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Medical Aid Year: 
2020
Day to day Benefits: 

Principal Mem: R15 743
Adult Dep: R11 807
Child Dep: R1 646

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

PRIVATE HOSPITALS:Unlimited.
Procedure co-payments may also
be applicable. Subject to Scheme
Protocols and option-specific
exclusion list. For procedural and
admission co-payments PROVINCIAL HOSPITALS:Unlimited. Subject to Scheme
Protocols.

Upfront Payments to hospitals: 

Unlimited.
Procedure co-payments may also
be applicable. Subject to Scheme
Protocols and option-specific
exclusion list. For procedural and
admission co-payments

Casualty / Emergency Visits: 
Limited to R1 765 for emergency visits per family per annum unless PMBSubject
Specialists: 
Non-Contracted Providers at 100% of Scheme Rate. Contracted Providers at 100% of Contracted Rate (Up to 220% of Scheme Rate)
Radiology and pathology: 
Subject to Sub Limit: M R3 526 M+1 R4 328 M +2+ R5 228
ICU and High Care: 
100% of Contracted Rate.
Dialysis: 
Unlimited at Network Provider. Subject to Scheme Protocols. Preauth required.
Oncology / Cancer: 
Unlimited. Subject to ICON Network and standard protocols. Pre-auth required. 40% NON DSP CO payment.
Joint Replacements: 
R 12 000
Prosthesis: 

Limited to R65 966 per family per
annum. Subject to Prosthesis Sub-
Limits, Scheme Protocols.

Medical and Surgical Appliances: 
R16 595 per family per annum Subject to PMB, Scheme Protocols and appliance sub-limits.
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 R32 235 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: 

Unlimited.
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: 

M 4 visits per annum.
M+1 5 visits per annum.
M+2+ 6 visits per annum.
Non-Contracted Providers at
100% of Scheme Rate. Contracted
Providers at 100% of Contracted
Rate (Up to 220% of Scheme Rate)
CDL PMB consultations covered
separately. Subject to D...

Optometry benefits: 
1 consultation per beneficiary.1 pair of single vision spectacles inclusive of a frame and consultation per beneficiary limited to R2 340 Or 1 pair of flat top bifocal spectacles inclusive of a frame and consultation per beneficiary, limited to R2 82...
Basic dentistry: 
Covered as stated below. Subject to Scheme Protocols.Consultations: 2 Annual check-ups per beneficiary per annum. 2 Emergency consultations per beneficiary per annum. Covered at 100% Scheme Rate. X-rays: Intra-Oral: 8 per beneficiary per annum. Extra...
Orthodontics: 

Benefits on pre-authorisation
will be applied to cases assessed
as treatment mandatory, as per
orthodontic indices. Limited to
individuals younger than 38 years
of age. Orthognathic surgery is not
covered.

MRI and CT Scans (Out of Hospital): 
R20 776 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 Sub Limit: M R3 526 M+1 R4 328 M +2+ R5 228
Chronic Conditions
Chronic Conditions: 

M R6 080
M+ R12 145
Benefits subject to stated sub-limits
and thereafter to PMB CDLs.

Total Contributions
Ultimate
Medical Aid Plan Name Term: 
Any