Plans

Looking for the plan that’s perfect for you?
Read up on all the various plans we offer and compare benefits here.

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Welcome to our decision page.

Choosing a Plan to suit your healthcare needs can be hard. So we’ve made it easy!
We’ve put everything you need to choose your cover on one page. Browse and compare plans and then use the calculator to answer those burning budget questions!

What must I consider before making a choice?

Before you select your Plan for the coming benefit year, take the following factors into consideration:

  • The monthly contributions of each Plan to ensure that you can afford the Plan you select.
  • Whether the Plan you are considering offers adequate benefits most suited to your medical needs.
  • Your health history or what your medical expenses were during the previous benefit year.
  • Your anticipated healthcare needs during the coming year.
  • The number of dependants you have and whether this may change in the next benefit year.
  • If you have a chronic condition, whether the Plan you choose covers your condition, and whether you are comfortable with the formulary that is applicable to your Plan.
What must I consider before making a choice?

Before you select your Plan for the coming benefit year, take the following factors into consideration:

  • The monthly contributions of each Plan to ensure that you can afford the Plan you select.
  • Whether the Plan you are considering offers adequate benefits most suited to your medical needs.
  • Your health history or what your medical expenses were during the previous benefit year.
  • Your anticipated healthcare needs during the coming year.
  • The number of dependants you have and whether this may change in the next benefit year.
  • If you have a chronic condition, whether the Plan you choose covers your condition, and whether you are comfortable with the formulary that is applicable to your Plan.

Hospital Plan

Simple, cost-effective cover
A cost-effective solution with essential in-hospital cover and basic chronic, wellness and supplementary benefits.
DAY-TO-DAY BENEFITS
 

  • Limited Primary Care Benefits for specified procedures to the value of R2 230 pfpa.
  • No Personal Medical Savings Account.
MANAGED CARE BENEFITS
 

  • Chronic Medicine Benefits.
  • Mental Health Programme.
  • Back and Neck Rehabilitation Programme.
  • Oncology Programme.
  • HIV/AIDS Management Programme.
  • Active Disease Risk Management Programme.
  • Mother and Baby Care Programme
HOSPITAL BENEFITS
 

NEW Unlimited Overall Annual Limit (OAL):

  • Sub-limits apply:
    • Basic pathology: Subject to the Overall Annual Limit and Managed Care protocols.
    • Basic radiology: Unlimited Subject to the Overall Annual Limit and Managed Care protocols.
    • Physiotherapy: R6 050 per family per benefit year.
    • Quro (home-based monitoring service) Medical benefit. This benefit allows you to return home from hospital sooner. Member can recover in their own home while still being closely monitored 24 hours-a-day by a team of medical professionals.

NOTE: Under the Hospital, Network and Network SELECT Plans, certain elective procedures, including hip, knee, shoulder and elbow replacements, are not covered, other than in accordance with Prescribed Minimum Benefits.

SUPPLEMENTARY BENEFITS
 

  • Specialised Radiology R16 100 pfpa (co-payment of R1 500 per scan for non-PMBs).
  • Ultrasound scans (non-pregnancy) R5 480.
CHRONIC BENEFITS
 

Subject to restrictive formulary.

  • 27 PMB chronic conditions.
  • Additional 9 non-PMB chronic conditions covered up to R5 750.
MATERNITY BENEFITS
 

  • If you are on the Hospital Plan, you will not have out-of-hospital maternity benefits, but you will receive educational support and relevant contact information.
    • Delivery in-hospital will be subject to pre-authorisation and managed care protocols.
    • A Doula (birthing coach) as part of the in-hospital maternity benefit, subject to a limit of R2 730 per pregnancy for delivery only.
WELLNESS BENEFITS
 

  • Pharmacy-based health-screening tests: Blood pressure, blood glucose, cholesterol, HIV/AIDS, BMI. One of each screening test per beneficiary per benefit year.
  • Pharmacy-based vaccines: One flu vaccine per beneficiary per benefit year, one pneumococcal vaccine per lifetime.
  • Contraceptive benefit: R3 410 per beneficiary per benefit year. R2 140 sub-limit for oral contraceptives.
  • Non-pharmacy based benefits:
  • One Pap smear, Mammogram, Syphilis and Chlamydia infection screening, limited to 1 test per female beneficiary, including consultation with a Gynaecologist or General Practitioner. (Please note for the Pap smear, Mammogram and Syphilis and Chlamydia screening, only one Gynaecologist consultation per benefit year will be funded from the Screening Benefit.)
  • One prostate specific antigen test per male beneficiary.
  • Colorectal screening, limited to one test per beneficiary per benefit year.
  • One health risk assessment per beneficiary per benefit year for services rendered by a registered healthcare practitioner (such as a General Practitioner). It is very important that your service provider uses the correct ICD-10 code to claim for these benefits.
  • Nutritional assessment and healthy eating plan – Access to Universal network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring.
  • Childhood immunisations – Applicable for children up to the age of 12 years, as per recommendation of the Department of Health.
  • Pre-school eye and hearing screening – For children aged 5 and 6.
  • Hearing screening for newborns up to six weeks.
  • PAED-IQ’s Babyline: A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age registered on the Fund can phone in and get up-to-date child healthcare advice and reassurance.
  • COVID-19 Benefit Package: Any beneficiary who tested positive for COVID-19 will be able to access the following: Pulse oximeter, Nebuliser, Oxygenator, Thermometer, 2 GP consultations and Chest physiotherapy. Pre-authorisation and managed care protocols apply.
  • Dental caries (prevention and oral fluoride supplementation): limited to beneficiaries up to age 6 years, subject to Managed Care Protocols, including oral-hygienist consultation.
  • COVID-19 Vaccine: Vaccinations for all eligible beneficiaries in accordance with the Department of Health recommendation.

NOTE: Please ask the General Practitioner, Gynaecologist or Urologist (whichever is applicable) to submit the wellness consultation claim using the following primary ICD-10 code: Z00.0. If this code is not used, the benefit will be paid from your available Day-to-Day Benefit.

Savings Plan

Simple cover with savings
Get unlimited in-hospital cover, basic chronic, wellness, supplementary with day-to-day benefits linked to your personal medical savings account.

