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      • Home
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        • About us
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SAVER OPTION

View other options
  • Network Option
  • Saver Option
  • Comprehensive Option
Day-to-day Benefits
Hospitalisation Benefits
Maternity Benefits
Preventative Testing
Chronic Care
HIV/AIDS
2022 Benefits and Contributions
How to make a claim

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 Saver 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).

    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 R5 616 Member + adult R11 124
    Adult dependant R5 508 Member + child R7 332
    Child dependant R1 716 Member + adult + child R12 840

    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 need to pay for any additional day-to-day claims yourself. 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 authorisation for the visit.
Benefits Description  
Professional services benefit No benefit  
General practitioners (GPs) Paid at the Fund's tariff rate from your MSA  
Specialists

Paid at the Fund's tariff rate from your MSA

PMBs paid at the agreed tariff at network specialists

Call 0800 765 432 for specialist referral and authorisation

 
Pathology and radiology

Paid at the Fund's tariff rate from your MSA

 
Basic dentistry - Consultations, fillings, extractions, scaling and polishing

Paid at the Fund's tariff rate from your MSA

Click here for Dental Formulary

 
Specialised dentistry - dentures, crowns, bridges and orthodontic treatment Paid at the Fund's tariff rate from your MSA  
Optical benefits - eye tests, lenses, frames and contact lenses

Paid at the Fund's tariff rate from your MSA

 
OptiClear Network

Members can receive services and materials at reduced rates from our accredited OptiClear providers

Click here for details of opticians on the OptiClear Network.

 
Prescribed acute medication Paid at 100% of the Fund's reference price formulary and subject to your MSA 100% of formulary medication
Over-the-counter medication

Paid at 100% subject to the Fund's reference price formulary and subject to your MSA

100% of formulary medication
Associated health services - chiropractors, homeopaths, naturopaths and dieticians Paid at the Fund's tariff rate from your MSA  

Auxiliary services out of hospital:

  • Clinical psychology
  • Speech therapy
  • Audiology
  • Occupational therapy
  • Podiatry
  • Orthoptics
  • Biokinetics
  • Physiotherapy

Paid at the Fund's tariff rate from your MSA

No benefit for social workers, vocational guidance, child
guidance, marriage guidance, school therapy or attendance
at remedial education schools or clinics
 
Registered private nurse practitioners Paid at the Fund's tariff rate from your MSA  
Emergency visits / outpatients

Paid at the Fund's tariff rate from your MSA

 

Claims paid outside South Africa

Paid at 100% of the Fund's tariff rate from applicable benefit categories, as indicated above (including hospitalisation)

Members must pay the provider and then claim back from the Fund

Refunds to members in equivalent SA rand only

You are advised to buy travel insurance when travelling abroad

 
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Hospitalisation Benefits

  • Benefits will be allocated pro rata for beneficiaries or members joining during the year.
    You must obtain authorisation for any non-emergency hospital admission and related treatment by calling 0800 118 666.

    If you do not obtain authorisation at least two days before any non-emergency hospital admission or related treatment, penalties may be applied and benefits may be withheld.

  • YOUR MAJOR MEDICAL EXPENSES BENEFIT keyboard_arrow_down

    Your major medical expenses benefit consists out of three categories:

    Procedures performed in hospital Certain procedures performed in doctors'rooms, hospital medical facilities or day clinics, but paid from your major medical expenses benefit Other procedures that are not performed in or out of hospital, but paid from your major medical expenses benefit.
  • SPECIFIED TIME LIMITS FOR PRE-AUTHORISATION keyboard_arrow_down

    Non-emergency:

    You must obtain pre-authorisation at least two working days before any non-emergency hospital admission or related treatment.

    Emergency:

    Pre-authorisation must be obtained within 24 hours of admission to hospital or by the next working day.
    You will receive no benefit if pre-authorisation is not obtained within the specified time limits.

  • DESIGNATED SERVICE PROVIDERS (DSPs) - NETWORK SPECIALIST keyboard_arrow_down

    A DSP is a healthcare provider with whom the Fund has negotiated preferential rates. Should you need to be treated for any of the 270 PMB conditions, we recommend that you use a DSP.

  • HOW TO OBTAIN HOSPITAL PRE-AUTHORISATION keyboard_arrow_down

    You must call to obtain pre-authorisation before your consultation or treatment to ensure correct payment of your claim.
    Saver Option members must call 0800 118 666.

