Day-to-day Benefits

• Benefits will be allocated pro rata for members and their beneficiaries joining during the year.

  Once your day-to-day benefits are exhausted, you will be required to pay the healthcare providers/services in full.

  You may use any healthcare provider, and claims will be paid at the maximum rates as reflected below. PMB conditions will be paid at the designated service provider (DSP) agreed tariff if a DSP is used.

• WHAT ARE DAY-TO-DAY MEDICAL EXPENSES?

• Day-to-day medical expenses are your everyday medical expenses such as GP consultations, dentist visits, optical visits, etc.

  Day-to-day medical expenses on the Comprehensive Option are subject to your Medical Savings Account (MSA), which covers non-PMB, out-of-hospital claims such as GPs, dentists, specialists, medication, optometrists, etc. Claims are reimbursed at the agreed Wooltru Healthcare Fund Tariff (WHFT). Once you have exhausted your MSA, you will need to pay for any additional day-to-day claims yourself.

  A portion of your monthly contribution is allocated to your MSA. The annual savings amount is calculated over a period of 12 months or if you join the Fund during the year, the amount will be calculated on a pro rata basis. At the end of the year, any unused savings will roll over to the next year.

  Your annual savings amount
  Member	R10 896	Member + adult	R21 792
  Adult dependant	R10 896	Member + child	R14 520
  Child dependant	R3 624	Member + adult + child	R25 416

  NOTES:

  Your annual savings amount is allocated upfront. If you terminate your membership of the Fund before the end of the year and you have used more than the contributions that you have paid, you will be required to pay the difference to the Fund. Once you have exhausted your MSA, you will have to pay healthcare providers for day-to-day services out of your own pocket. Professional services benefit - added benefit on the Comprehensive Option: 50% of non-PMB, out-of-hospital claims for gynaecologists, paediatricians, psychiatrists, psychologists and physiotherapists are subject to the specified sub-limits referred to below. The balance of the claims will be paid from your MSA. Claims are paid at 100% of the WHFT. In order for your PMB specialist claims to be paid at cost, you will need to call 0802 228 922 for referral to a network specialist and to receive authorisation for the visit.

Benefits	Description
Professional services benefit	50% of non-PMB, out-of-hospital claims for gynaecologists, paediatricians, psychiatrists, psychologists and physiotherapists Paid at 1x the WHFT from MSA and professional services benefit. The risk benefit covers 50% of the claim up to an annual limit determined by the family make-up as follows: Member: R11 200 Adult dependant: R10 900 Child dependant: R3 800	50% of non-PMB
General practitioners (GPs)	Paid at 3x the WHFT from your MSA
Specialists	Non-DSP specialist. Paid at 3x the WHFT from your MSA DSP specialist: 100% of agreed tariff Benefit subject to MSA Call 0802 228 922 for specialist referral and authorisation
Pathology, radiology and ultrasounds	Paid at 3x the WHFT from your MSA, unless performed as part of a hospital admission
Basic dentistry - consultations, fillings, extractions, scaling and polishing	Paid at 3x the WHFT from your MSA
Specialised dentistry - dentures, crowns, bridges and orthodontic treatment	Paid at 3x the WHFT from your MSA
Optical benefits - eye tests, lenses, frames and contact lenses	Paid at 3x the WHFT from your MSA
OptiClear Network	Members can receive services and materials at reduced rates from accredited OptiClear providers Click here for details of opticians on the OptiClear Network
Prescribed acute medication	Paid at 100%, subject to the Fund’s formulary reference price and subject to your MSA	100% of formulary reference price
Over-the-counter medication	Paid at 100%, subject to the Fund’s formulary reference price and subject to your MSA	100% of formulary reference price
Associated health and auxiliary services: Chiropractor Homeopath Naturopath Clinical psychology Speech therapy Audiology Occupational therapy Podiatry Orthotics Biokinetics Physiotherapy Dietician Social worker (used for psychotherapy)	Paid at 3x the WHFT from your MSA No benefit for vocational guidance, child guidance, marriage guidance, school therapy or attendance at remedial education schools or clinics
Registered private nurse practitioners	Paid at 3x the WHFT from your MSA
Emergency visits / outpatients	Paid at 3x the WHFT from your MSA