DAY-TO-DAY BENEFITS

 

  • Limited to Personal Medical Savings Account only, no PCB limits.
  • At 100% of cost from PMSA and then from accumulated savings, subject to available funds.
  • The following services are covered at cost from your PMSA or accumulated savings, subject to available funds:
    • GP and specialist consultations.
    • Pathology.
    • Radiology.
    • Acute medicine paid at 100% of cost or Medicine Price, whichever is the lesser.
    • Dentistry.
    • Optometry.
    • Psychology and psychiatry.
    • Physiotherapy.
    • Auxiliary services.
    • Specified procedures in doctors’ rooms.
MANAGED CARE BENEFITS

 

The Old Mutual Staff Medical Aid Fund aims to identify and manage beneficiaries’ disease risks. The Fund has a number of programmes that form part of the Managed Care approach.

  • Back and Neck Rehabilitation Programme.
  • Oncology Benefit Management Programme.
  • HIV and AIDS Management Programme.
  • Mental Health Programme.
  • Active Disease Risk Management Programme.
  • Mother and Baby Care Programme.
HOSPITAL BENEFITS

Unlimited overall annual limit (subject to certain sub-limits).

  • Unlimited Prescribed Minimum Benefits (PMB) if obtained from a Designated Service Provider (DSP).
  • Basic pathology: Subject to the Overall Annual Limit and Managed Care protocols.
  • Basic radiology: Unlimited subject to the Overall Annual Limit and Managed Care protocols.
  • Physiotherapy: R6 050 per family per benefit year.
  • Quro (home-based monitoring service) Medical benefit. This benefit allows you to return home from hospital sooner. Member can recover in their own home while still being closely monitored 24 hours-a-day by a team of medical professionals.
SUPPLEMENTARY BENEFITS
 

  • Specialised Radiology R16 100 pfpa (co-payment of R1 500 per scan for non-PMBs).
  • Ultrasound scans (non-pregnancy) R5 480 pfpa.
  • Maternity Benefits (Antenatal classes/visits, 2D-scans, vitamins, pathology tests).
CHRONIC BENEFITS
 

  • 27 PMB chronic conditions.
  • Additional 18 non-PMB chronic conditions covered up to R5 750 pfpa.
  • MMAP and out-of-formulary co-payments will still apply to medicine that is pre-approved.
MATERNITY BENEFITS
 

  • All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
  • Antenatal classes: R1 460 per family per benefit year.
  • Antenatal visits: R3 450 per pregnancy.
  • Ultrasound scans (pregnancy): Two 2-D scans per beneficiary.
  • Out-of-hospital pathology tests (pregnancy): R2 840 per family per benefit year.
  • Antenatal vitamins: 100% of MMAP or Medicine Price, whichever is the lesser, subject to the prescription from an approved list and included in the Hospital Benefit.
  • A Doula (birthing coach): as part of the in-hospital maternity benefit, subject to a limit of R2 730 per pregnancy for delivery only.
    WELLNESS BENEFITS
     

    • Pharmacy-based health-screening tests: Blood pressure, blood glucose, cholesterol, HIV/AIDS, BMI. One of each screening test per beneficiary per benefit year.
    • Pharmacy-based vaccines: One flu vaccine per beneficiary per benefit year, one pneumococcal vaccine per lifetime.
    • Contraceptive benefit: R3 410 per beneficiary per benefit year. R2 140 sub-limit for oral contraceptives.
    • Non-pharmacy based benefits:
    • One Pap smear, Mammogram, Syphilis and Chlamydia infection screening, limited to 1 test per female beneficiary, including consultation with a Gynaecologist or General Practitioner. (Please note for the Pap smear, Mammogram and Syphilis and Chlamydia screening, only one Gynaecologist consultation per benefit year will be funded from the Screening Benefit.)
    • One prostate specific antigen test per male beneficiary.
    • Colorectal screening, limited to one test per beneficiary per benefit year.
    • One health risk assessment per beneficiary per benefit year for services rendered by a registered healthcare practitioner (such as a General Practitioner). It is very important that your service provider uses the correct ICD-10 code to claim for these benefits.
    • Nutritional assessment and healthy eating plan – Access to Universal network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring.
    • Childhood immunisations – Applicable for children up to the age of 12 years, as per recommendation of the Department of Health.
    • Pre-school eye and hearing screening – For children aged 5 and 6.
    • Hearing screening for newborns up to six weeks.
    • PAED-IQ’s Babyline: A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age registered on the Fund can phone in and get up-to-date child healthcare advice and reassurance.
    • COVID-19 Benefit Package: Any beneficiary who tested positive for COVID-19 will be able to access the following: Pulse oximeter, Nebuliser, Oxygenator, Thermometer, 2 GP consultations and Chest physiotherapy. Pre-authorisation and managed care protocols apply.
    • Dental caries (prevention and oral fluoride supplementation): limited to beneficiaries up to age 6 years, subject to Managed Care Protocols, including oral-hygienist consultation.
    • COVID-19 Vaccine: Vaccinations for all eligible beneficiaries in accordance with the Department of Health recommendation.

    NOTE: Please ask the General Practitioner, Gynaecologist or Urologist (whichever is applicable) to submit the wellness consultation claim using the following primary ICD-10 code: Z00.0. If this code is not used, the benefit will be paid from your available Day-to-Day Benefit.

    COVER AND COST

    Lower cost plans offer basic cover while more expensive plans offer more comprehensive cover.

    OMSMAF OFFERS CHOICE!

    Eight plans means we offer our members as much choice as possible.

    Network Plan

    Simple cover with benefits
    Get essential in-hospital cover, basic chronic, wellness and supplementary benefits, as well as basic day-to-day benefits.
    DAY-TO-DAY BENEFITS
     

    • Primary healthcare benefits via Universal Healthcare Network Provider.
    • Annual Flexi Benefit (AFB), subject to R5 820 per beneficiary per benefit year and R9 700 per family per benefit year.
    • Annual Flexi Benefit (AFB) for pathology, radiology, optometry, psychology and auxiliary services.
    • GP consultations.
    • Basic dentistry.
    • Prescribed (acute) Medicines.
    • Specialists consultations.
    • Specified procedures in doctors rooms.
    MANAGED CARE BENEFITS

     

    The Old Mutual Staff Medical Aid Fund aims to identify and manage beneficiaries’ disease risks. The Fund has a number of programmes that form part of the Managed Care approach.

