Benefits: Everyday Services

What will be paid from Everyday Services Benefits?

Everyday Services Benefits typically cover medical treatment that you receive out of hospital or as an outpatient at a hospital. Unlike the services and procedures covered under Hospital and Trauma Benefits, these are expenses that occur more frequently. Examples include visits to your doctor or dentist, as well as prescribed medicines.

The services you receive before being admitted to hospital are covered by your Everyday Services Benefits, even if these services are directly related to your hospital admission. Similarly, any follow-up services after you have been discharged from hospital also fall under Everyday Services Benefits. (However, there is a sub-limit under Hospital and Trauma Benefits for physiotherapy treatment after hospitalisation, if approved by the Case Manager.) Please refer to the tables that follow for more information.

Anti-malaria tablets and contraceptives (excluding condoms) are covered under Everyday Services Benefits. Vaccines, other than those covered under the Wellness Benefit, are only covered under the Savings and Platinum Plans from available benefits. Child immunisation vaccinations are subject to the acute medication benefit on all plans, except the Platinum Plan. Please refer to the tables below for more information. In addition, you may claim from your Everyday Services Benefits for prescribed vitamins and treatments for pregnancy-related anaemia as well as other supplements prescribed during pregnancy.

 

Additional out-of-hospital benefits that will be covered separately

There are a number of out-of-hospital benefits that you have access to on all Plans (unless otherwise specified), that are covered from your Hospital and Trauma Benefits. These include:

  • Services in doctors’ rooms
  • Nursing services
  • Specialised Radiology
  • Dental implants / building up of teeth (not available on the Hospital Network Plan); covered at Medical Scheme Rate
  • Oncology: PET scans, social worker, specialised drugs (PMB only on the Savings and Hospital Network Plans)
  • Other specialised drugs (cover for Multiple Sclerosis only on the Savings and Hospital Network Plans)
  • Artificial limbs and artificial eyes
  • Home Oxygen Therapy
  • Stoma care products

You can read more about these benefits in the BENEFITS: HOSPITAL AND TRAUMA chapter of this website.

 

How do the different plans cover Everyday Services claims?

PLEASE NOTE

  • Member +3 benefit limits will also apply to families with more than three dependants.
  • Unless stated otherwise, the benefit limits shown below apply to the benefit year running from 1 January to 31 December.
  • If there is a shortfall between the benefit covered by the Scheme and the actual cost of the service, you will need to pay this difference at the point of sale.
  • The Hospital Network Plan does not offer any of the benefits below, and therefore does not form part of the comparison in this chapter.

 

Benefits are paid at up to 3 x MSR.
Sub-limits are available for certain benefits. Other specific benefits are covered from the Routine Medical Benefit (RMB) limit.
Once these sub-limits are depleted, the available RMB limit can also be used to cover the above benefits.
Once your sub-limits and RMB are depleted, you will be liable for payment.

ROUTINE MEDICAL
BENEFIT LIMIT

Member: R25 000
Member +1: R42 000
Member +2: R44 600
Member +3: R54 200
This benefit can also be used to pay for certain other services, once you have used up those limits.

15% of your monthly contribution is allocated to your PMSA. Benefits with sub-limits are paid at MSR, while benefits payable from PMSA are covered at cost.
Sub-limits are available for certain benefits. Other specific benefits are covered from your Personal Medical Savings Account (PMSA).
Once your sub-limits and/or PMSA (whichever is applicable to the specific benefit) are depleted, you will be liable for payment.

ANNUAL PMSA AMOUNT
(AVAILABLE UPFRONT)

Add up the amounts per beneficiary to calculate the total available for your family.

If you earn less than R10 001 pm Member: R8 460
Adult: R6 600
Child (max 2): R1 884
If you earn R10 001 pm or more Member: R8 637
Adult: R6 732
Child (max 2): R1 944

Benefits are paid at MSR.
Sub-limits are available for certain benefits.
Once your sub-limits are depleted, you will be liable for payment.

21.3% of your monthly contribution is allocated to your PMSA. Benefits with sub-limits are paid at MSR, while benefits payable from PMSA are covered at cost.
Most of the listed benefits are covered from your Personal Medical Savings Account (PMSA). Sub-limits are available for certain maternity benefits only.
Once your sub-limits and/or PMSA (whichever is applicable to the specific benefit) are depleted, you will be liable for payment.

ANNUAL PMSA AMOUNT
(AVAILABLE UPFRONT)

Add up the amounts per beneficiary to calculate the total available for your family.

