We use cookies to make your experience of our website better. By using and further navigating this website, you accept this. Detailed information about the use of cookies on this website is available here.

Accept Close
menu Wooltru - Welcome to Wooltru Healthcare
      • Home
      • About
        • About us
        • Board of Trustees
        • Council for Medical Schemes
        • Fund Rules
        • Complaints process
        • Annual General Meetings
        • Giving back
      • Membership
        • Joining
        • Managing membership
        • Contributions
      • Benefits
        • Network Option
        • Saver Option
        • Comprehensive Option
        • Claims
        • Fund Tariff (WHFT) Lookup
      • Healthcare Programmes
        • Hospital pre-authorisation
        • HomeCare+
        • Chronic Medication Risk Management
        • Prescribed Minimum Benefits
        • HIV/AIDS
        • Oncology
      • Complementary Products
        • Multiply
        • HealthSaver
        • HealthReturns
        • Hello Doctor
      • Contact
      • Sign in
    Wooltru - Welcome to Wooltru Healthcare
    lock Sign-in
    account_circle Register
      • Home
      • About
        • About us
        • Board of Trustees
        • Council for Medical Schemes
        • Fund Rules
        • Complaints process
        • Annual General Meetings
        • Giving back
      • Membership
        • Joining
        • Managing membership
        • Contributions
      • Benefits
        • Network Option
        • Saver Option
        • Comprehensive Option
        • Claims
        • Fund Tariff (WHFT) Lookup
      • Healthcare Programmes
        • Hospital pre-authorisation
        • HomeCare+
        • Chronic Medication Risk Management
        • Prescribed Minimum Benefits
        • HIV/AIDS
        • Oncology
      • Complementary Products
        • Multiply
        • HealthSaver
        • HealthReturns
        • Hello Doctor
      • Contact
      • Sign in

NETWORK OPTION

View other options
  • Network Option
  • Saver Option
  • Comprehensive Option
Day-to-day Benefits
GPs and Dentists Networks
Hospitalisation Benefits
Maternity Benefits
Preventative Testing
Chronic Care
HIV/AIDS
2022 Benefits and Contributions
How to make a claim
Summary of Services
Understanding your claims statement

Day-to-day Benefits

  • Benefits will be allocated pro rata for members and their beneficiaries joining during the year.
    You may only use network providers.

  • 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.

    Members on the Network Option must obtain all healthcare services from network providers. To access your day-to-day medical benefits, you must choose a network GP, dentist and optometrist from the Network Option lists.

    If you do not use a network provider you will have to pay for the difference out of your own pocket. Please contact 0800 765 432 to find a suitable network provider.

    The Network Option does not offer a medical savings account (MSA).

Benefits Description  
Professional services benefit No benefit  
Network providers You may ONLY use network providers  
General practitioners (GPs) 100% of the agreed tariff at your chosen network GP 100% of the agreed tariff
Specialists

Only network specialists, limited to: R2 700 per beneficiary per year

These amounts include the cost of consultations, medication, procedures, radiology and pathology

Call 0800 765 432 for specialist referral and authorisation

 
Pathology and radiology

100% of the agreed tariff if referred by a network provider

Restricted to the network provider list of investigations

100% of the agreed tariff
Basic dentistry - Consultations, fillings, extractions, scaling and polishing

100% of the agreed tariff at network dentists

Subject to the approved dental tariff list

Click here for Dental Formulary

100% of the agreed tariff
Specialised dentistry - dentures, crowns, bridges and orthodontic treatment No benefit  
Optical benefits - eye tests, lenses, frames and contact lenses

One eye test per beneficiary every 24 months at a network optometrist

One pair of clear, mono-, bi- or multifocal lenses, plus standard frame every 24 months at a network optometrist

A benefit of R210 will be paid towards a frame selected outside the standard range every 24 months at a network optometrist

OR

One set of approved contact lenses limited to the value of R540 per beneficiary every 24 months at network optometrists

 
 