    • Back and Neck Rehabilitation Programme.
    • Oncology Benefit Management Programme.
    • HIV and AIDS Management Programme.
    • Mental Health Programme.
    • Active Disease Risk Management Programme.
    • Mother and Baby Care Programme.
    HOSPITAL BENEFITS

     

    Overall Annual Limit (OAL): R1 000 000 per beneficiary per benefit year (subject to certain sub-limits).

    • UNLIMITED Prescribed Minimum Benefits (PMB).
    • Certain elective procedures, including hip, knee, shoulder and elbow replacements, are not covered, other than in accordance with Prescribed Minimum Benefits.
    • Quro Medical – Hospital at Home.
    SUPPLEMENTARY BENEFITS
     

    • Specialised Radiology R16 100 pfpa (co-payment of R1 500 per scan for non-PMB’s).
    • Utrasound scans (non-pregnancy) R5 480 pfpa.
    • Antenatal visit: R3 450 per pregnancy.
    • Antenatal classes: R1 460 pfpa.
    • Antenatal vitamins as per the approved list and prescription, subject to registration on the Mother and Baby Programme.
    CHRONIC BENEFITS
     

    (Medicine formularly applies.)

    • 27 PMB chronic conditions.
    • Additional 16 non-PMB chronic conditions managed by your network GP.
    MATERNITY BENEFITS
     

    • All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
    • Antenatal classes: R1 460 per family per benefit year.
    • Antenatal visits: R3 450 per pregnancy.
    • Ultrasound scans (pregnancy): Two 2-D scans per beneficiary.
    • Out-of-hospital pathology tests (pregnancy): R2 840 per family per benefit year.
    • Antenatal vitamins: 100% of MMAP or Medicine Price, whichever is the lesser, subject to the prescription from an approved list and included in the Hospital Benefit.
    • A Doula (birthing coach): as part of the in-hospital maternity benefit, subject to a limit of R2 730 per pregnancy for delivery only.
      WELLNESS BENEFITS
       

      • Pharmacy-based health-screening tests: Blood pressure, blood glucose, cholesterol, HIV/AIDS, BMI. One of each screening test per beneficiary per benefit year.
      • Pharmacy-based vaccines: One flu vaccine per beneficiary per benefit year, one pneumococcal vaccine per lifetime.
      • Contraceptive benefit: R3 410 per beneficiary per benefit year. R2 140 sub-limit for oral contraceptives.
      • Non-pharmacy based benefits:
      • One Pap smear, Mammogram, Syphilis and Chlamydia infection screening, limited to 1 test per female beneficiary, including consultation with a Gynaecologist or General Practitioner. (Please note for the Pap smear, Mammogram and Syphilis and Chlamydia screening, only one Gynaecologist consultation per benefit year will be funded from the Screening Benefit.)
      • One prostate specific antigen test per male beneficiary.
      • Colorectal screening, limited to one test per beneficiary per benefit year.
      • One health risk assessment per beneficiary per benefit year for services rendered by a registered healthcare practitioner (such as a General Practitioner). It is very important that your service provider uses the correct ICD-10 code to claim for these benefits.
      • Nutritional assessment and healthy eating plan – Access to Universal network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring.
      • Childhood immunisations – Applicable for children up to the age of 12 years, as per recommendation of the Department of Health.
      • Pre-school eye and hearing screening – For children aged 5 and 6.
      • Hearing screening for newborns up to six weeks.
      • PAED-IQ’s Babyline: A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age registered on the Fund can phone in and get up-to-date child healthcare advice and reassurance.
      • COVID-19 Benefit Package: Any beneficiary who tested positive for COVID-19 will be able to access the following: Pulse oximeter, Nebuliser, Oxygenator, Thermometer, 2 GP consultations and Chest physiotherapy. Pre-authorisation and managed care protocols apply.
      • Dental caries (prevention and oral fluoride supplementation): limited to beneficiaries up to age 6 years, subject to Managed Care Protocols, including oral-hygienist consultation.
      • COVID-19 Vaccine: Vaccinations for all eligible beneficiaries in accordance with the Department of Health recommendation.

      NOTE: Please ask the General Practitioner, Gynaecologist or Urologist (whichever is applicable) to submit the wellness consultation claim using the following primary ICD-10 code: Z00.0. If this code is not used, the benefit will be paid from your available Day-to-Day Benefit.

      Network SELECT Plan

      Simple cover with benefits at a lower cost
      Get all the cover of Network for a more cost-effective monthly contribution, based on a restriction to select hospital providers.

      DAY-TO-DAY BENEFITS
       

      • Primary healthcare benefits via Universal Healthcare Network Provider.
      • Annual Flexi Benefit (AFB), subject to R5 820 per beneficiary per benefit year and R9 700 per family per benefit year.
      • Annual Flexi Benefit (AFB) for pathology, radiology, optometry, psychology and auxiliary services.
      • GP consultations.
      • Basic dentistry.
      • Prescribed (acute) Medicines.
      • Specialists consultations.
      • Specified procedures in doctors rooms.
      MANAGED CARE BENEFITS

       

      The Old Mutual Staff Medical Aid Fund aims to identify and manage beneficiaries’ disease risks. The Fund has a number of programmes that form part of the Managed Care approach.

      • Back and Neck Rehabilitation Programme.
      • Oncology Benefit Management Programme.
      • HIV and AIDS Management Programme.
      • Mental Health Programme.
      • Active Disease Risk Management Programme.
      • Mother and Baby Care Programme.
      HOSPITAL BENEFITS

       

      Overall Annual Limit (OAL): R1 000 000 per beneficiary per benefit year (subject to certain sub-limits).

