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Optimum 2021

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

Medical Savings Account(MSA) for GP and specialist consultations, basic dentistry and optometry. MSA annual value of M = R9 240; Adult dependant = R7 704; Child dependant: R3 156.
There is a Benefit Booster which covers specialised dentistry, specified preventative care benefits and clinic nurse consultations. There is also cover for psychological and psychiatric treatment, subject to a sub-limit of R6 150. Benefit Booster limits: M = R7 938; M+1 = R9 615; M+2 = R11 069; M+3 = R12 573; M+4+ = R14 200

In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
Unlimited at 100% of Contracted Rate(CR)
Hospitals: 

Any. Planned PMB procedures are subject to a Designated Service Provider(DSP) hospital. Subject to Scheme Protocols and option-specific exclusion list

Upfront Payments to hospitals: 

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

Casualty / Emergency Visits: 
Unlimited for trauma and PMB. Verification of pre-authorisation within 72 hours of the event
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 at 100% of SR. Physiotherapy for non-PMB limited to R12 970 at 100% 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 R17 554 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: 
Unlimited. Subject to PMB's and Scheme Protocols
Oncology / Cancer: 
Unlimited. Subject to ICON Network and Enhanced protocols. Pre-authorisation required. 40% co-payment for use of non-DSP. Biologicals and Targeted Therapies included in ICON Core protocols
Neck and Back Operations: 
Subject to a co-payment of R15 048 and prosthesis sub-limit of R44 724
Joint Replacements: 
Subject to a co-payment of R15 048 and prosthesis sub-limit of R44 724
Prosthesis: 

Internal: Unlimited per family per annum. Subject to prosthesis sub-limits and Scheme Protocols.
Non-PMB's subject to overall annual limit of R134 172 per family per annum.
Coronary stents are subject to overall limit; knee, hip, shoulder, elbow, ankle and spinal fusions limited to R44 724; hernia mesh; R8 752; intraocular lenses R4 073 per lens

Medical and Surgical Appliances: 
Subject to available MSA
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 for 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 R9 615 per family per annum
Treatment for Mental Health: 
Psychiatric disorders are limited to Network Providers and subject to PMB's and Scheme Protocols. Non-PMB's limited to R20 990 per family per annum
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: 

Subject to available MSA. Contracted Providers at 100% of CR. Non-contracted Providers at 100% SR

Specialist consultations: 

Subject to available MSA. Contracted Providers at 100% of CR - up to 150% SR. Non-contracted Providers at 100% SR

Acute medicine: 

Subject to available MSA and PMB's, Optimum formulary and Preferred Provider Pharmacy. Reference and Generic Reference Pricing(GRP) may apply

Over-the-counter (OTC) Medicine: 

Subject to available MSA and PMB's, Optimum formulary and Preferred Provider Pharmacy. Reference and Generic Reference Pricing(GRP) may apply

Optometry benefits: 
Subject to a 24 month cycle, available MSA and Network Provider. Consultation and 1 pair of spectacles or contact lenses, with a sub-limit of R2 838 per beneficiary and frame sub limit of R1 328
Basic dentistry: 
Subject to Scheme Protocols and available MSA. Consultations, x-rays, fillings, oral hygiene, preventative dentistry, extractions and root canal therapy
Specialised Dentistry: 
Subject to Benefit Booster and sub-limits of: M = R5 869; M+1 = R7 380; M+2 = R8 778; M+3 = R10 343; M+4+ = R11 852. Implants limited to R 4 305 per Implant Cover for plastic dentures, crowns, bridges, implants and partial metal dentures
Orthodontics: 

Subject to Benefit Booster. 1 per lifetime for individuals younger than 18 years. Benefits on pre-authorisation will be applied to cases assessed as treatment mandatory, as per orthodontic indices. No benefit for corrective jaw surgery

MRI and CT Scans (Out of Hospital): 
Unlimited for emergency, injury-related and trauma. Non-PMB's limited to R17 554 per annum, with a co-payment of R3 612. Scheme rules and Protocols apply
Radiology and Pathology: 
Subject to available MSA
Pregnancy benefits: 
Subject to registration on the Maternity programme: Consultations are subject to available MSA, 4x 2D scans. Specified Clinic nurse consultations available subject to Benefit Booster
Physiotherapy and Occupational Therapy day to day: 
Subject to available MSA
Chronic Conditions
Provider: 
Medipost, Dischem and Clicks pharmacies. 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 + 6. Subject to available MSA
Preventative Care Benefits
Preventative Benefits: 

Subject to Benefit Booster and sub-limit of R2 952 per family at a Preferred Provider for; HIV test and Clinic nurse consultations. Screening benefits. mammogram and pap smear are subject to a sub-limit of R1 677. Flu and HPV vaccines, childhood immunisations, prostate test and oral contraceptives are subject to available MSA 

Total Contributions
Total Contribution Main Member: 
5500.00
Total Contribution Adult: 
4586.00
Total Contribution Child*: 
1882.00
Optimum
Annual Medical Savings Account
Annual Medical Savings Main Member: 
9240.00
Annual Medical Savings Adult: 
7704.00
Annual Medical Savings Child*: 
3156.00
Monthly Medical Savings
Savings Child*: 
263.00
Savings Adult: 
642.00
Savings Main Member: 
770.00
Risk Contributions
Risk Contribution Main Member: 
4730.00
Risk Contribution Adult: 
3944.00
Risk Contribution Child: 
1619.00
Medical Aid Plan Name Term: 
Optimum