No benefit if a non-network provider is used

 
OptiClear Network Members can receive services and materials at reduced rates from our accredited OptiClear providers  
OPTICAL NETWORK: For details of providers on the Opticlear Network, click on the links below:
Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo
Mpumalanga North West Province Northern Cape Western Cape  
Prescribed acute medication 100% of formulary medication as prescribed by a network provider  
Over-the-counter medication No benefit  
Associated health services - chiropractors, homeopaths, naturopaths and dieticians No benefit  

Auxiliary services out of hospital:

  • Clinical psychology
  • Speech therapy
  • Audiology
  • Occupational therapy
  • Podiatry
  • Orthoptics
  • Biokinetics
  • Physiotherapy
No benefit  
Registered private nurse practitioners No benefit  
Emergency visits / outpatients

Limited to three visits per family per year up to a limit of R2 160

Paid at the Fund's tariff rate per visit

 

Claims paid outside South Africa
Members must pay the provider and then claim back from the Fund

No benefit  
Close

GP and dentist networks

You will need to choose a network GP and dentist in your area:

NETWORK GPs: NETWORK DENTISTS:
Eastern Cape Eastern Cape
Free State Free State
Gauteng Gauteng
KwaZulu-Natal KwaZulu-Natal
Limpopo Limpopo
Mpumalanga Mpumalanga
North West Province North West Province
Northern Cape Northern Cape
Western Cape Western Cape
Close

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 765 432.

    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.
    Network Option members must call 0800 765 432.

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

100% of the agreed tariff for authorised admissions, if referred by a network provider

Authorisation: 0800 765 432

100% of the agreed tariff
Ward accommodation

Paid at general ward tariffs, subject to pre-authorisation

Authorisation: 0800 765 432

 
Take-home medication (after discharge from hospital)

Limited to 7 days

 
GPs - including surgery, procedures and consultations

100% of the agreed tariff for authorised admissions, if referred by a network GP

Authorisation: 0800 765 432

100% of the agreed tariff
Specialists - including surgery, procedures and consultations

100% of the agreed tariff for authorised admissions, if referred by a network specialist

Call 0800 765 432 for specialist referral and authorisation

100% of the agreed tariff
Radiology - including MRIs, CT scans and radio-isotope studies

100% of the agreed tariff if requested by a network specialist on referral by a network GP

Subject to clinical motivation and pre-authorisation

Authorisation: 0800 765 432

100% of the agreed tariff
Pathology 100% of the agreed tariff if requested by a network specialist on referral by a network GP 100% of the agreed tariff
Organ transplants

Subject to pre-authorisation and PMBs

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 100% of the agreed tariff 100% of the agreed tariff
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 No benefit  
Blood transfusions, transportation of blood and blood products 100% of the agreed tariff at approved network providers 100% of the agreed tariff

Auxiliary services in hospital:

  • Clinical psychology
  • Speech therapy
  • Occupational therapy
  • Physiotherapy

100% of the agreed tariff for authorised admissions at network providers

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

100% of the agreed tariff
Psychiatric treatment in hospital or at a registered facility

Prescribed minimum benefits (PMBs) only

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

Authorisation: 0800 765 432

 
Maxillofacial treatment

100% of the agreed tariff, subject to pre-authorisation

Only covers facial trauma and removal of impacted wisdom teeth
100% of the agreed tariff

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

Benefits Description  
Certain procedures performed in doctors' rooms only 100% of the agreed tariff if performed at network GPs and limited to the DSP list of procedure codes 100% of the agreed tariff
Hospitalisation is subject to approval of clinical motivation and managed care protocols

Authorisation: 0800 765 432

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

PMBs only

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

Registration: 0800 765 432

 

Endoscopic examinations:

  • gastroscopy
  • oesophagoscopy
  • colonoscopy
  • sigmoidoscopy

100% of the agreed tariff, subject to pre-authorisation and clinical
motivation by a network provider

100% of the agreed tariff
These procedures can be performed in doctors' rooms, and in outpatient/medical/surgical facilities

 

