User login

You are here

Home

Aspire 2021

Add to compare
Type of Medical Aid Plan: 
Hospital
Medical Aid Year: 
2021
Day to day Benefits: 

A limit of 3 Primary Care Network Provider visits per family, per annum, subject to a co-payment of R75 per visit. If Primary Care Network Providers are not used, a limit of 2 visits per family, per annum applies, subject to a co-payment of R150 per visit. Specialist visits limited to PMB's only and subject to pre-authorisation

In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
Unlimited at 100% of Contracted Rate(CR)
Hospitals: 

Any. Subject to Scheme Protocols, hospital procedure list and option-specific exclusion list

Upfront Payments to hospitals: 

Procedure co-payments may apply to admissions; full details in the 2021 brochure

Casualty / Emergency Visits: 
No Benefit for non-PMB. Unlimited for trauma and PMB. Verification of pre-authorisation within 72 hours of the event
Specialists: 
Contracted Providers at 100% of CR. Non-contracted Providers at 100% of Scheme Rate(SR)
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Contracted Providers at 100% of CR. Non-contracted Providers and Physiotherapy at 100% of SR
Radiology and pathology: 
100% of CR
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Subject to co-payments of R7 524 for a gastroscopy and R3 762 for a colonoscopy
MRI and CT scans: 
Unlimited for emergency, injury-related and trauma. Non-PMB limited to R8 850 per annum, with a co-payment of R3 612. Scheme rules and Protocols apply
ICU and High Care: 
100% of CR
Dialysis: 
Unlimited at Network Provider. Subject to Scheme Protocols. Pre-authorisation required
Organ Transplants: 
Limited to PMB's only
Oncology / Cancer: 
Unlimited. Non-PMB limited to R201 348 per family, per annum. Subject to ICON Network and Essential protocols. Pre-authorisation required. 40% Non-DSP co-payment
Neck and Back Operations: 
Limited to PMB's only. Subject to prosthesis sub-limit
Joint Replacements: 
Limited to PMB's only. Subject to prosthesis sub-limit
Prosthesis: 

Internal: Unlimited per family, per annum. Subject to prosthesis sub-limits and Scheme Protocols.
Non-PMB subject to overall annual limit of R42 136

Medical and Surgical Appliances: 
Limited to R4 334 per family, per annum. Scheme Protocols and appliance sub-limits apply. Must be prescribed by a registered Healthcare practitioner and obtained from a supplier registered with the Board of Healthcare Funders
Maternity Confinements: 
Normal delivery; 3 days and 2 night: Caesarean section if clinically indicated; 4 days and 3 nights. Pre-authorisation required for elective Caesarean section
In Hospital Dentistry: 
Limited to R5161 for impacted wisdom teeth, includes hospital and anaesthetist. No cover for dental surgeon. Co-payment of R3 762 and Scheme Protocols apply
Take home Medicine: 
Maximum of 7 days supply
Rehabilitation, Hospice and Step-down facilities: 
Unlimited in lieu of hospitalisation. Subject to pre-authorisation. Non-PMB's limited to 10 days per family, per annum
Treatment for Mental Health: 
Psychiatric disorders are limited to Network Providers and subject to PMB's and Scheme Protocols
HIV / AIDS: 
Subject to registration on the HIV Management Programme. Hospitalisation at Network Provider hospitals. Subject to Scheme Protocols and PMB's
Ambulance Service: 
Netcare 911 in an emergency
Day-to-day benefits
GP consultations: 

A limit of 3 Primary Care Network Provider visits per family, per annum and subject to a co-payment of R75 per visit. If Primary Care Network Providers are not used, a limit of 2 visits per family, per annum, subject to a co-payment of R150 per visit

Specialist consultations: 

Specialist visits limited to PMB's only, subject to pre-authorisation

Acute medicine: 

Subject to PMB's

Over-the-counter (OTC) Medicine: 

No benefit

Optometry benefits: 
No benefit
Basic dentistry: 
No Benefit
Specialised Dentistry: 
No Benefit
Orthodontics: 

No Benefit

MRI and CT Scans (Out of Hospital): 
Unlimited for emergency, injury-related and trauma. Non-PMB limited to R8 850 per annum, with a co-payment of R3 612. Scheme rules and Protocols apply
Radiology and Pathology: 
No Benefit
Pregnancy benefits: 
Subject to registration on the Maternity Programme. Consultations are subject to Scheme Protocols and PMB's, 2x 2D scans
Physiotherapy and Occupational Therapy day to day: 
No Benefit
Chronic Conditions
Provider: 
Medipost, Dischem and Clicks pharmacies. 40% Non-DSP co-payment. Subject to chronic formulary. Reference and Generic Reference Pricing(GRP) may apply
Chronic Conditions: 

Diagnosis, treatment and care costs of 27 chronic conditions that fall under the PMB Chronic Disease List (CDL), issued by the Council for Medical Schemes. Benign Prostatic Hypertrophy and Hormone Replacement Therapy also covered as PMB's. Subject to Disease Management Protocols and pre-authorisation

Additional Chronic Conditions: 
As above
Preventative Care Benefits
Preventative Benefits: 

Subject to a limit of R2 778 per family per annum. Pap smear and PSA screening for beneficiaries older than 45 years, HIV test, flu vaccine, childhood immunisations as recommended by the Department of Health, up to 18 months and subject to a limit of R2 097, oral contraceptives limit of R1 116 per female beneficiary per annum, with a sub-limit of R93 per month

Total Contributions
Total Contribution Main Member: 
2178.00
Total Contribution Adult: 
1761.00
Total Contribution Child*: 
777.00
Aspire
Medical Aid Plan Name Term: 
Aspire