IN-HOSPITAL BENEFITS

Benefits Description  
Ambulance services - Netcare - 082 911 100% of the agreed tariff. Unlimited if Netcare 911 is used. Subject to authorisation by Netcare 911 within 72 hours of the transport occurring. Unauthorised use of an ambulance for non-emergency treatment will not be covered by the Fund. For authorisation please call 082 911 100% of the agreed tariff
Hospitalisation - private, provincial or State hospitals

Paid at the Fund’s tariff rate for authorised admissions

Authorisation: 0800 118 666

 
Ward accommodation

Paid at general ward tariffs, subject to pre-authorisation

Authorisation: 0800 118 666

 
Take-home medication (after discharge from hospital)

Limited to 7 days

 
GPs - including surgery, procedures and consultations

Paid at the Fund's tariff rate
PMB admissions paid in full at network GPs, if pre-authorisation obtained
Call 0800 765 432 for GP referral and authorisation

 
Specialists - including surgery, procedures and consultations

Non-PMB claims will be paid at the Fund's tariff rate
PMB admissions paid in full at network specialists
Call 0800 765 432 for specialist referral and authorisation

 
Radiology - including MRIs, CT scans and radio-isotope studies

Paid at the Fund's tariff rate
MRIs and CT scans require an upfront co-payment of 25% of cost up to a maximum of R2 400
Subject to doctor's motivation and pre-authorisation
Authorisation: 0800 118 666

 
Pathology Paid at the Fund's tariff rate  
Organ transplants

Subject to pre-authorisation, managed care protocols, PMBs and networks

Where the recipient is a beneficiary of the Fund, services rendered to the donor and the transportation of the organ are included in this benefit

Where the donor is a beneficiary of the Fund, but the recipient is not, the donor costs will not be covered by the Fund, since these costs should be covered by the recipient's medical scheme

 
Hospitalisation, organ and patient preparation Paid at the Fund's tariff rate  
Immuno-suppressant drugs dispensed in hospital or dispensed by the hospital to take out for use after discharge 100% of cost  
Subsequent supplies of immunosuppressant drugs 100% of cost, subject to pre-authorisation  
Robotic-assisted laparoscopic prostatectomy

Paid at the Fund's tariff rate

Subject to clinical motivation, pre-authorisation and managed care protocols

Must be performed at an accredited hospital

Limited to R141 000 per qualifying beneficiary per year for hospital and equipment

Blood transfusions, transportation of blood and blood products

Paid at the Fund's tariff rate

Auxiliary services in hospital:

  • Clinical psychologyy
  • Speech therapy
  • Occupational therapy
  • Physiotherapy
  • Dietician
  • Social worker for psychotherapy
  • Biokineticist

Paid at the Fund's tariff rate for authorised admissions

The service/procedure must be directly related to the authorised admission

Post-operative auxiliary services may be approved and benefits granted on condition that these services are received within six weeks after the hospital admission

Subject to clinical motivation, pre-authorisation and managed care protocols

 
Psychiatric treatment in hospital or at a registered facility

Subject to pre-authorisation and limited to 21 days per beneficiary per year

Authorisation: 0800 118 666

 
Maxillofacial treatment

Paid at the Fund’s tariff rate, subject to pre-authorisation

 

IN-DOCTORS' ROOMS, HOSPITAL MEDICAL FACILITIES OR DAY CLINICS

PAID FROM MAJOR MEDICAL EXPENSES BENEFIT
Benefits Description  
Certain procedures performed in doctors' rooms only Paid at the Fund's tariff rate
Excludes general anaesthetic
 
Hospitalisation is subject to approval of clinical motivation and managed care protocols

Cone biopsy, cauterisation of warts, colposcopy, nasal polypectomy, nasal cautery, meibomian cyst excision, circumcision, drainage of superficial abscess, superficial foreign body removal and breast biopsy

Authorisation: 0800 118 666

 
Oncology, radiotherapy and chemotherapy in and out of hospital - medication/chemicals, related radiology, including MRIs and CT scans and pathology

Paid at 100% of negotiated DSP tariffs, subject to PMBs and South African Oncology Consortium (SAOC) protocols

Subject to pre-authorisation, registration on the Oncology Programme and oncology management protocols.

Registration: 0800 118 666

100% of negotiated DSP tariffs

Endoscopic examinations:

  • gastroscopy
  • oesophagoscopy
  • colonoscopy
  • sigmoidoscopy

Paid at the Fund's tariff rate if performed in doctors' rooms/outpatient/medical or surgical facilities

R2 400 co-payment applies if performed in hospital and patient is admitted to a ward.

