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book Glossary
Agreed Rate The agreed rate is the negotiated tariff fee payable to any Designated Service Provider including those listed on the Network. GRP The generic reference price - the Fund basis its medicine benefits on the cost of generic medicines instead of brand name medicines. Momentum Health Solutions Momentum Health Solutions is contracted to the Scheme for all managed healthcare services and the management of the Scheme's provider network. Scheme rate The Scheme rate is the tariff set by the Fund for reimbursement of claims, in the absence of any other agreed or contracted tariff with any service provider. SEP The single exit price is the legislated price of medicine. UPFS The uniform patient fee schedule is the fee schedule applied by the public sector. PMB CDL Prescribed Minimum Benefits(PMB) Chronic Disease List (CDL): PMBs are benefits that medical scheme must offer in terms of the Medical Schemes Act 131 of 1998.
Standard Option
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General practitioner (GPs) (limited to 7 visits per beneficiary per year)
Consultations
Please note a co-payment equal to the difference between the Scheme rate and GP rate may apply
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Scheme rate
Emergency consultations
Please note a co-payment equal to the difference between the Scheme rate and GP rate may apply
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Scheme rate
Acute medication
Subject to R360 per beneficiary per day
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of single exit price (SEP) and generic reference price (GRP), subject to overall annual day-to-day limit
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Over-the-counter (OTC) medication
OTC medication(includes homeopathic, herbal and natural medication)
Subject to R360 per beneficiary per day, with a maximum of R1 570 per family per year
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of single exit price (SEP) and generic reference price (GRP), subject to overall annual day-to-day limit
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Specialists
Consultations (non-network provider)
A co-payment equal to the difference between the Scheme rate and specialist rate may apply
The member is responsible for ensuring that an authorisation number is obtained before consulting a specialist
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per familyUp to 140%
of Scheme rate, subject to overall annual day-to-day limit
Consultations (network provider)
The member is responsible for ensuring that an authorisation number is obtained before consulting a specialist
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Agreed rate, subject to overall annual day-to-day limit
Acute medication
The medication may be obtained at any pharmacy
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of single exit price (SEP) and generic reference price (GRP), subject to overall annual day-to-day limit
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Emergency room/casualty department (hospital unit)
Excludes facility fee
Primary care benefits for acute illnesses or injuries which may require immediate attention
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Agreed rate
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Dental
Basic dentistry, advanced/specialised dentistry, dentures and procedures under conscious sedation in a doctor's rooms
Dentistry
Members are liable for all costs related to dental care by any general or specialist dentist where costs exceed the dental rate and/or dental limit
Includes the following:
- Basic dentistry
- Advanced/specialised dentistry
- Dentures
- Procedures under conscious sedation in a doctor's rooms
- Clinical guidelines apply Annual limit:
M R6 800
M + 1 R8 200
M + 2 R9 700
M + 3 R9 900
M + 4 R10 100
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Scheme rate; dental limit subject to overall annual day-to-day limit
Dental therapist
Members are liable for all costs related to dental care by any general or specialist dentist where costs exceed the dental rate and/or dental limit
Annual Limit:
M R6 800
M + 1 R8 200
M + 2 R9 700
M + 3 R9 900
M + 4 R10 100
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family80%
of Scheme rate; dental limit subject to overall annual day-to-day limit
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Optometrists
Frames, lenses, contact lenses, tints and eye tests
Optometrists must obtain authorisation for patient referral to a specialist
Optical limit: R3 100 per beneficiary every two years; i.e. 2023 to 2024
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Scheme rate; optical limit subject to overall annual day-to-day limit
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Radiology
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Scheme rate, subject to overall annual day-to-day limit
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Pathology
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Scheme rate, subject to overall annual day-to-day limit
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Allied health services
Nursing services, speech therapist, dietician, occupational therapist, social worker, audiologist, chiropody, chiropractor and physiotherapy and Art therapy
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Scheme rate, subject to overall annual day-to-day limit
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Appliances
Nebulisers, crutches, glucometers, hearing aids, hire of oxygen cylinders, etc.
Subject to registration with the appropriate Disease Risk Management Programme
Written motivation from a general practitioner is required; subject to approval from a medical advisor
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Scheme rate, subject to overall annual day-to-day limit
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Clinical psychology
The member is responsible for ensuring that an authorisation number is obtained before consulting a specialist
Subject to overall annual day-to-day limit
M R13 700 per single member
M + 1 R20 900 per family
M + 2 R27 400 per family
M + 3 R28 200 per family
M + 4 R28 700 per family100%
of Scheme rate, subject to overall annual day-to-day limit
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Chronic medication
To obtain benefits for chronic medication, the patient must be registered with the Medicine Risk Management Programme
The Fund's approved chronic condition list is applicable
Medication approved as per Chronic Disease Medication Formulary
All medication may be obtained from a pharmacy or a dispensing network general practitioner PMB CDL conditions: Unlimited
Non-CDL conditions: Limited to R3 000 per beneficiary per year
100%
of single exit price (SEP) and generic reference price (GRP)
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Ambulance services
Members must make use of Netcare 911
Members must call 082 911 for all ambulance services
For voluntary use of any other service provider, members will be liable for a 20% co-payment
Netcare 911
only
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HIV/AIDS
This benefit includes medication, doctor's consultations and blood tests at contracted service providers required for the treatment of the condition, as well as the cost of prophylaxis for preventative treatment
This benefit is subject to enrolment on the HIV/AIDS Programme
Medicine and hospital pre-authorisation is required
R15 200 per beneficiary per year
100%
of Scheme rate
Medicine: 100% of single exit price (SEP) and generic reference price (GRP)