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Flex 2021

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Type of Medical Aid Plan: 
Traditional
Medical Aid Year: 
2021
Day to day Benefits: 

Stated benefits for Primary Care Network Provider consultations, Non-network GP consultations, specialist consultations, basic and advanced dentistry, optometry, acute and over-the-counter medication. A Flexi Benefit is available for Alternative Healthcare Services, radiology, pathology, speech therapy and audiology

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
Unlimited at 100% of Contracted Rate(CR)
Hospitals: 

Only at Designated Service Provider(DSP) hospitals. Subject to Scheme Protocols and option-specific exclusion list

Upfront Payments to hospitals: 

Voluntary use of a non-DSP hospital will have a co-payment of 30%, with a minimum of R7 000. Procedure co-payments may apply to admissions; full details in the 2021 brochure

Casualty / Emergency Visits: 
Unlimited for trauma and PMB. Verification of pre-authorisation within 72 hours of the event. Non-PMB limited to R1 879 per family per annum, for emergency visits
Specialists: 
Contracted Providers at 100% of CR. Non-contracted Providers at 100% of Scheme Rate(SR)
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Contracted Providers at 100% of CR. Non-contracted Providers and Physiotherapy at 100% of SR
Radiology and pathology: 
100% of CR
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Subject to co-payments of R7 524 for a gastroscopy and R3 762 for a colonoscopy
MRI and CT scans: 
Unlimited for emergency, injury-related and trauma. Non-PMB's limited to R11 133 per annum, with a co-payment of R3 612. Scheme rules and Protocols apply
ICU and High Care: 
100% of CR
Dialysis: 
Unlimited at Network Provider. Subject to Scheme Protocols. Pre-authorisation required
Organ Transplants: 
Limited to PMB's only
Oncology / Cancer: 
Unlimited. Non-PMB's limited to R308 529 per family per annum. Subject to ICON Network and Essential protocols. Pre-authorisation required. 40% Non-DSP co-payment
Neck and Back Operations: 
25% co-payment and prosthesis sub-limit of R15 285 for non-PMB's surgery
Joint Replacements: 
25% co-payment and prosthesis sub-limit of R15 000 for non-PMB's surgery
Prosthesis: 

Internal: Unlimited per family, per annum. Subject to prosthesis sub-limits and Scheme Protocols.
Non-PMB's subject to overall annual limit of R63 214 per family, per annum.
Coronary stents to a maximum of R62 035 for 2 stents; knee, hip, shoulder, elbow, ankle R15 000; spinal fusions per level to a maximum of R15 285; hernia mesh R8 752; intraocular lenses R3 517 per lens

Medical and Surgical Appliances: 
Limited to R4 595 per family, per annum. Scheme Protocols and appliance sub-limits apply. Must be prescribed by a registered Healthcare practitioner and obtained from a supplier registered with the Board of Healthcare Funders
Maternity Confinements: 
Normal delivery; 3 days and 2 night: Caesarean section if clinically indicated; 4 days and 3 nights. Pre-authorisation required for elective Caesarean section
In Hospital Dentistry: 
Cover for impacted wisdom teeth and extensive dental procedures in children under 5 years. Co-payment of R3 762 and Scheme Protocols apply
Take home Medicine: 
Maximum of 7 days supply
Rehabilitation, Hospice and Step-down facilities: 
Unlimited in lieu of hospitalisation. Subject to pre-authorisation. Non-PMB's limited to 12 days per family per annum
Treatment for Mental Health: 
Psychiatric disorders are limited to Network Providers and subject to PMB's and Scheme Protocols
HIV / AIDS: 
Subject to registration on the HIV Management Programme. Hospitalisation at Network Provider hospitals. Subject to Scheme Protocols and PMB's
Ambulance Service: 
Netcare 911 in an emergency
Day-to-day benefits
GP consultations: 

Primary Care Network Providers for GP, physiotherapy and psychology combined: M = 6; M+1 = 10; M+2+ = 13. Non-network GP consultations: M = 4; M+1 = 7; M+2+ = 9

Specialist consultations: 

M = 2; M+ =3

Acute medicine: 

Subject to Acute medicine limit and Flex formulary; M = R2 652; M+ = R3 427. and Preferred Provider Pharmacies. Reference and Generic Reference Pricing(GRP) may apply

Over-the-counter (OTC) Medicine: 

Subject to Acute medicine limit and Flex formulary, with a sub-limit of M = R678; M+ = R1 025 and Preferred Provider Pharmacies. Reference and Generic Reference Pricing(GRP) may apply

Optometry benefits: 
Subject to a 24 month cycle and Network Provider. 1 pair of spectacles with frame and eye test: single vision; R1 460, or bifocal; R2 225 or multifocal; R2 557 or contact lenses; R1 460 per beneficiary
Basic dentistry: 
Subject to Scheme Protocols and annual limits of M = R3 894; M+ = R6 262. 2 annual check-ups, 2 emergency consultations and 2 annual scale and polish. Cover for x-rays, fillings, extractions and root canal therapy at 100% SR
Specialised Dentistry: 
1 set of partial or full plastic dentures per beneficiary per 4 year cycle, crowns and bridges
Orthodontics: 

No benefit

MRI and CT Scans (Out of Hospital): 
Unlimited for emergency, injury-related and trauma. Non-PMB's limited to R11 133 per annum, with a co-payment of R3 612. Scheme rules and Protocols apply
Radiology and Pathology: 
Subject to Annual Flexi Benefit of M = R2 675; M+ = R3 294
Pregnancy benefits: 
Subject to registration on the Maternity Programme. 3 specialist consultations, 2x 2D scans and 1x 3D scan
Physiotherapy and Occupational Therapy day to day: 
Primary Care Network Providers for GP, physiotherapy and psychology combined: M = 6; M+1 = 10; M+2+ = 13. Non-network providers subject to Annual Flexi Benefit
Chronic Conditions
Provider: 
Medipost, Dischem and Clicks pharmacies. 40% Non-DSP co-payment. Subject to chronic formulary. Reference and Generic Reference Pricing(GRP) may apply
Chronic Conditions: 

Diagnosis, treatment and care costs of 27 chronic conditions that fall under the PMB Chronic Disease List (CDL), issued by the Council for Medical Schemes. Benign Prostatic Hypertrophy and Hormone Replacement Therapy also covered as PMB's. Subject to Disease Management Protocols and pre-authorisation

Additional Chronic Conditions: 
As above
Preventative Care Benefits
Preventative Benefits: 

Limited to R2 999 per family, per annum. Scheme Rate applies. Screening benefit with a sub-limit of R139 per beneficiary per annum only at a pharmacy, pap smear, mammogram for female beneficiaries older than 40 years, prostate test for males older than 45 years, flu vaccine and HIV test, childhood immunisations as recommended by the Department of Health up to 18 months with a sub-limit of R2 211 and oral contraceptives limited to R1 776 per beneficiary per annum, with a sub-limit of R148 per month

Total Contributions
Total Contribution Main Member: 
3106.00
Total Contribution Adult: 
2790.00
Total Contribution Child*: 
966.00
Flex
Medical Aid Plan Name Term: 
Flex