Plans

• 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

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 710 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.

• Specialised Radiology R17 900 pfpa (co-payment of R1 500 per scan for non-PMBs).
• Ultrasound scans (non-pregnancy): R6 080 per family.
  

Subject to restrictive formulary.

• 27 PMB chronic conditions PLUS 10 additional DTP chronic conditions
• Additional 6 non-PMB chronic conditions covered up to R7 880 pfpa.

• 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 R3 030 per pregnancy, specifically for the confinement (delivery). No post-natal/out-of-hospital follow-ups.

• 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 780per beneficiary per benefit year. R2 370 sub-limit for oral contraceptives.
• Non-pharmacy based benefits:
  *NEW! One consultation per beneficiary per benefit year with a GP paid at 100% of MSR or a Gynaecologist or a Urologist or a Dermatologist paid at 200% of MSR from the Wellness benefit for any of the following non-pharmacy screenings 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
• 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.
• Dermatologist Consultation – limited to 1 consultation for cancer screening per beneficiary every 2 years, for beneficiaries 35-years and older
• Bone Density Scan – limited to 1 bone density scan per beneficiary, per annum
• *NEW! HPV vaccine has been extended to all females up to the age of 26 years.

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.

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.

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.

• Specialised Radiology R17 900 pfpa (co-payment of R1 500 per scan for non-PMB’s).
• Utrasound scans (non-pregnancy) R6 080 pfpa.
• Antenatal visit: 8 visits per pregnancy, paid at MSR.
• Antenatal classes: R1 620 pfpa.
• Antenatal vitamins as per the approved list and prescription, subject to registration on the Mother and Baby Programme.

(Medicine formularly applies.)

• 27 PMB chronic conditions PLUS 10 additional DTP chronic conditions.
• Additional 6 non-PMB chronic conditions managed by your network GP.

• All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
• Antenatal classes: R1 620 per family per benefit year.
• Antenatal visits: 8 visits per pregnancy, paid at MSR.
• Ultrasound scans (pregnancy): Two 2-D scans per beneficiary.
• Out-of-hospital pathology tests (pregnancy): R3 150 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 R3 030 per pregnancy, specifically for the confinement (delivery).

• 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 780 per beneficiary per benefit year. R2 370 sub-limit for oral contraceptives.
• Non-pharmacy based benefits:
• *NEW! One consultation per beneficiary per benefit year with a GP paid at 100% of MSR or a Gynaecologist or a Urologist or a Dermatologist paid at 200% of MSR from the Wellness benefit for any of the following non-pharmacy screenings 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.
• Dermatologist Consultation – limited to 1 consultation for cancer screening per beneficiary every 2 years, for beneficiaries 35-years and older.
• Bone Density Scan – limited to 1 bone density scan per beneficiary, per annum.
• Over-the-Counter medication available at your Universal Healthcare Pharmacy Network, subject to Network formulary, MMAP and limited to R400 per family and R110 per event.
• *NEW! HPV vaccine has been extended to all females up to the age of 26 years.

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.

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.

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.

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

• Medical Appliance overall limit of R12 200 pfpa (Comprehensive, paid at 1 x MSR).
• Foot Orthotics R5 520 pfpa (subject to overall limit).
• Hearing Aids R21 700 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 R21 000 pfpa (co-payment of R1 500 per scan for non-PMBs)
• Ultrasound scans (non-pregnancy) R9 040 pfpa.
• Refractive Procedures sub-limit of R19 400 per beneficiary per benefit year.
• Maternity Benefits refer to member guide for full benefit structure.
• Dental implants R18 400 pfpa.

Subject to Enhanced Formulary

• 27 PMB chronic conditions PLUS 10 additional DTP chronic conditions.
• Additional 27 non-PMB chronic conditions covered up to R15 500 pfpa.

• All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
• Antenatal classes: R2 540 per family per benefit year.
• Antenatal visits: 12 visits per pregnancy, paid at MSR.
• Ultrasound scans: Two 2-D scans per beneficiary.
• Out-of-hospital pathology tests: R3 940 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 R3 030per pregnancy for delivery only.

(1 per beneficiary per benefit year)

*NEW! One consultation per beneficiary per benefit year with a GP paid at 100% of MSR or a Gynaecologist or a Urologist or a Dermatologist paid at 200% of MSR from the Wellness benefit for any of the following non-pharmacy screenings 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 780 per beneficiary per benefit year. R2 370 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.  *NEW! HPV vaccine has been extended to all females up to the age of 26 years.
• 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.
• Dermatologist Consultation – limited to 1 consultation for cancer screening per beneficiary every 2 years, for beneficiaries 35-years and older
• Bone Density Scan – limited to 1 bone density scan per beneficiary, per annum

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.

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.

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

• Medical Appliance overall limit of R11 600 pfpa (Comprehensive, paid at 3 x MSR)
• Foot Orthotics R5 260 pfpa (subject to overall limit).
• Hearing Aids R20 700 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 R21 000 pfpa.
• Ultrasound scans (non-pregnancy) R8 610 pfpa.
• Refractive Procedures sub-limit of R18 500 per beneficiary per benefit year.
• Maternity Benefits refer to member guide for full benefit structure.
• Dental implants R17 500 pfpa.

Subject to Enhanced Formulary

• 27 PMB chronic conditions PLUS 10 additional DTP chronic conditions.
• Additional 27 non-PMB chronic conditions covered up to R17 700 pfpa.

• All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
• Antenatal classes: R2 420 per family per benefit year.
• Antenatal visits: 12 visits per pregnancy, paid at MSR.
• Ultrasound scans: Two 2-D scans per beneficiary.
• Out-of-hospital pathology tests: R3 750 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 890 per pregnancy for delivery only.

(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 600 per beneficiary per benefit year. R2 260 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.
• Dermatologist Consultation – limited to 1 consultation for cancer screening per beneficiary every 2 years, for beneficiaries 35-years and older
• Bone Density Scan – limited to 1 bone density scan per beneficiary, per annum