If you earn less than R10 001 pm Member: R5 844
Adult: R5 031
Child (max 2): R1 785
If you earn R10 001 pm or more but less than R20 001 pm Member: R6 378
Adult: R6 258
Child (max 2): R2 118
If you earn R20 001 pm or more Member: R6 468
Adult: R6 348
Child (max 2): R2 145

HOSPITAL NETWORK
1 x Network GP consultation per beneficiary per year.
1 x dentist consultation per beneficiary per year. NEW!

 

Remember that certain benefit limits and conditions such as treatment protocols apply – see the 2021 Member Guide.

  PLATINUM COMPREHENSIVE TRADITIONAL SAVINGS
consultations
Consultations with General Practitioners and Homeopaths

Visits, consultations, outpatients, procedures out of hospital not covered under Hospital and Trauma Benefits

Payable from Routine Medical Benefit limit. Covered from available PMSA. Member: R2 795
Member +1: R5 165
Member +2: R5 640
Member +3: R6 920
Covered from available PMSA.
HOSPITAL NETWORK PLAN: 1 x Network GP consultation per beneficiary per year.

Specialists Benefits
Subject to referral from GP – please see If you want to see a Specialist.
Limited to and included in above Consultations limit.
Subject to referral from GP – please see If you want to see a Specialist.
Limited to and included in above Consultations limit.
Subject to referral from GP – please see If you want to see a Specialist.
Limited to and included in above Consultations limit.
Subject to referral from GP – please see If you want to see a Specialist.
Limited to and included in above Consultations limit.
optical
Optical benefits

  • Eye tests
  • Lenses, contact lenses and fittings

Eye tests are payable from this benefit limit.
Lenses, contact lenses and fittings are paid up to the available sub-limits.

R5 600 per beneficiary

Once the limit is exhausted, this benefit will be paid from the Routine Medical Benefit limit.

Member: R2 890
Member +1: R4 515
Member +2: R4 760
Member +3: R5 570

A sub-limit of R1 085 per beneficiary applies to frames for the 2-year cycle starting 1 January 2020

Member: R2 890
Member +1: R4 515
Member +2: R4 760
Member +3: R5 570

A sub-limit of R1 085 per beneficiary applies to frames for the 2-year cycle starting 1 January 2020

Covered from available PMSA.
maternity
Maternity benefits
  • Antenatal visits
R8 580 combined maternity benefit per family.

Once the limit is exhausted, this benefit will be paid from the Routine Medical Benefit limit.

R4 655 per family R4 655 per family R4 655 per family
  • Antenatal classes
R1 715 per family R1 715 per family R1 715 per family
  • Ultrasound scans
3 x 2D or 3D scans per family 3 x 2D scans per family 3 x 2D scans per family 3 x 2D scans per family
  • Child Vaccinations
At a private clinic: R6 140 per family per year Medication cost only, excluding facility fee or nursing consultations
  • Amniocentesis
1 per beneficiary per year
dentistry
Dentistry benefits
  • Basic dental services

Removal of teeth and roots, removal of wisdom teeth, exposure of teeth for orthodontic reasons and suturing of traumatic wounds, diagnosis and treatment of oral and associated conditions, plastic dentures.

R9 180 per beneficiary per year for Basic and Advanced dentistry.

Once the limit is exhausted, this benefit will be subject to the Routine Medical Benefit limit.

R3 645 per beneficiary

Once the limit is exceeded, claims will be paid from Advanced dentistry limit.

R3 645 per beneficiary

Once the limit is exceeded, claims will be paid from Advanced dentistry limit.

Covered from available PMSA.
HOSPITAL NETWORK PLAN: 1 x dentist consultation per beneficiary. NEW!
  • Advanced dentistry

Inlays, bridgework, crowns excluding gold content, mounted study models, metal base partial dentures, orthodontics (up to age 21), periodontists, prosthodontists and dental technicians.

Member: R4 865
Member +1: R8 830
Member +2: R9 110
Member +3: R10 870
Member: R4 865
Member +1: R8 830
Member +2: R9 110
Member +3: R10 870
Covered from available PMSA.
medicines
Medicines
  • Prescribed medicine (acute)
  • Antenatal vitamins prescribed during pregnancy – excluding calcium supplements and Omega preparations
Payable from Routine Medical Benefit limit. Covered from available PMSA. Paid at Medicine Price or Medicine Price List, whichever is the lesser Member: R3 830
Member +1: R5 970
Member +2: R6 300
Member +3: R7 370

Paid at Medicine Price or Medicine Price List, whichever is the lesser.

