Day-to-day Benefits
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Benefits will be allocated pro rata for members and their beneficiaries joining during the year.
When your Day-to-day is exhausted, you will be required to pay the providers/services in full.
You may use any provider and claims will be met at the maximum rates reflected below. PMB conditions will be paid at the 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 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 508 Member + adult R10 908 Adult dependant R5 400 Member + child R7 188 Child dependant R1 680 Member + adult + child R12 588 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 |
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| Pathology and radiology | Paid at the Fund's tariff rate from your MSA |
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| Basic dentistry - Consultations, fillings, extractions, scaling and polishing | Paid at the Fund's tariff rate from your MSA Click here for Dental Formulary |
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| Specialised dentistry - dentures, crowns, bridges and orthodontic treatment | Paid at the Fund's tariff rate from your MSA | |
| Optical benefits - Eye test Lenses and frames Contact lenses |
Paid at the Fund's tariff rate from your MSA |
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| OptiClear Network | Members can receive services and materials at reduced rates from our 2 700 accredited OptiClear providers Click here for details of opticians on the OptiClear Network. |
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| 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:
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Paid at the Fund's tariff rate 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 the Fund's tariff rate from your MSA | |
| Emergency visits / outpatients | Paid at the Fund's tariff rate from your MSA |
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Claims paid outside South Africa |
Paid at the Fund's tariff rate from applicable benefit categories, as indicated above (including hospitalisation). Refunds to members in equivalent SA rand only You are advised to buy travel insurance when travelling abroad |
Hospitalisation Benefits
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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.
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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.
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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 nonemergency 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 |
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| Ward accommodation | Paid at general ward tariffs, subject to pre-authorisation Authorisation: 0800 118 666 |
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| Take-home medication (after discharge from hospital) | Limited to 7 days |
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| GPs - including surgery, procedures and consultations | Paid at the Fund's tariff rate |
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| Specialists - including surgery, procedures and consultations | Non-PMB claims will be paid at the Fund's tariff rate |
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| Radiology - including MRIs, CT scans and radio isotope studies | Paid at the Fund's tariff rate |
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| 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 |
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| 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 | 100% of the agreed tariff at approved network providers Subject to clinical motivation, pre-authorisation and managed care protocols. Must be performed at an accredited hospital Limited to R135 000 for hospital and equipment |
100% of the agreed tariff |
Auxiliary services in hospital:
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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
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Saver:
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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 |
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| 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 |
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| 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 |
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| 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:
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Paid at the Fund's tariff rate if performed in doctors' rooms/outpatient/medical or surgical facilities R2 300 co-payment applies if performed in hospital and patient is admitted to a ward. |
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| 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 |
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| If performed in hospital, it will attract a member co-payment | ||
Ophthalmologist examinations:
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Paid at the Fund's tariff rate if performed in doctors' rooms/outpatient/medical or surgical facilities Anaesthetic costs related to these procedures are limited to local or regional anaesthetic General anaesthetic costs are not covered |
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| 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 |
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| 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 200 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 |
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| 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 050 per beneficiary per month Subject to clinical motivation by GP or specialist |
| Internal prostheses - including external fixators, colostomy kits, and appliance 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 R66 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 C-pap 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 R60 000 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 Members must pay the provider and then claim back from the Fund |
Paid at the Fund's tariff rate paid from applicable benefit categories, as indicated above (including hospitalisation) Refunds to members in equivalent SA rand only You are advised to buy travel insurance when travelling outside South Africa |
Maternity Benefits
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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 section | 100% of the agreed tariff |
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: |
100% of the agreed tariff |
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 |
Preventative Testing
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The cost of the test will be paid by the Fund and the consultation will be paid from the Day-to-day.
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 designated pharmacy e.g. Dis-Chem or Clicks 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 test - finger-prick (Tariff code 3932) |
Limited to one per beneficiary per 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 710429 - Gardasil) |
All female beneficiaries (non-HIV) between the ages of 9 and 13 Only Saver and Comprehensive Options |
| Flu vaccine | Limited to one per beneficiary per year |
Chronic Care
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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
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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.
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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
Members must email their chronic application forms to [email protected] or ask their healthcare providers to call 0802 228 922.
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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) |
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| 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 | Hypertension (high blood pressure) |
| 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-PMBs |
Limited to R14 500 per beneficiary per year for approved medication Subject to registration on the Chronic Medication Risk Management Programme Call 0802 228 922 |
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| Speciality chronic medication benefits (biological) | Limited to R156 000 per beneficiary per year
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| PMB chronic conditions | Members will be required to register on the Chronic Medication Risk Management Programme to ensure that their PMB chronic medication is approved. Members on the Saver option that 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. |
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Click here to view formulary medication.
HIV/AIDS
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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 R290 for testing Pathology-related treatment will not be deducted from your MSA |
100% of cost |
| Circumcision Uninfected adult and newborn males |
2021 Benefits and Contributions
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Please click on the links below to view and print the benefit schedules.
NON-TCOE BENEFIT SCHEDULE
TCOE BENEFIT SCHEDULE