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HEALTH SQUARED OPTIMUM 2019

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Medical Aid Year: 
2019
In Hospital Benefits
Hospital Rate of Payment: 
Unlimited.
Hospitals: 

Unlimited.
Planned PMB procedures are
subject to DSP hospital networks
& co- payment for use of non-DSP
applies. Procedure co-payments
may also be applicable. Subject
to Scheme Protocols and
option-specific exclusion list.

Upfront Payments to hospitals: 

Arthroscopy R 4 000

Circumcision, Vasectomy R 3 000

Colonoscopy R 3 000

Conservative back / spine treatment R 6 000

Cystoscopy R 2 000

Dental Admissions R 3 000

Endometrial ablation R 4 000

Excision nail bed R 2 000

Gastroscopy R 5 000

Hernia Repair R 5 000

Hysterectomy R 6 000

Hysteroscopy R 6 000

Joint replacements R 12 000

Laparoscopic procedures R 4 000

Medical admission Co-pay (Including Maternity and
Psychitric admissions) R 2 500

Myringotomy R 2 500

Nasal surgery (including endoscopy) R 6 000

Non Surgical admission co-pay (Including Maternity and
Psychiatry) R 2 500

Reflux surgery R 12 000

Rotator Cuff Surgery R 10 000

Sigmoidoscopy R 1 500

Skin lesions R 2 000

Specialised radiology (MRI, CT,PET Scan ) per scan R 2 000

Spinal surgery R 12 000

Tonsillectomy and Adenoidectomy R 0

Tympanoplasty R 0

Urinary Incontinence Repair R 4 000

Use of Non-DSP Hospital (Planned PMB's) 30% (Minimum R 7 000)

Varicose veins R 4 000

Casualty / Emergency Visits: 
Subject to MSA.
Specialists: 
Non-Contracted Providers at 100% of Scheme Rate. Contracted Providers at 100% of Contracted Rate.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Subject to MSA.
Radiology and pathology: 
R16 485 per family per annum. Subject to Scheme Protocols and PMB. Pre-auth required. Co-payment of R2 000 per incident. (In-and-out of hospital). 100% of Scheme Rate
MRI and CT scans: 
R16 485 per family per annum. Subject to Scheme Protocols and PMB. Pre-auth required. Co-payment of R2 000 per incident. (In-and-out of hospital). 100% of Scheme Rate
Dialysis: 
Covered at Network Provider. Subject to Scheme Protocols and PMB. Pre- auth required.
Organ Transplants: 
Unlimited, subject to PMB and Scheme Protocols.
Oncology / Cancer: 
Unlimited. Subject to ICON Network and standard protocols. Pre-auth required. 40% NON DSP CO payment. Biologicals and Targeted Therapies Sub limit R220 500
Neck and Back Operations: 
Limited to R126 000 per family per annum. Subject to Prosthesis Sub- Limits, Scheme Protocols.
Joint Replacements: 
Limited to R126 000 per family per annum. Subject to Prosthesis Sub- Limits, Scheme Protocols.
Prosthesis: 

Unlimited per family per annum. Subject to Prosthesis Sub-Limits, Scheme Protocols.

Overall Option Limit R126 000 per Event

Knee, Hip, Shoulder, Elbow, Ankle R 42 000

External Fixator Overall Option Limit

Medical and Surgical Appliances: 
Subject to My Saver and PMB’s
Maternity Confinements: 
Length of stay: 3 days & 2 nights.
In Hospital Dentistry: 
Subject to Scheme protocols and MSA
Take home Medicine: 
Maximum of 7 days’ supply
Rehabilitation, Hospice and Step-down facilities: 
Sub Limit R9 030 per family 100% of Scheme Rate.
HIV / AIDS: 
HIV Management Programme
Ambulance Service: 
NETCARE
International Travel Benefit: 
Limited to emergency medical cover up to R2 million per beneficiary per incident
Day-to-day benefits
GP consultations: 

Non-Contracted Providers at
100% of Scheme Rate. Contracted
Providers at 100% of Contracted
Rate.

Specialist consultations: 

Non-Contracted Providers at
100% of Scheme Rate. Contracted
Providers at 100% of Contracted
Rate.

