists, Dietician Services, Chiropractor, Homeopath, Osteopaths, Naturopaths, Podiatrists, Chiropodists, Ayurvedic and Taditional Healers, Therapeutic Massage Therapist, Social Workers

    Includes consultations and treatment out of hospital by an approved and registered paramedical and auxiliary service provider (subject to registration with the HPCSA and AHPCSA).

    Consultations in respect of a PMB condition are subject to the Care Plan and Appendix 1 of the Society's rules.

    Once the limit is reached, only services in respect of PMB conditions will be paid.

    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.

    Benefit is pro-rated if member joins during benefit year.

    All Out of Hospital Auxiliary Services are limited to:
    M: R7 860
    M+1: R10 510
    M+2: R13 100
    M+3: R15 770

    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

    R13 770 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

    R13 770 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

    R25 880 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

    R5 430 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

    R9 280 per family per annum

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

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

    R24 160 per beneficiary per 2 year cycle

    100% of cost
  • Mental Health and Drug and Alcohol Rehabilitation
    Consultations and treatment in respect of a PMB condition are subject to the Care Plan and Appendix 1 of the Society's rules.
    Once the limit is reached, only services in respect of PMB conditions will be paid.
    Benefit is pro-rated if member joins during benefit year.
    Psychologist: Consultations and treatment

    Subject to PMBs and pre-authorisation

    Benefit is pro-rated if member joins during benefit year.

    PMB   100% of cost

    Non-PMB   80% of Society rate
    Psychiatrist: Consultations and treatment

    Subject to PMBs and pre-authorisation

    Benefit is pro-rated if member joins during benefit year.

    PMB   100% of Agreed Tariff if a network or non-network service provider is used

    Non-PMB   100% Agreed Tariff if a network service provider is used

    or

    80% of Society Rate if a non-network service provider is used
  • 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
    Benefits included:
    • Conservative and restorative dentistry (includes plastic dentures and extractions under conscious sedation)
    • Special dentistry (Including metal base dentures)
    • Implants

    General anesthetic and hospitalisation for conservative dental work excluded, except in the case of trauma and impacted third molars.

    All orthodontic services are subject to prior approval.

    In-hospital dentistry subject to pre-authorisation 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: R12 350
    M+1: R18 440
    M+2: R22 840
    M+3: R24 660

    100% of Society rate
  • Optical Services
    Iso Leso is the Society's Designated Service Provider for providing optical care to its members.
    Iso Leso out of network rates will apply if service obtained from a non-network provider.
    Comprehensive consultation (inclusive of tonometry, glaucoma screening and visual screening)
    Limited to one per beneficiary per cycle


    One pair of clear single vision spectacle lenses per cycle
    OR






    One pair of clear bifocal lenses per cycle
    OR






    One pair of clear Multifocal lenses per cycle

    100% of Iso Leso rate if obtained from Iso Leso
    100% of Iso Leso rate if obtained from Iso Leso
    100% of Iso Leso rate if obtained from Iso Leso
    Frames and/or prescription lens enhancements
    100%of Iso Leso rate if obtained from Iso Leso
    Contact lenses instead of spectacles

    Either the Spectacle or Contact lenses benefit may be used

    100%of Iso Leso rate if obtained from Iso Leso
    Lens enhancements
    100% of Iso Leso rate if obtained from Iso Leso
    Refractive surgery
    Provided for under the hospitalisation benefit and is subject to pre-authorisation and the guidelines of the Society’s designated agent