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Medical Aid Year: 
2020
Day to day Benefits: 

As specified.

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

PRIVATE HOSPITALS:Unlimited.
Subject to use of DSP hospital
networks & co- payment for use of
non-DSP applies. Procedure copayments
may also be applicable.
Subject to Scheme Protocols and
option-specific exclusion list. For
procedural and admission c...

Upfront Payments to hospitals: 

Unlimited.
Subject to use of DSP hospital
networks & co- payment for use of
non-DSP applies. Procedure copayments
may also be applicable.
Subject to Scheme Protocols and
option-specific exclusion list. For
procedural and admission copayments

Casualty / Emergency Visits: 
Limited to R1 765 for emergency visits per family per annum unless PMBSubject
Specialists: 
Non-Contracted Providers at 100% of Scheme Rate. Contracted Providers at 100% of Contracted Rate.
Radiology and pathology: 
Limited to Flexi-Benefit.
ICU and High Care: 
100% of Contracted Rate.
Dialysis: 
Covered at Network Provider. Subject to Scheme Protocols and PMB. Preauth required.
Oncology / Cancer: 
Limited to R289 738 per family per annum. Subject to ICON Network and standard protocols. Pre-auth required. 40% NON DSP co-payment
Joint Replacements: 
No Benefit
Prosthesis: 

Limited to R59 364 per family per
annum. No benefit other than PMB
for joint replacements and spinal
procedures. Subject to Prosthesis
Sub-Limits, Scheme Protocols.

Medical and Surgical Appliances: 
R4 315 per family per annum Subject to PMB, Scheme Protocols and appliance sub-limits.
Take home Medicine: 
Maximum of 7 days’ supply
Rehabilitation, Hospice and Step-down facilities: 
Limited to Network Providers and subject to PMB and Scheme Protocols.
HIV / AIDS: 
HIV Management Programme.
International Travel Benefit: 
Limited to emergency medical cover up to R750 000 per beneficiary per incident
Day-to-day benefits
GP consultations: 

M 4 visits per annum.
M+1 7 visits per annum.
M+2+ 9 visits per annum.
Non-Contracted Providers at
100% of Scheme Rate. Contracted
Providers at 100% of Contracted
Rate.
CDL PMB consultations covered
separately. Subject to Disease
Management Protocols...

Specialist consultations: 

M 2 visits per annum.
M+1 3 visits per annum.
M+2+ 3 visits per annum.
Non-Contracted Providers at
100% of Scheme Rate. Contracted
Providers at 100% of Contracted
Rate.
CDL PMB consultations covered
separately. Subject to Disease
Management Protocols...

Optometry benefits: 
1 consultation per beneficiary. 1 pair of single vision spectacles inclusive of a frame and consultation per beneficiary limited to R1 270 Or 1 pair of flat top bifocal spectacles inclusive of a frame and consultation per beneficiary, limited to R1 9...
Basic dentistry: 
Subject to Scheme Protocols and annual limits of: M R3 451 M+ R5 548. Consultations: 2 Annual check-ups per beneficiary per annum 2 Emergency consultations per beneficiary per annum Covered at 100% Scheme Rate. X-rays: Intra-Oral: 8 per beneficiary p...
Orthodontics: 

No Benefit.

MRI and CT Scans (Out of Hospital): 
R10 455 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: 
Limited to Flexi-Benefit.
Chronic Conditions
Chronic Conditions: 

Subject to Scheme’s Chronic
Formulary. Reference and GRP
pricing applies.

Total Contributions
Flex
Medical Aid Plan Name Term: 
Any