      • UNLIMITED Prescribed Minimum Benefits (PMB).
      • Certain elective procedures, including hip, knee, shoulder and elbow replacements, are not covered, other than in accordance with Prescribed Minimum Benefits.
      • Quro Medical – Hospital at Home.
      SUPPLEMENTARY BENEFITS
       

      • Specialised Radiology R16 100 pfpa (co-payment of R1 500 per scan for non-PMB’s).
      • Utrasound scans (non-pregnancy) R5 480 pfpa.
      • Antenatal visit: R3 450 per pregnancy.
      • Antenatal classes: R1 460 pfpa.
      • Antenatal vitamins as per the approved list and prescription, subject to registration on the Mother and Baby Programme.
      CHRONIC BENEFITS
       

      (Medicine formularly applies.)

      • 27 PMB chronic conditions.
      • Additional 16 non-PMB chronic conditions managed by your network GP.
      MATERNITY BENEFITS
       

      • All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
      • Antenatal classes: R1 460 per family per benefit year.
      • Antenatal visits: R3 450 per pregnancy.
      • Ultrasound scans (pregnancy): Two 2-D scans per beneficiary.
      • Out-of-hospital pathology tests (pregnancy): R2 840 per family per benefit year.
      • Antenatal vitamins: 100% of MMAP or Medicine Price, whichever is the lesser, subject to the prescription from an approved list and included in the Hospital Benefit.
      • A Doula (birthing coach): as part of the in-hospital maternity benefit, subject to a limit of R2 730 per pregnancy for delivery only.
        WELLNESS BENEFITS
         

        • Pharmacy-based health-screening tests: Blood pressure, blood glucose, cholesterol, HIV/AIDS, BMI. One of each screening test per beneficiary per benefit year.
        • Pharmacy-based vaccines: One flu vaccine per beneficiary per benefit year, one pneumococcal vaccine per lifetime.
        • Contraceptive benefit: R3 410 per beneficiary per benefit year. R2 140 sub-limit for oral contraceptives.
        • Non-pharmacy based benefits:
        • One Pap smear, Mammogram, Syphilis and Chlamydia infection screening, limited to 1 test per female beneficiary, including consultation with a Gynaecologist or General Practitioner. (Please note for the Pap smear, Mammogram and Syphilis and Chlamydia screening, only one Gynaecologist consultation per benefit year will be funded from the Screening Benefit.)
        • One prostate specific antigen test per male beneficiary.
        • Colorectal screening, limited to one test per beneficiary per benefit year.
        • One health risk assessment per beneficiary per benefit year for services rendered by a registered healthcare practitioner (such as a General Practitioner). It is very important that your service provider uses the correct ICD-10 code to claim for these benefits.
        • Nutritional assessment and healthy eating plan – Access to Universal network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring.
        • Childhood immunisations – Applicable for children up to the age of 12 years, as per recommendation of the Department of Health.
        • Pre-school eye and hearing screening – For children aged 5 and 6.
        • Hearing screening for newborns up to six weeks.
        • PAED-IQ’s Babyline: A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age registered on the Fund can phone in and get up-to-date child healthcare advice and reassurance.
        • COVID-19 Benefit Package: Any beneficiary who tested positive for COVID-19 will be able to access the following: Pulse oximeter, Nebuliser, Oxygenator, Thermometer, 2 GP consultations and Chest physiotherapy. Pre-authorisation and managed care protocols apply.
        • Dental caries (prevention and oral fluoride supplementation): limited to beneficiaries up to age 6 years, subject to Managed Care Protocols, including oral-hygienist consultation.
        • COVID-19 Vaccine: Vaccinations for all eligible beneficiaries in accordance with the Department of Health recommendation.

        NOTE: Please ask the General Practitioner, Gynaecologist or Urologist (whichever is applicable) to submit the wellness consultation claim using the following primary ICD-10 code: Z00.0. If this code is not used, the benefit will be paid from your available Day-to-Day Benefit.

        Traditional Plan

        Complete cover
        Get fully comprehensive, unlimited in-hospital cover, comprehensive chronic and supplementary benefits, enhanced wellness benefits and comprehensive day-to-day benefits.

        DAY-TO-DAY BENEFITS

         

        • PMSA is used to pay for day-to-day medical services such as GPs, dentistry, acute medicine etc.
        • Paid from Personal Medical Savings Account at cost; then from PCB at 1 x MSR.
        • Unused PMSA carries over to the new benefit year and becomes accumulated savings.
        • Primary Care Benefit (PCB) is used similar to the PMSA when you’ve run out of PMSA.
        • Any unused PCB does not carry over.
        • PMSA can be used to purchase vitamins.
        • Accumulated Savings can be used for frail care from registered frail care facilities.
        • Members are required to consult with their GP first, to obtain a referral to a specialist.
        • Specialist claims without a referral will have 25% co-payment levied on the total specialist bill. This will exclude the following practice types: Ophthalmologist;  Psychiatrist;  Gynaecologist;  Oncologist;  Haematologist;  Urologist (for lives > 40 years);  Paediatrician (for lives < 2 years).

        E-mail for specialist referral and authorisation: spec.auth@omsmaf.co.za

        MANAGED CARE BENEFITS

         

        Members have access to treatment plans and chronic medication for the medical management of their PMB conditions.

        • Chronic Medicine Benefits.
        • Mental Health Programme.
        • Back and Neck Rehabilitation Programme.
        • Oncology Programme.
        • HIV/AIDS Management Programme.
        • Active Disease Risk Management Programme.
        • Mother and Baby Care Programme.
        HOSPITAL BENEFITS

         

        Unlimited overall annual limit (subject to certain sub-limits)

        • Basic pathology: Subject to the Overall Annual Limit and Managed Care protocols.
        • Basic radiology: Subject to the Overall Annual Limit and Managed Care protocols.
        • Physiotherapy: Subject to the Overall Annual Limit and Managed Care protocols.
        • Quro (home-based monitoring service) Medical benefit. This benefit allows you to return home from hospital sooner. Member can recover in their own home while still being closely monitored 24 hours-a-day by a team of medical professionals.
        SUPPLEMENTARY BENEFITS

         

        (Paid from Risk and not from your Day-to-Day Benefits.)

