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Equilibrium

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Medical Aid Year: 
2020
Day to day Benefits: 

A combined out-of-hospital limit which may be used
by any beneficiary in respect of general practitioners,
specialists, radiology, optical, pathology, prescribed
medicine and auxiliary services, and which may
include a sub-limit for self-medication. ...

In Hospital Benefits
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.
Hospitals: 

PMB entitlement only for varicose vein surgery and reflux surgery. The other
procedures will be covered at 100% of Agreed Tariff.

Upfront Payments to hospitals: 
Specialists: 
Specialist and anaesthetist services 100% Unlimited, subject to use of DSP provider.
Radiology and pathology: 
Pre-authorisation: specialised radiology, including MRI, CT and PET scans. Hospitalisation not covered if radiology is for investigative purposes only. (MSA / day-to-day benefits will then apply.)
Dialysis: 
Pre-authorisation compulsory and subject to Case Management and Scheme Protocols. PMB entitlement only.
Oncology / Cancer: 
Pfpa. Pre-authorisation compulsory and subject to Case Management, Scheme Protocols and use of DSP providers.
Joint Replacements: 
Prosthesis: 

R3 200 Pfpa. Pre-authorisation compusory and subject to Case Management,
reference pricing, DSP and Scheme Protocols.

Medical and Surgical Appliances: 
Wheelchairs, orthopaedic appliances and incontinence equipment (incl. contraceptive devices) 100% R7 250 Pfpa. Combined in- and out-of-hospital benefit, subject to quantities and protocols. No pre-authorisation required. Oxygen/nebulizer/glucometer P...
In Hospital Dentistry: 
Hospitalisation (general anesthesia) 100% R1 640 co-payment per hospital admission. DENIS pre-authorisation compulsory. Laughing gas in dental rooms 100% DENIS pre-authorisation not required. IV conscious sedation in dental rooms 100% DENIS pre-autho...
Take home Medicine: 
R525 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. Pre-authorisation compulsory and subject to Case Management. In-hospital benefit only. Out-of-hospital: PMB entitlement
HIV / AIDS: 
Unlimited. Chronic Disease Programm, managed by Lifesense, applicable.HIV/AIDS test (Pathologist) Beneficiaries aged ≥15 – once per year.
Day-to-day benefits
GP consultations: 

Annual Medical Savings Account (MSA):
Principal member: R1 884 p.a.
Adult dependant: R1 164 p.a.
Child dependant: R576 p.a.
Additional day-to-day benefits:
Principal member: R2 830 p.a.
Adult dependant: R1 945 p.a.
Child dependant: R865 p.a.

Specialist consultations: 

Annual Medical Savings Account (MSA):
Principal member: R1 884 p.a.
Adult dependant: R1 164 p.a.
Child dependant: R576 p.a.
Additional day-to-day benefits:
Principal member: R2 830 p.a.
Adult dependant: R1 945 p.a.
Child dependant: R865 p.a.

Over-the-counter (OTC) Medicine: 

Subject to MSA / day-to-day benefit.

Optometry benefits: 
Optical Management applicable. Benefit confirmation compulsory.
Basic dentistry: 
Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
Orthodontics: 

Orthodontics (non-cosmetic treatment only) 80% DENIS pre-authorisation compulsory. Subject to DENIS protocols, Managed Care
interventions and Scheme Rules. Exclusions apply in terms of Scheme Rules.

MRI and CT Scans (Out of Hospital): 
Pfpa. R1 000 co-payment per scan (in- or out-of-hospital), excluding confirmed PMBs.
Radiology and Pathology: 
Pre-authorisation: specialised radiology, including MRI, CT and PET scans. Hospitalisation not covered if radiology is for investigative purposes only. (MSA / day-to-day benefits will then apply.)
Chronic Conditions
Provider: 
Category A (CDL) 100% Unlimited – subject to reference pricing and protocols. Registration on Chronic Disease Programme compulsory. Category B (other) 90% Additional 3 non-PMB/CDL conditions (Acne/ADHD or ADD/Rhinitis) for children up to the age of 2...
Chronic Conditions: 

Unlimited – subject to reference pricing and protocols.
Registration on Chronic Disease Programme compulsory

Total Contributions
Equilibrium
Medical Aid Plan Name Term: 
Any