Hospital Rate of Payment:
Private hospitals Unlimited, up to 100% of Agreed Tariff, subject to use of DSP hospital
(Netcare or Life Healthcare). (30% co-payment at non-DSP hospital.)
State hospitals Unlimited, up to 100% of Agreed Tariff.
Specialists:
Unlimited, subject to use of DSP provider.
Radiology and pathology:
Pre-authorisation compulsory for specialised radiology, including MRI and CT
scans. Hospitalisation not covered if radiology is for investigative purposes only.
Dialysis:
Pre-authorisation compulsory and subject to Case Management and
Scheme Protocols. PMB entitlement only.
Oncology / Cancer:
R154 500 benefit Pfpa. Pre-authorisation compulsory and subject to Case Management,
Scheme Protocols and the use of DSP providers.
Joint Replacements:
PMB entitlement only. Hysterectomies will be covered at 100% of
Agreed Tariff.
Medical and Surgical Appliances:
Wheelchairs, orthopaedic appliances
and incontinence equipment
(incl. contraceptive devices).
R7 250 benefit Pfpa. Combined in- and out-of-hospital benefit, subject to quantities and
protocols. No pre-authorisation required.
Oxygen/nebulizer/glucomet...
Take home Medicine:
Medicine on discharge R525 benefit. Per admission.
Rehabilitation, Hospice and Step-down facilities:
Pre-authorisation compulsory and subject to Case Management and
Scheme Protocols. PMB entitlement only.
Treatment for Mental Health:
R19 700 Pfpa. In-hospital services. Pre-authorisation compusory and subject to
Case Management.
HIV / AIDS:
Unlimited. Chronic Disease Programme, managed by Lifesense, applicable.