        • Medical Appliance overall limit of R11 000 pfpa (Comprehensive, paid at 1 x MSR).
        • Foot Orthotics R4 980 pfpa (subject to overall limit).
        • Hearing Aids R19 600 per ear per beneficiary, subject to a co- payment of 10%. Benefit is available every 3 years for beneficiaries under age 7, and every 5 years for beneficiaries older than 7 years.
        • Specialised Radiology R19 900 pfpa (co-payment of R1 500 per scan for non-PMBs)
        • Ultrasound scans (non-pregnancy) R8 150 pfpa.
        • Refractive Procedures sub-limit of R17 500 per beneficiary per benefit year.
        • Maternity Benefits refer to member guide for full benefit structure.
        • Dental implants R16 600 pfpa.
        CHRONIC BENEFITS

         

        Subject to Enhanced Formulary

        • 27 PMB chronic conditions.
        • Additional 34 non-PMB chronic conditions covered up to R14 000 pfpa.
        MATERNITY BENEFITS

         

        • All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
        • Antenatal classes: R2 290 per family per benefit year.
        • Antenatal visits: R5 750 per pregnancy.
        • Ultrasound scans: Two 2-D scans per beneficiary.
        • Out-of-hospital pathology tests: R3 550 per family per benefit year.
        • Antenatal vitamins: 100% of MMAP or Medicine Price, subject to prescription from an approved list and included in the Hospital Benefit.
        • A Doula (birthing coach): as part of the in-hospital maternity benefit, subject to a limit of R2 730 per pregnancy for delivery only.
          WELLNESS BENEFITS
           

          (1 per beneficiary per benefit year)

          • Pharmacy-based health-screening tests: Blood pressure, blood glucose, cholesterol, HIV/AIDS, BMI. One of each screening test per beneficiary per benefit year.
          • Pharmacy-based vaccines: One flu vaccine per beneficiary per benefit year, one pneumococcal vaccine per lifetime.
          • Contraceptive benefit: R3 410 per beneficiary per benefit year. R2 140 sub-limit per beneficiary for oral contraceptives.
          • Non-pharmacy based benefits:
          • One Pap smear, Mammogram, Syphilis and Chlamydia infection screening, limited to 1 test per female beneficiary, including consultation with a Gynaecologist or General Practitioner. (Please note for the Pap smear, Mammogram and Syphilis and Chlamydia screening, only one Gynaecologist consultation per benefit year will be funded from the Screening Benefit.)
          • One prostate test per male beneficiary, as well as colorectal screening, limited to one test per beneficiary per benefit year including the consultation at the GP or gynaecologist (for female beneficiaries) or urologist (for male beneficiaries), paid up to the Medical Scheme Rates for a visit to a GP, gynaecologist, or urologist, plus one health risk assessment per beneficiary per benefit year for services rendered by a registered healthcare practitioner (such as a General Practitioner). It is very important that your service provider uses the correct ICD-10 code to claim for these benefits.
          • Nutritional assessment and healthy eating plan: Access to the Universal Healthcare network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring. An additional assessment for pregnant beneficiaries.
          • Childhood immunisations for children up to the age of 12 years, as per recommendation of the Department of Health.
          • Pre-school eye and hearing screening for children aged 5 and 6.
          • Hearing screening for newborns up to six weeks.
          • PAED-IQ’s Babyline: A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age registered on the Fund can phone in and get up-to-date child healthcare advice and reassurance.
          • Fitness Assessment and Exercise Prescription Benefit: Only available on the Traditional and Traditional Plus Plans, members will have access to the Universal Healthcare network of Biokineticists, who will assess the members’ needs and prescribe a relevant exercise plan that can be filled at a contracted fitness facility. This benefit will be paid from the Wellness Benefit. It is subject to registration on the program and Universal Healthcare protocols.
          • COVID-19 Benefit Package: Any beneficiary who tested positive for COVID-19 will be able to access the following: Pulse oximeter, Nebuliser, Oxygenator, Thermometer, 2 GP consultations, 3 PCR tests and Chest physiotherapy. Pre-authorisation and managed care protocols apply.
          • Dental caries (prevention and oral fluoride supplementation) – limited to beneficiaries up to age 6 years, subject to Managed Care Protocols, including oral-hygienist consultation.
          • COVID-19 Vaccine: Vaccinations for all eligible beneficiaries in accordance with the Department of Health recommendation.

          Traditional SELECT Plan

          Complete cover at a lower cost
          Get all the cover of the Traditional Plan for a more cost-effective monthly contribution based on a restriction to select hospital providers.
          DAY-TO-DAY BENEFITS

           

          • PMSA is used to pay for day-to-day medical services such as GPs, dentistry, acute medicine etc.
          • Paid from Personal Medical Savings Account at cost; then from PCB at 1 x MSR.
          • Unused PMSA carries over to the new benefit year and becomes accumulated savings.
          • Primary Care Benefit (PCB) is used similar to the PMSA when you’ve run out of PMSA.
          • Any unused PCB does not carry over.
          • PMSA can be used to purchase vitamins.
          • Accumulated Savings can be used for frail care from registered frail care facilities.
          • Members are required to consult with their GP first, to obtain a referral to a specialist.
          • Specialist claims without a referral will have 25% co-payment levied on the total specialist bill. This will exclude the following practice types: Ophthalmologist;  Psychiatrist;  Gynaecologist;  Oncologist;  Haematologist;  Urologist (for lives > 40 years);  Paediatrician (for lives < 2 years).

          E-mail for specialist referral and authorisation: spec.auth@omsmaf.co.za

          MANAGED CARE BENEFITS

           

          Members have access to treatment plans and chronic medication for the medical management of their PMB conditions.

          • Chronic Medicine Benefits.
          • Mental Health Programme.
          • Back and Neck Rehabilitation Programme.
          • Oncology Programme.
          • HIV/AIDS Management Programme.
          • Active Disease Risk Management Programme.
          • Mother and Baby Care Programme.
          HOSPITAL BENEFITS

           

          Unlimited overall annual limit (subject to certain sub-limits)

          • Basic pathology: Subject to the Overall Annual Limit and Managed Care protocols.
          • Basic radiology: Subject to the Overall Annual Limit and Managed Care protocols.
          • Physiotherapy: Subject to the Overall Annual Limit and Managed Care protocols.
          • Quro (home-based monitoring service) Medical benefit. This benefit allows you to return home from hospital sooner. Member can recover in their own home while still being closely monitored 24 hours-a-day by a team of medical professionals.
          SUPPLEMENTARY BENEFITS
           

          (Paid from Risk and not from your Day-to-Day Benefits.)