 
These procedures can be performed in doctors' rooms, and in outpatient/medical/surgical facilities

Anaesthetic costs related to these scopes are limited to local or regional anaesthet

 
If performed in hospital, it will attract a member co-payment

General anaesthetic costs are not covered

Pathology costs related to these procedures will be covered from major medical expenses

 

Ophthalmologist examinations:

  • treatment of retina and choroids by cryotherapy
  • panretinal photocoagulation
  • laser capsulotomy
  • laser trabeculoplasty
  • laser apparatus

Benefit not deducted from your MSA

No co-payment applies if performed in doctor's rooms

A co-payment of R2 400 applies if performed in hospital without an approved clinical indication and Fund approval

Anaesthetic costs related to these procedures will be limited to local or regional anaesthetic

General anaesthetic costs are not covered

Pathology costs related to these procedures will be covered from major medical expenses

 
Basic dentistry procedures in hospital - removal of teeth and multiple fillings for children 7 years and younger

Paid at the Fund's tariff rate, subject to pre-authorisation

The dentist will be paid from your available MSA

 
Specialised dentistry procedures in and out of hospital - dental implants and removal of impacted wisdom teeth Paid at the Fund's tariff rate, subject to pre-authorisation and limited to R15 900 per beneficiary per year  
Refractive surgery

Paid at the Fund's tariff rate, subject to pre-authorisation

LASIK surgery benefit subject to guidelines for refractive surgery required for medical reasons

A motivation, including the refractive error, is required

Subject to approval by medical advisor and based on refraction levels

 
Peritoneal dialysis and haemodialysis

Paid at the Fund's tariff rate, subject to pre-authorisation and managed care protocols

 

OTHER BENEFITS

Benefits Description
Private nursing in lieu of hospitalisation OR frail care

Paid at the Fund's tariff rate and limited to R5 280 per beneficiary per month

Subject to clinical motivation by GP or specialist

Internal prostheses - including external fixators, colostomy kits and appliances placed in the body as an internal adjuvant during an operation

Paid at the Fund's tariff rate, subject to pre-authorisation and limited to R69 900 per beneficiary per year

No benefit if pre-authorisation is not obtained

Authorisation: 0800 118 666

External prostheses - including hearing aids, hearing aid repairs, wheelchairs and CPAP machines

Paid at the Fund's tariff rate, subject to written motivation, which must be received 72 hours before the request for pre-authorisation.

Subject to managed care protocols

Limited to R62 700 per beneficiary every two years

Authorisation: 0802 228 922

Medical and surgical appliances - including nebulisers, crutches, blood pressure machines, glucometers, etc.

Paid at the Fund's tariff rate, subject to clinical motivation and approval

Subject to available MSA where pre-authorisation is not obtained

Claims paid outside South Africa

Paid at 100% of the Fund's tariff rate from applicable benefit categories, as indicated above (including hospitalisation)

Members must pay the provider and then claim back from the Fund

Refunds to members in equivalent SA rand only

You are advised to buy travel insurance when travelling abroad

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Maternity Benefits

  • You must register your pregnancy by calling the pre-authorisation department. This will ensure that your maternity claims are paid correctly. For pre-authorisation, Saver Option members must call 0800 118 666.

Benefits Description  
Vaginal delivery

100% of the agreed tariff

100% of the agreed tariff
Caesarean delivery

100% of the agreed tariff
A co-payment of R3 200 will apply where no clinical motivation for the caesarean has been received from the gynaecologist

100% of the agreed tariff
Two ultrasound scans - at 12 and 24 weeks

100% of the agreed tariff

100% of the agreed tariff

Ward rates

General ward rates, subject to the following:
Vaginal delivery (3 days)
Caesarean delivery (4 days)

 

Pathology

100% of the agreed tariff, as per the maternity treatment plan

100% of the agreed tariff
Maternity pathology paid by the Fund
TEST PER YEAR TARIFF CODE
Full blood count 1 3755
Blood test: Blood group 1 3764
Blood test: Rhesus antigen 1 3765
Urine culture 1 3893
HIV Elisa or other screening test 1 3932
Rubella antibody 1 3948
VDRL (Venereal Disease Research Laboratory) 1 3949
Glucose strip test 1 4050
Urine analysis dipstick 13 4188
HIV antibody rapid test 1 4614
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Preventative Testing

  • TEST - PAID FROM MAJOR MEDICAL EXPENSES BENEFIT
    CONSULTATION - PAID FROM DAY-TO-DAY BENEFIT

Benefits Description
Health risk assessment
Body mass index, blood pressure, cholesterol (finger-prick test) and blood sugar (finger-prick test)

Limited to one screening per adult per year

To be performed at a suitable pharmacy

Should your health risk assessment be performed in the doctor's rooms, the consultation fee will be paid from your day-to-day benefit

Mammogram
(Tariff code 34100 & 3605)
Limited to one per female (over 40 years) every two years or as clinically indicated (family history)
Pap smear and liquid-based cytology
(Tariff code 4566 & 4559)
Limited to one per adult female every year
HIV finger-prick test
(Tariff code 3932)
Limited to one per beneficiary every year
Glaucoma screening
(Tariff code 3014)
Limited to one screening per adult (over 40 years) every two years
HPV vaccine
(Nappi code 710020 - Cervarix®)
(Nappi code 710249 - Gardasil®)

All HIV-negative female beneficiaries between the ages of nine and 13

Flu vaccine Limited to one per beneficiary per year
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Chronic Care

  • Saver Option members must call 0802 228 922 for their Chronic Care application forms and queries.

