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MediBonus 2019

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Medical Aid Year: 
2019
Day to day Benefits: 

DAY-TO-DAY LIMIT Limited to the following:
M = R10 400
M+1 = R14 550
M+2 = R16 150
M+3 = R17 800
M4+ = R19 250

In Hospital Benefits
Hospital Rate of Payment: 
100% of Scheme Rate
Hospitals: 

Unlimited.

Upfront Payments to hospitals: 

Non-PMB Specialised Radiology 10% upfront co-payment
Non-PMB Internal Prosthesis and Devices 20% upfront co-payment
Voluntary use of a non-DSP for HIV & AIDS related medication 40% upfront co-payment
Voluntary use of a non-DSP or a non-Medshield Pharmacy Network 40% upfront co-payment
Voluntarily obtained out of formulary medication 40% upfront co-payment
Voluntary use of a non-ICON provider - Oncology 40% upfront co-payment
Voluntary use of a non-DSP provider - Chronic Renal Dialysis 40% upfront co-payment

 

In-Hospital Procedural upfront co-payments
Endoscopic procedures (refer to Addendum B or list of services) R1 000 upfront co-payment
Functional Nasal surgery R1 000 upfront co-payment
Laparoscopic procedures R2 000 upfront co-payment
Arthroscopic procedures R2 000 upfront co-payment
Wisdom Teeth R2 000 upfront co-payment
Hernia Repair (except in infants) R3 000 upfront co-payment
Back and Neck surgery R4 000 upfront co-payment
Nissen Fundoplication R5 000 upfront co-payment
Hysterectomy R5 000 upfront co-payment

Specialists: 
Specialists are subject to pre-authorisation.
Radiology and pathology: 
Specialists are subject to pre-authorisation.
MRI and CT scans: 
Subject to Specialised Radiology Limit. No co-payment applies to CT Colonography. Unlimited.
Dialysis: 
Unlimited. 40% upfront co-payment for the use of a non-DSP. Use of a DSP applicable from Rand one for PMB and non- PMB.
Organ Transplants: 
Unlimited. Organ harvesting is limited to the Republic of South Africa.
Oncology / Cancer: 
R450 000 per family per annum.
Prosthesis: 

PROSTHESIS AND DEVICES INTERNAL
Subject to pre-authorisation by the relevant Managed Healthcare Programme on
086 000 2121 (+27 11 671 2011). Preferred Provider Network will apply.
Surgically Implanted Devices.
Clinical Protocols apply.

R43 100 per family per annum.
20% upfront co-payment for non-PMB.
Sub-limit for hips and knees: R30 000 per beneficiary
- subject to Prosthesis and Devices Internal Limit

(global fee).

 

PROSTHESIS EXTERNAL
Services must be pre-approved or pre-authorised by the Scheme on
086 000 2120 (+27 10 597 4701) and must be obtained from the DSP,
Network Provider or Preferred Provider.
Including Ocular Prosthesis.
Clinical Protocols apply.

Subject to Prosthesis and Devices Internal Limit.
No co-payment applies to External Prosthesis.

Medical and Surgical Appliances: 
R12 800 per family per annum.
Maternity Confinements: 
Unlimited.
In Hospital Dentistry: 
In-Hospital (only for beneficiaries under the age of 6 years old) Subject to pre-authorisation by the relevant Managed Healthcare Programme
Take home Medicine: 
Limited to R700 per admission. According to the Maximum Generic Pricing or Medicine Price List and Formularies.
Rehabilitation, Hospice and Step-down facilities: 
R80 000 per family per annum.
Treatment for Mental Health: 
R37 100 per family per annum. DSP applicable from Rand one for PMB and non-PMB admissions. Subject to Mental Health Limit.
HIV / AIDS: 
As per Managed Healthcare Protocols.
International Travel Benefit: 
R500 000 per journey per beneficiary.
Day-to-day benefits
GP consultations: 

Unlimited.

Extended Benefit Cover (up to 200%)

Specialist consultations: 

Unlimited.

Extended Benefit Cover (up to 200%)

Acute medicine: 

Subject to Day-to-Day Limit.

Over-the-counter (OTC) Medicine: 

Subject to Day-to-Day Limit.
Further limited to: Single member R810
Family R1 390
Limited to R210 per script.

Optometry benefits: 
1 test per beneficiary per 24 month optical cycle. Subject to Overall Annual Limit
Basic dentistry: 
Unlimited.
Specialised Dentistry: 
R16 000 per family per annum.
Orthodontics: 

Subject to the Specialised Dentistry Limit.

MRI and CT Scans (Out of Hospital): 
Subject to Specialised Radiology Limit. No co-payment applies to CT Colonography. Unlimited.
Radiology and Pathology: 
R20 000 per family per annum. 10% upfront co-payment for non-PMB.
Pregnancy benefits: 
Two 2D Scans per pregnancy. 1 Amniocentesis per pregnancy. 12 Antenatal consultations per pregnancy.
Total Contributions
MediBonus
Medical Aid Plan Name Term: 
Any