          • Medical Appliance overall limit of R11 000 pfpa (Comprehensive, paid at 1 x MSR).
          • Foot Orthotics R4 980 pfpa (subject to overall limit).
          • Hearing Aids R19 600 per ear per beneficiary, subject to a co- payment of 10%. Benefit is available every 3 years for beneficiaries under age 7, and every 5 years for beneficiaries older than 7 years.
          • Specialised Radiology R19 900 pfpa (co-payment of R1 500 per scan for non-PMBs)
          • Ultrasound scans (non-pregnancy) R8 150 pfpa.
          • Refractive Procedures sub-limit of R17 500 per beneficiary per benefit year.
          • Maternity Benefits refer to member guide for full benefit structure.
          • Dental implants R16 600 pfpa.
          CHRONIC BENEFITS
           

          Subject to Enhanced Formulary

          • 27 PMB chronic conditions.
          • Additional 34 non-PMB chronic conditions covered up to R14 000 pfpa.
          MATERNITY BENEFITS
           

          • All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
          • Antenatal classes: R2 290 per family per benefit year.
          • Antenatal visits: R5 750 per pregnancy.
          • Ultrasound scans: Two 2-D scans per beneficiary.
          • Out-of-hospital pathology tests: R3 550 per family per benefit year.
          • Antenatal vitamins: 100% of MMAP or Medicine Price, subject to prescription from an approved list and included in the Hospital Benefit.
          • A Doula (birthing coach): as part of the in-hospital maternity benefit, subject to a limit of R2 730 per pregnancy for delivery only.
            WELLNESS BENEFITS
             

            (1 per beneficiary per benefit year)

            • Pharmacy-based health-screening tests: Blood pressure, blood glucose, cholesterol, HIV/AIDS, BMI. One of each screening test per beneficiary per benefit year.
            • Pharmacy-based vaccines: One flu vaccine per beneficiary per benefit year, one pneumococcal vaccine per lifetime.
            • Contraceptive benefit: R3 410 per beneficiary per benefit year. R2 140 sub-limit per beneficiary for oral contraceptives.
            • Non-pharmacy based benefits:
            • One Pap smear, Mammogram, Syphilis and Chlamydia infection screening, limited to 1 test per female beneficiary, including consultation with a Gynaecologist or General Practitioner. (Please note for the Pap smear, Mammogram and Syphilis and Chlamydia screening, only one Gynaecologist consultation per benefit year will be funded from the Screening Benefit.)
            • One prostate test per male beneficiary, as well as colorectal screening, limited to one test per beneficiary per benefit year including the consultation at the GP or gynaecologist (for female beneficiaries) or urologist (for male beneficiaries), paid up to the Medical Scheme Rates for a visit to a GP, gynaecologist, or urologist, plus one health risk assessment per beneficiary per benefit year for services rendered by a registered healthcare practitioner (such as a General Practitioner). It is very important that your service provider uses the correct ICD-10 code to claim for these benefits.
            • Nutritional assessment and healthy eating plan: Access to the Universal Healthcare network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring. An additional assessment for pregnant beneficiaries.
            • Childhood immunisations for children up to the age of 12 years, as per recommendation of the Department of Health.
            • Pre-school eye and hearing screening for children aged 5 and 6.
            • Hearing screening for newborns up to six weeks.
            • PAED-IQ’s Babyline: A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age registered on the Fund can phone in and get up-to-date child healthcare advice and reassurance.
            • Fitness Assessment and Exercise Prescription Benefit: Only available on the Traditional and Traditional Plus Plans, members will have access to the Universal Healthcare network of Biokineticists, who will assess the members’ needs and prescribe a relevant exercise plan that can be filled at a contracted fitness facility. This benefit will be paid from the Wellness Benefit. It is subject to registration on the program and Universal Healthcare protocols.
            • COVID-19 Benefit Package: Any beneficiary who tested positive for COVID-19 will be able to access the following: Pulse oximeter, Nebuliser, Oxygenator, Thermometer, 2 GP consultations, 3 PCR tests and Chest physiotherapy. Pre-authorisation and managed care protocols apply.
            • Dental caries (prevention and oral fluoride supplementation) – limited to beneficiaries up to age 6 years, subject to Managed Care Protocols, including oral-hygienist consultation.
            • COVID-19 Vaccine: Vaccinations for all eligible beneficiaries in accordance with the Department of Health recommendation.

            ON A BUDGET?

            Our SELECT Plans offer reduced contribution rates for using selected hospitals.

            CONSIDER YOUR NEEDS

            Does the Plan you are considering offers adequate benefits most suited to you or your families medical needs?

            Traditional Plus Plan

            Full cover and total peace of mind
            The most comprehensive medical cover solution, with the highest day-to-day benefits, all-inclusive, unlimited in-hospital cover, full chronic and supplementary benefits and enhanced wellness benefits.

            DAY-TO-DAY BENEFITS

             

            • PMSA is used to pay for day-to-day medical services such as GPs, dentistry, acute medicine etc.
            • Paid from Personal Medical Savings Account at cost; then from PCB at 3 x MSR.
            • Unused PMSA carries over to the new benefit year and becomes accumulated savings.
            • Primary Care Benefit (PCB) is used similar to the PMSA when you’ve run out of PMSA.
            • Any unused PCB does not carry over.
            • PMSA can be used to purchase vitamins.
            • Accumulated Savings can be used for frail care from registered frail care facilities.
            • Members are required to consult with their GP first, to obtain a referral to a specialist.
            • Specialist claims without a referral will have 25% co-payment levied on the total specialist bill. This will exclude the following practice types: Ophthalmologist;  Psychiatrist;  Gynaecologist;  Oncologist;  Haematologist;  Urologist (for lives > 40 years);  Paediatrician (for lives < 2 years).

            E-mail for specialist referral and authorisation: spec.auth@omsmaf.co.za

            MANAGED CARE BENEFITS

             

            Members have access to treatment plans and chronic medication for the medical management of their PMB conditions.

