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Medical Aid Year: 
2020
Day to day Benefits: 

Subject to MSA

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: 
Subject to MSA.
Specialists: 
Non-Contracted Providers at 100% of Scheme Rate. Contracted Providers at 100% of Contracted Rate.
Radiology and pathology: 
Subject to MSA.
ICU and High Care: 
100% of Contracted Rate.
Dialysis: 
Covered at Network Provider. Subject to Scheme Protocols and PMB. Preauth required.
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
Joint Replacements: 
R 12 000
Prosthesis: 

Limited to R126 000 per family per
annum. Subject to Prosthesis Sub-
Limits, Scheme Protocols.

Medical and Surgical Appliances: 
Subject to My Saver and PMB’s
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. Non PMB limited to R19 425 per family per annum.
HIV / AIDS: 
HIV Management Programme.
International Travel Benefit: 
Limited to emergency medical cover up to R2 million per beneficiary per incident
Day-to-day benefits
GP consultations: 

Subject to MSA
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 and preauth.

Specialist consultations: 

Non-Contracted Providers at
100% of Scheme Rate. Contracted
Providers at 100% of Contracted
Rate (Up to 150% of Scheme Rate)
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: 
Subject to Scheme protocols and MSA
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: 
Subject to MSA.
Chronic Conditions
Chronic Conditions: 

Subject to MSA

Total Contributions
Optimum
Medical Aid Plan Name Term: 
Any