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

Authorisation: 0800 765 432

 

Ophthalmologist examinations

No benefit  
Basic dentistry procedures in hospital - removal of teeth and multiple fillings for children 7 years and younger No benefit  
Specialised dentistry procedures in and out of hospital - dental implants and removal of impacted wisdom teeth No benefit
Removal of impacted wisdom teeth covered under maxillofacial benefit
 
Refractive surgery No benefit  
Peritoneal dialysis and haemodialysis

100% of the agreed tariff at network providers, subject to pre-authorisation

100% of the agreed tariff

OTHER BENEFITS

PAID FROM MAJOR MEDICAL EXPENSES BENEFIT
Benefits Description  
Private nursing in lieu of hospitalisation OR frail care

100% of the agreed tariff and limited to R5 280 per beneficiary per month

Subject to clinical motivation by a network provider

100% of the agreed tariff
Internal prostheses - including external fixators, colostomy kits and appliances placed in the body as an internal adjuvant during an operation

100% of the agreed tariff at network providers, subject to pre-authorisation and limited to R69 900 per beneficiary per year

Authorisation: 0800 765 432

100% of the agreed tariff
External prostheses - including hearing aids, hearing aid repairs, wheelchairs and CPAP machines

100% of the agreed tariff, subject to written motivation, which must be received 72 hours before the request for pre-authorisation

Subject to the terms, conditions and protocols of the network DSP

Limited to R52 300 per beneficiary every two years

Authorisation: 0800 765 432

100% of the agreed tariff

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

100% of the agreed tariff, subject to clinical motivation and approval

Subject to the terms, conditions and protocols of the network DSP

100% of the agreed tariff
Claims paid outside South Africa
Members must pay the provider and then claim back from the Fund
No benefit  
Close

Maternity Benefits

  • Subject to pre-authorisation and registration within the first 16 weeks of pregnancy.

    You must register your pregnancy by calling the pre-authorisation department. This will ensure that your maternity claims are paid correctly. For pre-authorisation Network Option members must call 0800 765 432.

Benefits Description  
Vaginal delivery

100% of the agreed tariff

100% of the agreed tariff
Caesarean delivery

100% of the agreed tariff if motivated by a network specialist

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
Close

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 test - finger-prick
(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
Flu vaccine Limited to one per beneficiary per year
Close

Chronic Care

  • Network Option members must call 0800 765 432 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

    NETWORK OPTION: Members must fax their chronic application forms to 021 673 1815 or email it to [email protected]. Call 0800 765 432 for any queries.

  • 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)  
Additional chronic contitions subject to chronic fomulary:
Acne Gout Stroke (CVA/TIA)
Allergic rhinitis Menopause Thromboembolic disorder
Cardiac arrythmia Migraine prophylaxis  
Depression Osteo-arthritis  
Benefits Description
Chronic medication
26 PMB conditions

100% of approved medication

Subject to registration on the Chronic Medication Risk Management Programme

Call 0800 765 432

Chronic medication
non-PMBs

Limited to R12 750 per beneficiary per year for approved medication

Subject to registration on the Chronic Medication Risk Management Programme

Call 0800 765 432

Speciality chronic medication benefits (biological) No benefit
  • Members on the Network Option with chronic conditions must register on the Chronic Medication Risk Management Programme and obtain pre-authorisation for their medication and approval from their network GP or network specialist on their condition, in order to obtain benefits.

    On approval of your PMB-related chronic condition, a treatment plan, which lists additional services recommended to treat your chronic condition will be sent to you.

    Medication for the 26 PMB conditions will be restricted to the formulary at the network providers (GPs and specialists).

    Click here to view formulary medication.

    Call 0800 765 432 to register.

Close

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)

100% of cost at network providers

100% of cost
Circumcision
Uninfected adult and newborn males

100% of the agreed tariff at network providers

 
Close

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
Close

Please select a login option below

account_circle

Member

local_hospital

Provider

Close
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.

© 2021 Wooltru Healthcare Fund | [email protected] | Privacy Policy