            • Chronic Medicine Benefits.
            • Mental Health Programme.
            • Back and Neck Rehabilitation Programme.
            • Oncology Programme.
            • HIV/AIDS Management Programme.
            • Active Disease Risk Management Programme.
            • Mother and Baby Care Programme.
            HOSPITAL BENEFITS

             

            Unlimited overall annual limit (subject to certain sub-limits.)

            • Basic pathology: Subject to the Overall Annual Limit and Managed Care protocols.
            • Basic radiology: Subject to the Overall Annual Limit and Managed Care protocols.
            • Physiotherapy: Subject to the Overall Annual Limit and Managed Care protocols.
            • Quro (home-based monitoring service) Medical benefit. This benefit allows you to return home from hospital sooner. Member can recover in their own home while still being closely monitored 24 hours-a-day by a team of medical professionals.
            SUPPLEMENTARY BENEFITS
             

            (Paid from Risk and not from your Day-to-Day Benefits.)

            • Medical Appliance overall limit of R11 000 pfpa (Comprehensive, paid at 1 x MSR)
            • Foot Orthotics R4 980 pfpa (subject to overall limit).
            • Hearing Aids R19 600 per ear per beneficiary, subject to a co- payment of 10%. Benefit is available every 3 years for beneficiaries under age 7, and every 5 years for beneficiaries older than 7 years.
            • Specialised Radiology R19 900 pfpa.
            • Ultrasound scans (non-pregnancy) R8 150 pfpa.
            • Refractive Procedures sub-limit of R17 500 per beneficiary per benefit year.
            • Maternity Benefits refer to member guide for full benefit structure.
            • Dental implants R16 600 pfpa.
            CHRONIC BENEFITS
             

            Subject to Enhanced Formulary

            • 27 PMB chronic conditions.
            • Additional 34 non-PMB chronic conditions covered up to R16 700 pfpa.
            MATERNITY BENEFITS
             

            • All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
            • Antenatal classes: R2 290 per family per benefit year.
            • Antenatal visits: R5 750 per pregnancy.
            • Ultrasound scans: Two 2-D scans per beneficiary.
            • Out-of-hospital pathology tests: R3 550 per family per benefit year.
            • Antenatal vitamins: 100% of MMAP or Medicine Price, subject to prescription from an approved list and included in the Hospital Benefit.
            • A Doula (birthing coach): as part of the in-hospital maternity benefit, subject to a limit of R2 730 per pregnancy for delivery only.
              WELLNESS BENEFITS
               

              (1 per beneficiary per benefit year)

              • Pharmacy-based health-screening tests: Blood pressure, blood glucose, cholesterol, HIV/AIDS, BMI. One of each screening test per beneficiary per benefit year.
              • Pharmacy-based vaccines: One flu vaccine per beneficiary per benefit year, one pneumococcal vaccine per lifetime.
              • Contraceptive benefit: R3 410 per beneficiary per benefit year. R2 140 sub-limit per beneficiary for oral contraceptives.
              • Non-pharmacy based benefits:
              • One Pap smear, Mammogram, Syphilis and Chlamydia infection screening, limited to 1 test per female beneficiary, including consultation with a Gynaecologist or General Practitioner. (Please note for the Pap smear, Mammogram and Syphilis and Chlamydia screening, only one Gynaecologist consultation per benefit year will be funded from the Screening Benefit.)
              • One prostate test per male beneficiary, as well as colorectal screening, limited to one test per beneficiary per benefit year including the consultation at the GP or gynaecologist (for female beneficiaries) or urologist (for male beneficiaries), paid up to the Medical Scheme Rates for a visit to a GP, gynaecologist, or urologist, plus one health risk assessment per beneficiary per benefit year for services rendered by a registered healthcare practitioner (such as a General Practitioner). It is very important that your service provider uses the correct ICD-10 code to claim for these benefits.
              • Nutritional assessment and healthy eating plan: Access to the Universal Healthcare network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring. An additional assessment for pregnant beneficiaries.
              • Childhood immunisations for children up to the age of 12 years, as per recommendation of the Department of Health.
              • Pre-school eye and hearing screening for children aged 5 and 6.
              • Hearing screening for newborns up to six weeks.
              • PAED-IQ’s Babyline: A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age registered on the Fund can phone in and get up-to-date child healthcare advice and reassurance.
              • Fitness Assessment and Exercise Prescription Benefit: Only available on the Traditional and Traditional Plus Plans, members will have access to the Universal Healthcare network of Biokineticists, who will assess the members’ needs and prescribe a relevant exercise plan that can be filled at a contracted fitness facility. This benefit will be paid from the Wellness Benefit. It is subject to registration on the program and Universal Healthcare protocols.
              • COVID-19 Benefit Package: Any beneficiary who tested positive for COVID-19 will be able to access the following: Pulse oximeter, Nebuliser, Oxygenator, Thermometer, 2 GP consultations, 3 PCR tests and Chest physiotherapy. Pre-authorisation and managed care protocols apply.
              • Dental caries (prevention and oral fluoride supplementation) – limited to beneficiaries up to age 6 years, subject to Managed Care Protocols, including oral-hygienist consultation.
              • COVID-19 Vaccine: Vaccinations for all eligible beneficiaries in accordance with the Department of Health recommendation.

              Traditional Plus SELECT Plan

              Full cover at a lower cost
              Get all the cover of Traditional Plus for a more cost-effective monthly contribution based on a restriction to select hospital providers.
              DAY-TO-DAY BENEFITS

               

              • PMSA is used to pay for day-to-day medical services such as GPs, dentistry, acute medicine etc.
              • Paid from Personal Medical Savings Account at cost; then from PCB at 3 x MSR.
              • Unused PMSA carries over to the new benefit year and becomes accumulated savings.
              • Primary Care Benefit (PCB) is used similar to the PMSA when you’ve run out of PMSA.
              • Any unused PCB does not carry over.
              • PMSA can be used to purchase vitamins.
              • Accumulated Savings can be used for frail care from registered frail care facilities.
              • Members are required to consult with their GP first, to obtain a referral to a specialist.
              • Specialist claims without a referral will have 25% co-payment levied on the total specialist bill. This will exclude the following practice types: Ophthalmologist;  Psychiatrist;  Gynaecologist;  Oncologist;  Haematologist;  Urologist (for lives > 40 years);  Paediatrician (for lives < 2 years).

