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Ultimate 2021

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

Annual Benefit of M = R16 764; Adult dependant = R12 572; Child = R1 753 for GP consultations, specialist consultations, conservative and advanced dentistry with an annual sub-limit and optometry. An Additional Day-to-Day benefit of M = R8 757: M+1= R15 413; M+2+= R16 740 is available for Alternative Healthcare Services, radiology, pathology, physiotherapy, psychology, psychiatry, speech therapy, audiology, acute and over-the-counter medication. Sub-limits apply to these services

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

Any. Subject to Scheme Protocols and option-specific exclusion list

Upfront Payments to hospitals: 

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's limited to R1 879 per family per annum, for emergency visits
Specialists: 
Contracted Providers at 100% of CR, up to 220% of Scheme Rate(SR). Non-contracted Providers at 100% of 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 limited to R22 124 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% Non-DSP co-payment
Neck and Back Operations: 
Subject to co-payment of R15 048 and prosthesis sub-limit for non-PMB surgery
Joint Replacements: 
Subject to co-payment of R15 048 and prosthesis sub-limit for non-PMB surgery
Prosthesis: 

Internal: Unlimited per family per annum. Subject to prosthesis sub-limits and Scheme Protocols.
Non-PMB subject to overall annual limit of R76 425 per family per annum.
Cochlear implants once per lifetime per beneficiary R 147 515; Coronary stents to a maximum of R68 934 for 2 stents; knee, hip, shoulder, elbow, ankle varying to a maximum of R68 934; spinal fusions per level to a maximum of R68 934; hernia mesh R8 752; intraocular lenses R4 073 per lens

Medical and Surgical Appliances: 
Limited to R17 671 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; 4 days and 3 nights
In Hospital Dentistry: 
Limited to 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 21 days 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 R34 326
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: 

Unlimited. Subject to Annual Benefit of M = R16 764; Adult dependant = R12 572; Child = R1 753. Contracted Providers at 100% of CR. Non-contracted Providers at 100% of SR

Specialist consultations: 

Limited to M = 4; M+1= 5; M+2+= 6

Acute medicine: 

Subject to Additional Day-to-Day Benefit and a sub-limit of M = R8 796; M+1 =  R15 472; M+2+=  R17 644, plan formulary and Preferred Provider Pharmacy. Reference and Generic Reference Pricing(GRP) may apply

Over-the-counter (OTC) Medicine: 

Subject to Additional Day-to-Day Benefit, Acute medicine limit and a sub-limit of M = R2 652; M+1 = R4 568; M+2+ = R4 989, plan formulary and Preferred Provider Pharmacy. Reference and Generic Reference Pricing(GRP) may apply

Optometry benefits: 
Subject to Annual Benefit, a 24 month cycle and Network Provider. 1 pair of spectacles with frame and eye test; single vision; R2 690, or bifocal; R3 245 or multifocal; R4 068 or contact lenses; R3 031
Basic dentistry: 
Subject to Scheme Protocols and Annual Benefit. 2 check-ups, 2 emergency consults and 2 scale and polish per beneficiary per annum. Cover for x-rays, fillings, extractions and root canal therapy at 100% of SR
Specialised Dentistry: 
Subject to Annual Benefit and a sub-limit of R15 756 per family. 1 set of partial or full plastic dentures pbp4a, crowns, bridges, implants and periodontics included. Pre-authorisation required
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. No benefit for corrective jaw surgery

MRI and CT Scans (Out of Hospital): 
Unlimited for emergency, injury-related and trauma. Non-PMB limited to R22 124 per annum, with a co-payment of R3 612. Scheme rules and Protocols apply
Radiology and Pathology: 
Subject to Additional Day-to-Day Benefit and a sub-limit of M = R3 755; M+1 = R4 608; M+2+ = R5 567
Pregnancy benefits: 
Subject to registration on the Maternity Programme. Consultations at any provider, 2x 2D scans
Physiotherapy and Occupational Therapy day to day: 
Subject to Additional Day-to-Day Benefit and a sub-limit of R1 730 per family
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: 
2 as above + 30. Limited to M = R6 475; M+= R12 933
Preventative Care Benefits
Preventative Benefits: 

Limited to R4 403 per family per annum. Scheme Rate applies. Screening benefit with a sub-limit of R139 per beneficiary over the age of 18 only at pharmacy, pap smear, mammogram for female beneficiaries older than 40 years, HPV vaccine for females between 9 and 46 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 and preventative dental fissure sealants programme for children younger than 16. Oral contraceptives limited to R1 776 per beneficiary per annum with a sub-limit of R148 per month

Total Contributions
Total Contribution Main Member: 
7570.00
Total Contribution Adult: 
6898.00
Total Contribution Child*: 
1876.00
Ultimate
Medical Aid Plan Name Term: 
Ultimate