    Please click here to read more and locate a network pharmacy near you

  • WHAT IS CHRONIC CARE? keyboard_arrow_down

    Chronic care refers to the medical care for a pre-existing or long-term illness where medication is required to be taken for a period exceeding three months at a time. The Fund provides a Chronic Medication Risk Management Programme to the benefit of members who have been diagnosed with certain chronic conditions.

  • YOU MUST OBTAIN PRE-AUTHORISATION FOR ALL CHRONIC MEDICATION keyboard_arrow_down

    All chronic medication benefits are subject to pre-authorisation.

    Chronic medication application form
    get_appDownload

    Members must email their chronic application forms to [email protected] or ask their healthcare providers to call 0802 228 922.

  • WHAT ARE PRESCRIBED MINIMUM BENEFITS (PMBs)? keyboard_arrow_down

    PMBs are a set of defined benefits to ensure that all Fund members have access to certain minimum health services, regardless of the option they have selected.

The 26 common chronic health conditions on the chronic disease list (CDL)
Addison's disease Crohn's disease Hypertension (high blood pressure)
Asthma Diabetes insipidus Hypothyroidism
Bipolar mood disorder Diabetes mellitus types 1 & 2 Multiple sclerosis
Bronchiectasis Dysrhythmia (irregular heartbeats) Parkinson's disease
Cardiac failure Epilepsy Rheumatoid arthritis
Cardiomyopathy disease
(disease of the heart muscle)
Glaucoma Schizophrenia
Chronic renal disease Haemophilia Systemic lupus erythematosus
Coronary artery disease HIV/AIDS Ulcerative colitis
Chronic obstructive pulmonary disorder (COPD) Hyperlipidaemia (high cholesterol)  
Benefits Description  
Chronic medication
26 PMB conditions

100% of approved medication

Subject to registration on the Chronic Medication Risk Management Programme

You will receive a treatment plan listing the additional services recommended to treat your approved chronic condition

These services are paid by the Fund and not from your MSA

Call 0802 228 922

100% of approved medication
Chronic medication
non-PMB conditions

Limited to R15 150 per beneficiary per year for approved medication

Subject to registration on the Chronic Medication Risk Management Programme

Call 0802 228 922

 
Speciality chronic medication benefits

Limited to R163 000 per beneficiary per year
Subject to registration on the Chronic Medication Risk Management Programme
Subject to the following PMB conditions only:

  • Asthma
  • Crohn's disease
  • Haemophilia
  • Multiple sclerosis
  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Ulcerative colitis
Call 0802 228 922
 
PMB chronic conditions Members on the Saver Option will be required to register on the Chronic Medication Risk Management Programme to ensure that their PMB chronic medication is approved. Members who require chronic medication for one of the 26 PMB conditions will receive a treatment plan. A treatment plan lists additional services recommended to treat your chronic condition. These services are recommended in order to maintain optimal health and benefits are covered by the Fund and are not paid from your MSA. The medication will be paid subject to the Fund's approved formulary.  
Non-PMB chronic conditions Members are required to register on the Chronic Medication Risk Management Programme to ensure that their non-PMB chronic medication is approved. The medication will be paid subject to the Fund's approved formulary.

Call 0802 228 922 to register.

 
  • Click here to view formulary medication.

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HIV/AIDS

  • To register on the HIV YourLife Programme, call 0860 109 793 or click here for more information.

Benefits Description  
HIV counselling and testing (HCT)

Testing fee for GPs

100% of cost, subject to PMBs

Limited to R300 for testing

Pathology-related treatment will not be deducted from your MSA

100% of cost
Circumcision
Uninfected adult and newborn males

Paid at the Fund's tariff rate from your MSA

 
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2022 Benefits and Contributions

  • Please click on the links below to view and print the benefit schedules.

    NON-TCOE BENEFIT SCHEDULE
    get_appDownload
    TCOE BENEFIT SCHEDULE
    get_appDownload
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Contact Us
Client Service Team

WhatsApp

0860005037

Saver and Comprehensive Option members

local_phone0802 228 922 / 021 480 4849

email[email protected]

Network Option members

local_phone0800 765 432

email[email protected]

Emergency
Netcare 911

local_phone 082911

Fraud
Fraud hotline

local_phone0800 000 436

Disclaimer:

Although every attempt has been made to replicate information accurately on this website, errors may occur. In the case of a dispute, the Fund's registered rules will always apply.

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