PLANS | NETWORK SELECT

NETWORK SELECT

A simple cover solution with added benefits, that includes essential in-hospital cover, basic chronic, wellness, and supplementary benefits, as well as basic day-to-day benefits. Get all this cover at a lower cost 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 340 per beneficiary per benefit year and R8 900 per family per benefit year
  • Annual Flexi Benefit (AFB) for pathology, radiology, optometry and auxiliary services
  • GPs and Specialists
  • Specified doctor’s room procedures
  • Basic Dentistry
  • Radiology
  • Pathology
  • Psychology subject to AFB
  • Prescribed (acute) Medicines
  • Auxiliary services subject to AFB
  • Optical benefits

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

HOSPITAL BENEFITS

Overall Annual Limit (OAL): R500 000 per beneficiary per benefit year

  • R1 000 000 per family per benefit year (subject to certain sub-limits)
  • Oncology covered within ICON Essential Protocols
    • Under the SELECT Plan, members’ choice of hospitals is restricted
  • Sub-limits apply:
    • Basic pathology: R18 900 per family per benefit year
    • Basic radiology: R25 400 per family per benefit year
    • Physiotherapy: R5 550 per family per benefit year
  • Unlimited Prescribed Minimum Benefits (PMB) is obtained from a Designated Service Provider (DSP)

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

  • Ultrasound scans in and out of hospital (excluding maternity)
  • Specialised Radiology in and out of hospital

CHRONIC BENEFITS

Non-PMB conditions:

  • Subject to the Universal Healthcare Network Formulary approval and Chronic Medicine Management
  • Benefit for Acne, Allergic rhinitis, Cardiac Arrhythmia, Depression, Gout, Female Hormone Replacement Therapy, Migraine and Osteoarthritis
  • In addition, the Fund offers cover for Chronic Hepatitis, Macular Degeneration and Oedema, Anxiety and Post-Traumatic Stress Disorder
  • Preauthorised by Universal Healthcare

PMB Conditions:

  • Unlimited subject to Universal Healthcare Network Formulary and approval
  • Preauthorised by Universal Healthcare Chronic Medicine Management

MATERNITY BENEFITS

  • All pregnant beneficiaries have to register on the Mother and Baby Care Programme
  • If you are on the Network (including SELECT) or Hospital Plan, you will not have additional benefits, but you will receive educational support and relevant contact information
  • Ultrasound scans: Two 2D scans per pregnancy at Universal Healthcare Network GP, or referral by Universal Healthcare Network GP to a radiologist
  • Members on the Network (including SELECT) Plans may visit a Universal Healthcare GP for the management of their pregnancy
  • Out-of-hospital pathology tests (pregnancy) – Basic blood tests, if requested by Universal Healthcare Network GP and on the approved tariff list

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 (available from Clicks, Dis-Chem and Pick n Pay Pharmacy clinics)
  • Contraceptive benefit: R3 130 per beneficiary per benefit year. R1 970 sub-limit for oral contraceptives. (Products must be prescribed for contraception and not for the treatment of acne or skin conditions, unless otherwise specified as per managed care protocols.) The cost of a visit to a General Practitioner or gynaecologist will not be covered under this benefit.
  • Non-pharmacy based benefits:
    • One pap smear and mammogram per female beneficiary per benefit year
    • One prostate 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 to 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

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 Benefits.

WANT TO KNOW MORE?

Click here for the full membership guide.

PLANS | NETWORK SELECT

NETWORK SELECT

A simple cover solution with added benefits, that includes essential in-hospital cover, basic chronic, wellness, and supplementary benefits, as well as basic day-to-day benefits. Get all this cover at a lower cost 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 340 per beneficiary per benefit year and R8 900 per family per benefit year
  • Annual Flexi Benefit (AFB) for pathology, radiology, optometry and auxiliary services
  • GPs and Specialists
  • Specified doctor’s room procedures
  • Basic Dentistry
  • Radiology
  • Pathology
  • Psychology subject to AFB
  • Prescribed (acute) Medicines
  • Auxiliary services subject to AFB
  • Optical benefits

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

HOSPITAL BENEFITS

Overall Annual Limit (OAL): R500 000 per beneficiary per benefit year

  • R1 000 000 per family per benefit year (subject to certain sub-limits)
  • Oncology covered within ICON Essential Protocols
    • Under the SELECT Plan, members’ choice of hospitals is restricted
  • Sub-limits apply:
    • Basic pathology: R18 900 per family per benefit year
    • Basic radiology: R25 400 per family per benefit year
    • Physiotherapy: R5 550 per family per benefit year
  • Unlimited Prescribed Minimum Benefits (PMB) is obtained from a Designated Service Provider (DSP)

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

  • Ultrasound scans in and out of hospital (excluding maternity)
  • Specialised Radiology in and out of hospital

CHRONIC BENEFITS

Non-PMB conditions:

  • Subject to the Universal Healthcare Network Formulary approval and Chronic Medicine Management
  • Benefit for Acne, Allergic rhinitis, Cardiac Arrhythmia, Depression, Gout, Female Hormone Replacement Therapy, Migraine and Osteoarthritis
  • In addition, the Fund offers cover for Chronic Hepatitis, Macular Degeneration and Oedema, Anxiety and Post-Traumatic Stress Disorder
  • Preauthorised by Universal Healthcare

PMB Conditions:

  • Unlimited subject to Universal Healthcare Network Formulary and approval
  • Preauthorised by Universal Healthcare Chronic Medicine Management

MATERNITY BENEFITS

  • All pregnant beneficiaries have to register on the Mother and Baby Care Programme
  • If you are on the Network (including SELECT) or Hospital Plan, you will not have additional benefits, but you will receive educational support and relevant contact information
  • Ultrasound scans: Two 2D scans per pregnancy at Universal Healthcare Network GP, or referral by Universal Healthcare Network GP to a radiologist
  • Members on the Network (including SELECT) Plans may visit a Universal Healthcare GP for the management of their pregnancy
  • Out-of-hospital pathology tests (pregnancy) – Basic blood tests, if requested by Universal Healthcare Network GP and on the approved tariff list

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 (available from Clicks, Dis-Chem and Pick n Pay Pharmacy clinics)
  • Contraceptive benefit: R3 130 per beneficiary per benefit year. R1 970 sub-limit for oral contraceptives. (Products must be prescribed for contraception and not for the treatment of acne or skin conditions, unless otherwise specified as per managed care protocols.) The cost of a visit to a General Practitioner or gynaecologist will not be covered under this benefit.
  • Non-pharmacy based benefits:
    • One pap smear and mammogram per female beneficiary per benefit year
    • One prostate 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 to 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

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 Benefits.

WANT TO KNOW MORE?

Click here for the full membership guide.

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