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Medical Aid Year: 
2020
Day to day Benefits: 

No Benefits Subject to PMB’s

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

PRIVATE 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.
For proce...

Upfront Payments to 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.
For procedural and admissio...

Casualty / Emergency Visits: 
No Benefit unless proven PMB
Specialists: 
Non-Contracted Providers at 100% of Scheme Rate. Contracted Providers at 100% of Contracted Rate.
Radiology and pathology: 
No Benefit. Subject to PMB’s
ICU and High Care: 
100% of Contracted Rate.
Dialysis: 
Covered at Network Provider. Subject to Scheme Protocols and PMB. Preauth required.
Oncology / Cancer: 
Subject to ICON Network and standard protocols. Pre-auth required. 40% NON DSP co-payment
Joint Replacements: 
No Benefit
Prosthesis: 

Subject to Scheme Protocols and
PMB

Medical and Surgical Appliances: 
PMB’ Only
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: 

No Benefits Subject to PMB’s
CDL PMB consultations covered
separately. Subject to Disease
Management Protocols and preauth.

Specialist consultations: 

Limited to PMB at Network
Providers. Subject to preauthorisation
CDL PMB consultations covered
separately. Subject to Disease
Management Protocols and preauth.

Optometry benefits: 
Subject to MSA, ATB and sub-limit of R2 935 per beneficiary.
Basic dentistry: 
No Benefit.
Orthodontics: 

No Benefit.

MRI and CT Scans (Out of Hospital): 
Covered at Network Provider. Subject to Scheme Protocols and PMB. Preauth required.
Radiology and Pathology: 
No Benefit. Subject to PMB’s
Chronic Conditions
Chronic Conditions: 

Available from DSP 40% Non
DSP Co Payment. Subject to
Schemes Chronic Formulary.
Reference and GRP pricing applies.
Except for Oncology and HIV
member must pay and claim back

Total Contributions
Rise
Medical Aid Plan Name Term: 
Any