              E-mail for specialist referral and authorisation: spec.auth@omsmaf.co.za

              MANAGED CARE BENEFITS

               

              Members have access to treatment plans and chronic medication for the medical management of their PMB conditions.

              • Chronic Medicine Benefits.
              • Mental Health Programme.
              • Back and Neck Rehabilitation Programme.
              • Oncology Programme.
              • HIV/AIDS Management Programme.
              • Active Disease Risk Management Programme.
              • Mother and Baby Care Programme.
              HOSPITAL BENEFITS

               

              Unlimited overall annual limit (subject to certain sub-limits.)

              • Basic pathology: Subject to the Overall Annual Limit and Managed Care protocols.
              • Basic radiology: Subject to the Overall Annual Limit and Managed Care protocols.
              • Physiotherapy: Subject to the Overall Annual Limit and Managed Care protocols.
              • Quro (home-based monitoring service) Medical benefit. This benefit allows you to return home from hospital sooner. Member can recover in their own home while still being closely monitored 24 hours-a-day by a team of medical professionals.
              SUPPLEMENTARY BENEFITS
               

              (Paid from Risk and not from your Day-to-Day Benefits.)

              • Medical Appliance overall limit of R11 000 pfpa (Comprehensive, paid at 1 x MSR)
              • Foot Orthotics R4 980 pfpa (subject to overall limit).
              • Hearing Aids R19 600 per ear per beneficiary, subject to a co- payment of 10%. Benefit is available every 3 years for beneficiaries under age 7, and every 5 years for beneficiaries older than 7 years.
              • Specialised Radiology R19 900 pfpa.
              • Ultrasound scans (non-pregnancy) R8 150 pfpa.
              • Refractive Procedures sub-limit of R17 500 per beneficiary per benefit year.
              • Maternity Benefits refer to member guide for full benefit structure.
              • Dental implants R16 600 pfpa.
              CHRONIC BENEFITS
               

              Subject to Enhanced Formulary

              • 27 PMB chronic conditions.
              • Additional 34 non-PMB chronic conditions covered up to R16 700 pfpa.
              MATERNITY BENEFITS
               

              • All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
              • Antenatal classes: R2 290 per family per benefit year.
              • Antenatal visits: R5 750 per pregnancy.
              • Ultrasound scans: Two 2-D scans per beneficiary.
              • Out-of-hospital pathology tests: R3 550 per family per benefit year.
              • Antenatal vitamins: 100% of MMAP or Medicine Price, subject to prescription from an approved list and included in the Hospital Benefit.
              • A Doula (birthing coach): as part of the in-hospital maternity benefit, subject to a limit of R2 730 per pregnancy for delivery only.
                WELLNESS BENEFITS
                 

                (1 per beneficiary per benefit year)

                • Pharmacy-based health-screening tests: Blood pressure, blood glucose, cholesterol, HIV/AIDS, BMI. One of each screening test per beneficiary per benefit year.
                • Pharmacy-based vaccines: One flu vaccine per beneficiary per benefit year, one pneumococcal vaccine per lifetime.
                • Contraceptive benefit: R3 410 per beneficiary per benefit year. R2 140 sub-limit per beneficiary for oral contraceptives.
                • Non-pharmacy based benefits:
                • One Pap smear, Mammogram, Syphilis and Chlamydia infection screening, limited to 1 test per female beneficiary, including consultation with a Gynaecologist or General Practitioner. (Please note for the Pap smear, Mammogram and Syphilis and Chlamydia screening, only one Gynaecologist consultation per benefit year will be funded from the Screening Benefit.)
                • One prostate test per male beneficiary, as well as colorectal screening, limited to one test per beneficiary per benefit year including the consultation at the GP or gynaecologist (for female beneficiaries) or urologist (for male beneficiaries), paid up to the Medical Scheme Rates for a visit to a GP, gynaecologist, or urologist, plus one health risk assessment per beneficiary per benefit year for services rendered by a registered healthcare practitioner (such as a General Practitioner). It is very important that your service provider uses the correct ICD-10 code to claim for these benefits.
                • Nutritional assessment and healthy eating plan: Access to the Universal Healthcare network of dieticians for annual assessment, healthy eating plan prescription and regular monitoring. An additional assessment for pregnant beneficiaries.
                • Childhood immunisations for children up to the age of 12 years, as per recommendation of the Department of Health.
                • Pre-school eye and hearing screening for children aged 5 and 6.
                • Hearing screening for newborns up to six weeks.
                • PAED-IQ’s Babyline: A 24/7, paediatric telephone service, whereby parents or caregivers of children from birth to three years of age registered on the Fund can phone in and get up-to-date child healthcare advice and reassurance.
                • Fitness Assessment and Exercise Prescription Benefit: Only available on the Traditional and Traditional Plus Plans, members will have access to the Universal Healthcare network of Biokineticists, who will assess the members’ needs and prescribe a relevant exercise plan that can be filled at a contracted fitness facility. This benefit will be paid from the Wellness Benefit. It is subject to registration on the program and Universal Healthcare protocols.
                • COVID-19 Benefit Package: Any beneficiary who tested positive for COVID-19 will be able to access the following: Pulse oximeter, Nebuliser, Oxygenator, Thermometer, 2 GP consultations, 3 PCR tests and Chest physiotherapy. Pre-authorisation and managed care protocols apply.
                • Dental caries (prevention and oral fluoride supplementation) – limited to beneficiaries up to age 6 years, subject to Managed Care Protocols, including oral-hygienist consultation.
                • COVID-19 Vaccine: Vaccinations for all eligible beneficiaries in accordance with the Department of Health recommendation.

                CONTRIBUTION CALCULATOR

                Choose the plan that suits your pocket with the help of this handy tool.
                You’ve browsed the options available to you as an OMSMAF member, now use the calculator to help make an educated choice on what makes financial sense for you.

                Ready to make a decision?

                Download and email your completed form to membership@omsmaf.co.za or call 0860 100 076 for assistance.

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