Comprehensive Option
Day-to-day Benefits
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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.
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WHAT ARE DAY-TO-DAY MEDICAL EXPENSES?
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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 R14 736 Member + adult R29 172 Adult dependant R14 436 Member + child R19 644 Child dependant R4 908 Member + adult + child R34 080 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 three times the WHFT. In order for your PMB specialist claims to be paid at cost, you will need to call 0800 765 432 for referral to a network specialist and to receive authorisation for the visit.
Benefits | Description | |||||||
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Professional services benefit |
50% of non-PMB, out-of-hospital claims for gynaecologists, paediatricians, psychiatrists, psychologists and physiotherapists Paid at 3x the WHFT from MSA and professional services benefit.
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50% of non-PMB | ||||||
General practitioners (GPs) | Paid at 3x the WHFT from your MSA | |||||||
Specialists |
Paid at 3x the WHFT from your MSA PMBs paid at the WHFT at network specialists Call 0800 765 432 for specialist referral and authorisation |
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Pathology, radiology and ultrasounds |
Paid at 3x the WHFT from your MSA, unless performed as part of a hospital admission |
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Basic dentistry - Consultations, fillings, extractions, scaling and polishing |
Paid at 3x the WHFT from your MSA |
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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 |
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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. |
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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 services - chiropractors, homeopaths, naturopaths and dieticians | Paid at 3x the WHFT from your MSA | |||||||
Auxiliary services out of hospital:
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Paid at 3x the WHFT from your MSA No benefit for social workers, vocational guidance, childguidance, marriage guidance, school therapy or attendance at remedial education schools or clinics |
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Registered private nurse practitioners | Paid at 3x the WHFT from your MSA | |||||||
Emergency visits / outpatients |
Paid at 3x the WHFT from your MSA |