Covered from available PMSA.
  • Pharmacy advised therapy (PAT) – Medicines supplied by a registered pharmacist without a prescription from a medical practitioner or dentist. Benefit excludes the pharmacy’s administration fee.

    The funding of compound analgesics, for example, Myprodol®, Stilpane® and Syndol® will be restricted to a maximum supply of one hundred tablets or capsules per year. If your condition requires medication in excess of this limit, you, your doctor or pharmacist can contact the Scheme on 0860 100 080. He/she will be transferred to a clinical agent who will consider a verbal motivation.

Payable from Routine Medical Benefit limit. Covered from available PMSA. R1 525 per family, subject to the prescribed medicine limit. Covered from available PMSA.
pathology
Pathology

DSPs (Ampath, Lancet, PathCare, Vermaak & Partners) paid at cost; non-DSPs paid at Medical Scheme Rate.

Payable from Routine Medical Benefit limit. Member: R2 300
Member +1: R2 925
Member +2: R2 975
Member +3: R3 260
Member: R2 300
Member +1: R2 925
Member +2: R2 975
Member +3: R3 260
Covered from available PMSA.
radiology
Radiology (X-rays)

Payable from Routine Medical Benefit. R3 065 per family R3 065 per family Covered from available PMSA.
supplementary
Supplementary health services

20 practice areas including anthroscopical treatment, applied kinesiology, audiometry, audiology, autologous donation of blood, biokinetics, chiropody, chiropractic services, clinical technology, dieticians, genetic counselling, hearing aid acoustics, naturopaths, occupational therapy, orthoptic treatment, podiatry, private nurses, remedial therapy, speech therapists, and social workers.

Payable from Routine Medical Benefit. Covered from available PMSA. Member: R2 265
Member +1: R4 185
Member +2: R4 560
Member +3: R5 590
Covered from available PMSA.
physio
Physiotherapy

Physiotherapy following hospitalisation is covered under the Hospital and Trauma Benefits, provided it is pre-authorised by the Case Manager before discharge from hospital. See the Hospital and Trauma Benefits chapter in this guide for more information.

Payable from Routine Medical Benefit. Covered from available PMSA. R3 630 per family Covered from available PMSA.
psycology
Psychology

There is a difference in the benefits you receive for treatment by a psychiatrist and a psychologist. A psychiatrist is a medical specialist who may use psychotherapy as well as medication to treat patients. The consultation or treatment by a psychiatrist will be deducted from the General Practitioners and Specialists limit, where applicable. Psychotherapy by a clinical psychologist, who is not a specialist, will be deducted from the Psychology limit, where applicable.

Payable from Routine Medical Benefit. R6 800 per family R6 800 per family Covered from available PMSA.
appliances
Medical appliances

Not forming an integral part of an operation, for example, baumanometer, all orthopaedic braces, and crutches, as well as CPAP equipment. Maintenance and repairs are not covered by the Scheme, unless a full quote is received and pre-authorised by the Scheme.

Approval for moulded insoles is subject to motivation from a relevant specialist. The frequency of the benefit will be subject to the Scheme’s clinical protocols.

Payable from Routine Medical Benefit. R4 755 per family R4 755 per family Covered from available PMSA.
wheelchair
Wheelchair and associated appliances

Can be purchased or hired, if approved before acquisition.

R13 570 per family R13 570 per family R13 570 per family Covered from available PMSA.
hearing-aids
Hearing aids

This benefit covers the cost of the repair of the devices, subject to the quote being submitted to the Scheme and being approved. A registered provider must submit the claim.

The cost of batteries is excluded.

Payable from Routine Medical Benefit. R37 800 per family for beneficiaries 6 years and younger

R25 860 per family for beneficiaries 7 years and older

Benefit available per beneficiary every 2 years, starting 1 January 2020.

R37 800 per family for beneficiaries 6 years and younger

R25 860 per family for beneficiaries 7 years and older

Benefit available per beneficiary every 2 years, starting 1 January 2020.

Covered from available PMSA.
contraceptives
Oral contraceptives

Products must be prescribed for contraception and not for the treatment of acne or skin conditions, unless otherwise specified as per managed care protocols.

R3 525 per beneficiary for the Mirena device, with a R1 950 sub-limit for oral contraceptives, subject to managed care protocols.

The cost of a GP or gynaecologist consultation will be covered from the Routine Medical Benefit.

Covered from available PMSA. Payable from Prescribed medicine (acute) sub-limit. Covered from available PMSA.

 

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