Day-to-day Benefits
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Benefits will be allocated pro rata for members and their beneficiaries joining during the year.
You may only use network providers.
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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.
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 600 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 |
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| 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 test | One eye test per beneficiary every 24 months at a network optometrist One pair of clear, mono-, bi- or multifocal lenses, plus standard frame A benefit of R200 will be paid towards a frame selected outside the standard range |
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| Lenses and frames | No benefit if a non-network provider is used OR |
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| Contact lenses | One set of approved contact lenses limited to the value of R520 per beneficiary every 24 months at network optometrists | ||||||||||||
| OptiClear Network | Members can receive services and materials at reduced rates from our 2 700 accredited OptiClear providers | ||||||||||||
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| 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:
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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 070 Paid at the Fund's tariff rate per visit |
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Claims paid outside South Africa |
No benefit | ||||||||||||
GP, Dentist and Optometrist Networks
You will need to choose a network GP, Dentist and Optometrist in your area:
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 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.
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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.
Network 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 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 | 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 NETWORK authorisation: 0800 765 432 |
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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 | 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 |
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| 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:
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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 |
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| 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 |
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| 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 |
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Endoscopic examinations:
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100% of the agreed tariff, subject to pre-authorisation and clinical |
100% of the agreed tariff |
| These procedures can be performed in doctors' rooms, and in outpatient/medical/surgical facilities |
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| If performed in hospital, it will attract a member co-payment | Authorisation: 0800 765 432 |
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Ophthalmologist examinations:
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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 |
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| Refractive surgery | No benefit | |
| Peritoneal dialysis and haemodialysis | 100% of the agreed tariff at network providers, subject to preauthorisation |
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 050 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 appliance 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 R66 900 per beneficiary per year Authorisation: 0800 765 432 |
100% of the agreed tariff |
| External prostheses - including hearing aids, hearing aid repairs, wheelchairs and C-pap 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 R50 000 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 |
Maternity Benefits
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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 section | 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: |
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Pathology |
100% of the agreed tariff |
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 D2D.
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 |
| Flu vaccine | Limited to one per beneficiary per year |
Chronic Care
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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
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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
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.
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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) |
|---|
| 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) |
| Additional chronic contitions subject to chronic fomulary: |
|---|
| Acne | Menopause |
| Allergic rhinitis | Migraine prophylaxis |
| Depression | Osteoarthritis |
| Gout | Osteoporosis |
| 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 200 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 |
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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.
HIV/AIDS
CareWorks HIV Treatment Programme
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The Fund has contracted with CareWorks to provide their HIV treatment programme for the benefit of members who are HIV positive. CareWorks ensures absolute confidentiality. Through their outbound care centre, counsellors will make regular contact to help participating members to manage their condition appropriately. CareWorks focuses on education and support to empower you with the skills and knowledge you require to effectively manage your condition.
CareWorks has over 10 years' HIV/AIDS disease management experience. Since its inception, more than 13 000 enrolees have registered on the programme. The following medical benefits are covered:
Antiretroviral medication Blood tests related to HIV/AIDS Doctors' consultations If you are pregnant, treatment to help prevent your baby from contracting HIV Post-exposure prophylaxis (PEP) medication to prevent HIV infection if you are exposed to blood or fluids from an infected person or by any other means Management of TB for those who need it.
Please click on the links below to download and/or print these documents:
HIV Brochure - A quick guide
HIV Application form
Contact us on
0860 10 11 10 (members)
Email
[email protected]
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