Acute medicine: 

Subject to MSA

Optometry benefits: 
Subject to MSA per beneficiary Sub Limit R 2 520 Frame Sub Limit R 1 155
Basic dentistry: 
Subject to Scheme protocols and MSA
Specialised Dentistry: 
Subject to Benefit Booster and sub-limits of: M R5 512 M+1 R6 930 M+2 R8 243 M+3 R9 713 M+4+ R11 130 Implants R 4 043 per Implant
Orthodontics: 

Subject to Benefit Booster and
sub-limits of:
M R5 512
M+1 R6 930
M+2 R8 243
M+3 R9 713
M+4+ R11 130
Implants R 4 043 per Implant

MRI and CT Scans (Out of Hospital): 
R16 485 per family per annum. Subject to Scheme Protocols and PMB. Pre-auth required. Co-payment of R2 000 per incident. (In-and-out of hospital). 100% of Scheme Rate
Radiology and Pathology: 
R16 485 per family per annum. Subject to Scheme Protocols and PMB. Pre-auth required. Co-payment of R2 000 per incident. (In-and-out of hospital). 100% of Scheme Rate
Pregnancy benefits: 
Surgical operations & procedures Theatre fees Labour and recovery wards Ward accommodation Intensive care and high care units X-rays and pathology Ultrasound scans (other than for pregnancy) Blood transfusions 100% of Contracted Rate.
Chronic Conditions
Chronic Conditions: 

CDL CONDITIONS

ADDISON'S DISEASE, ASTHMA, BIPOLAR MOOD DISORDER, BRONCHIECTASIS, CARDIAC DYSRHYTHMIAS, CARDIAC FAILURE, CARDIOMYOPATHY, COPD, CROHN'S DISEASE, CHRONIC RENAL FAILURE, CORONARY ARTERY DISEASE, DIABETES INSIPIDUS, DIABETES MELLITUS TYPE 1, DIABETES MELLITUS TYPE 2, EPILEPSY, GLAUCOMA, HAEMOPHILIA, HIV, HYPERLIPIDAEMIA, HYPERTENSION, HYPOTHYROIDISM, MULTIPLE SCLEROSIS, PARKINSON'S DISEASE, RHEUMATOID ARTHRITIS, SCHIZOPHRENIA, SLE, ULCERATIVE COLITIS

Additional Chronic Conditions

CYSTIC FIBROSIS, ENDOMETRIOSIS, GORD/GERD, OSTEOPOROSIS, OSTEOARTHRITIS, PSORIASIS

Additional Chronic Conditions: 
(SUBJECT TO MSA)
Preventative Care Benefits
Preventative Benefits: 

Pro-rated for members who join during the year. (Excludes consultation) R2 772 per family per annum, Scheme Rate applies.

Screening Benefit:

Blood Pressure, Blood Sugar, Cholesterol, Body Mass Index, HIV Test, Mammogram (screening), Pap smears (Subject to Benefit Booster Sub Limit R 1575 per family at Preferred provider)

PSA Testing Subject to MSA

Vaccinations:

Flu,Childhood immunisations, HPV Vaccine (Cervical cancer prevention), Oral Contraception (Subject to MSA)

Clinic Nurse Consultation Subject to Preferred Provider Only Subject to Benefit Booster 1 - 30 min consult per beneficiary 2 - 15 min Consults per beneficiary:

Additional 15 min Consult + Flu vacine 2 - 15 min per beneficiary

Mother Ante-Natal visit 2 per Beneficiary

Mother and Well Baby Consult (incl admin of Immunisation) 1 per Beneficiary

MediBooster- Subject to Registration and Self Health Assesment at Preferred Provider only Subject to Benefit Booster Sub Limit R 1 600

Total Contributions
Total Contribution Main Member: 
4450.00
Total Contribution Adult: 
3710.00
Total Contribution Child*: 
1596.00
OPTIMUM
Annual Medical Savings Account
Annual Medical Savings Main Member: 
8808.00
Annual Medical Savings Adult: 
7344.00
Annual Medical Savings Child*: 
3228.00
Risk Contributions
Risk Contribution Main Member: 
4450.00
Risk Contribution Adult: 
3710.00
Risk Contribution Child: 
1596.00
Medical Aid Plan Name Term: 
Any