☑️ Hospital Admissions
High Care Unit
General Ward
Theatre
Recovery Room | Covered up to 100% of the Negotiated Tariff. |
| ✅ Medicines and consumables used in hospital and theatre | Covered up to 100% of the negotiated tariff. |
| 💊 Medicine to take home after discharge | Paid from the hospital benefit.
Limited to 7 days’ medicine. |
| 1️⃣ Consultations and Procedures | Covered up to 100% of the negotiated tariff. |
| 2️⃣ Basic Radiology and Pathology | Covered up to 100% of the scheme tariff. |
| 3️⃣ Specialized Radiology | Limited to two scans per beneficiary yearly.
There is a 10% co-payment for non-PMB MRI and CT scans. |
| 4️⃣ Oncology | Covered up to 100% of the DSP tariff.
Enhanced oncology DSP protocols will apply.
Unlimited Oncology treatment is available for PMB.
Benefits over R546,000 are subject to a 20% co-payment on non-PMBs. |
| 5️⃣ Renal Dialysis | Covered up to 100% of the negotiated tariff. |
| ❤️ Organ Transplants | Covered up to 100% of the scheme tariff. |
| 🦷 Dental Hospitalisation | Covered up to 100% of the scheme tariff.
Limited to PMBs.
Children under seven can receive general anesthesia benefits once per year for intensive dental treatment.
Symptomatic wisdom tooth removal is covered solely as Day Case.
Subject to pre-approval.
Treatment protocols will apply. |
| 😊 Maxillo-facial and Oral Surgery | Covered up to 100% of the scheme tariff.
Subject to managed care protocols.
Only symptomatic wisdom teeth and surgical exposure are allowed. All other operations are subject to PMB approval alone.
Only symptomatic impacted wisdom teeth are removed on a day-to-day basis. |
| 🩺 Drug and Alcohol Rehabilitation | Covered up to 100% of the scheme tariff.
Limited to R21,131 per family per year. |
🧠 Psychiatric Treatment (PMB)
Consultations
Ward Fees
Medicines
Psychiatry/psychology therapy sessions | Covered up to 100% of the scheme tariff.
21 in-patient days or up to 15 outpatient interactions per year per beneficiary
14 days per family with a maximum of R22,397 |
| ✔️ Non-PMB Psychiatric Treatment | Up to 3 days for the Psychologist for combined therapy sessions with the Psychiatrist at the same admission.
After that, pre-authorization with the treatment plan is required. |
| ⬇️ Step-down Facilities | Covered up to 100% of the negotiated tariff.
Limited to 14 days per beneficiary per year. |
| 🏡 Home-Based Care | Covered up to 100% of the negotiated tariff.
Limited to 14 days per beneficiary per year. |
| 🩹 Negative Pressure Wound Therapy | Covered up to 100% of the negotiated tariff.
Limited to R29,274 per family yearly. |
| 😮💨 Hyperbaric Oxygen Therapy | Covered up to 100% of the negotiated tariff.
Limited to R46,452 per family yearly. |
| 🅰️ Male Sterilisation/Vasectomy | Covered up to 100% of the negotiated tariff.
Sterilization is limited to R17,472 per beneficiary per year.
Subject to pre-approval and PMBs. |
| 🅱️ Female Sterilisation/Tubal Ligation | Covered up to 100% of the negotiated tariff.
Sterilization is limited to R17,472 per beneficiary per year.
Subject to pre-approval and PMBs. |
| 🧬 Back and Neck Surgery | Spinal surgery authorization for treating chronic back or neck pain is subject to managed care guidelines.
Before authorizing surgery, managed care may require adherence to conservative clinical treatment. |
| ↪️ Stereotactic Radiosurgery | Covered up to 100% of the scheme tariff.
Only covers Primary Central Nervous System tumors. |
| 📌 Age-related Muscular Degeneration Treatment | Covered up to 100% of the negotiated tariff.
Pre-authorization required. |
| 📍 Laparoscopic Hospitalisation and Associated Costs | Pre-authorization required.
Subject to PMBs. |
| 🧪 PMB Laparoscopic Procedures | PMBs are covered in DSP facilities.
Subject to clinical protocols.
In-hospital procedures will incur an R5,250 co-payment, except for diagnostic laparoscopy, aspiration/excision ovarian cyst, lap-appendicectomy, and treatment of recurrent or bilateral inguinal hernias.
A co-payment does not apply if procedures are done at a day hospital or as a day case. |
| 🦾 Internal and External Prostheses | Covered up to 100% of the negotiated tariff.
Subject to PMBs and pre-approval.
Overall prostheses limit of R52,406 per family per year within the hospital limit. |
| 🦿 Instrumentation and disc prostheses, including components and fixation devices for the back or spine. | Limited to 1 event per beneficiary per year.
The following sub-limits apply:
R25,499 per level, subject to the overall limit.
Limited to 2 levels unless there is clinical motivation or it has been approved within the PMB protocols. |
| 🦵 Internal Prostheses | Limited to R46,321 per year.
Subject to the overall limit.
Limited to one event per year unless it involves trauma or sepsis.
Cement is not included. |
| ✴️ Aphakic Lenses | Subject to the overall prostheses limits and PMB protocols.
Limited to R6,452 per lens. |
| 🔁 Cardiac Stents | One per lesion, maximum 3.
Subject to the overall prostheses limit.
Bare metal stents are limited to R16,774 per stent.
Drug-eluting stents are limited to R23,625 per stent. |
| ⚗️ Internal sphincters and stimulators | Limited to PMBs. |
| ☑️ Neurostimulators/Internal nerve stimulators for Parkinson’s disease | Subject to the overall prostheses limit. |
| ✅ Unlisted prostheses, artificial limbs, and external prostheses | Limited to R15,278 and subject to the overall limit. |
| 🩸 Blood Transfusions | Covered up to 100% of the scheme tariff. |
| 🏈 Physiotherapy and Biokinetics | Covered up to 100% of the scheme tariff. |
| 🍎 Dietician and Occupational Therapy | Covered up to 100% of the scheme tariff. |
| ❎ Deductibles – Applied for In-hospital procedures | Joint Replacement
Umbilical Hernia Repair
Hysterectomy
Functional Nasal Surgery
Elective Caesarean Section |
