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Platinum

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Medical Aid Year: 
2020
Day to day Benefits: 

General practitioner and specialist consultations,
radiology (incl. Nuclear Medicine Study and bone
density scans). Prescribed and over-the-counter
medicine. Optical and auxiliary services, e.g.
physiotherapy, occupational therapy, contraceptive
pill...

In Hospital Benefits
Hospital Rate of Payment: 
State hospitals Unlimited, up to 100% of Agreed Tariff. Specialist and anaesthetist services 100% Unlimited, subject to use of DSP provider.
Hospitals: 

Unlimited, up to 100% of Agreed Tariff.

Specialists: 
"PMB entitlement only. Hysterectomies will be covered at 100% of Agreed Tariff."
Radiology and pathology: 
"Radiology: Pre-authorisation compulsory for specialised radiology, including MRI and CT scans. Hospitalisation not covered if radiology is for investigative purposes only. (Day-to-day benefits will then apply.) Pathology: Unlimited."
Dialysis: 
Unlimited. Pre-authorisation compulsory and subject to Case Management and Scheme Protocols
Oncology / Cancer: 
Unlimited. Pre-authorisation compulsory and subject to Case Management, Scheme Protocols and use of DSP providers.
Joint Replacements: 
Unlimited, up to 100% of Agreed Tariff.
Prosthesis: 

Unlimited. Pre-authorisation compulsory and subject to Case Management,
reference pricing, DSP and Scheme Protocols.

Medical and Surgical Appliances: 
Wheelchairs, orthopaedic appliances and incontinence equipment (incl. contraceptive devices) R11 400 Pfpa. Combined in- and out-of-hospital benefit, subject to quantities and protocols. No pre-authorisation required. Insulin pump/oxygen/nebulizer/gl...
In Hospital Dentistry: 
R1 640 co-payment per hospital admission. DENIS pre-authorisation compulsory.
Take home Medicine: 
R525 benefit Per admission
Rehabilitation, Hospice and Step-down facilities: 
R48 900 benefit Pre-authorisation compulsory and subject to Case Management and Scheme Protocols. Pfpa. Wound care is included in this benefit, up to an amount of R17 000. Combined in- and out-of-hospital benefit.
Treatment for Mental Health: 
R55 200 Pre-authorisation compulsory. Pfpa. Combined benefit; in- and out-of-hospital. Out-of-hospital treatment is limited to R23 000.
HIV / AIDS: 
Unlimited. Chronic Disease Programme, managed by Lifesense, applicable.
Day-to-day benefits
GP consultations: 

PM: R10 700 p.a.
AD: R10 380 p.a.
CD: R2 540 p.a.
(When the routine benefits have been depleted, Member will enter the
Self-funding gap

Specialist consultations: 

PM: R10 700 p.a.
AD: R10 380 p.a.
CD: R2 540 p.a.
(When the routine benefits have been depleted, Member will enter the
Self-funding gap

Over-the-counter (OTC) Medicine: 

R3 005benefit Pfpa sublimit. Subject to day-to-day and Threshold Zone.

Optometry benefits: 
R5 150 Pbp2a total optical benefit. Subject to day-to-day benefit, Threshold Zone and Optical Management. Benefit confirmation compulsory
Basic dentistry: 
Consultations 2 check-ups pbpa. X-rays: Extra-oral 1 pbp3a. (Additional benefit may be granted where specialised dental treatment planning / follow-up is required.)
Orthodontics: 

Orthodontics
DENIS pre-authorisation compulsory. Cases will be clinically assessed using
orthodontic indices where function is impaired. Not for cosmetic reasons; laboratory
costs also excluded. Only 1 beneficiary per family may commence treatment pe...

MRI and CT Scans (Out of Hospital): 
R24 400 Pfpa. R1 000 co-payment per scan (in- or out-of-hospital), excluding confirmed PMBs.
Radiology and Pathology: 
"Radiology: Pre-authorisation compulsory for specialised radiology, including MRI and CT scans. Hospitalisation not covered if radiology is for investigative purposes only. (Day-to-day benefits will then apply.) Pathology: Unlimited."
Chronic Conditions
Provider: 
Category A (CDL) Unlimited – subject to reference pricing, protocols and registration on Chronic Disease Programme. Category B (other) R18 800 Pbpa. Subject to chronic benefit to a maximum of R38 400 pfpa.
Total Contributions
Platinum
Medical Aid Plan Name Term: 
Any