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  4.  | TRADITIONAL PLUS SELECT

TRADITIONAL PLUS SELECT

The most comprehensive medical cover solution, with the highest day-to-day benefits, fully comprehensive, unlimited in-hospital cover, comprehensive chronic and supplementary benefits and standard wellness benefits. Get all this cover at a lower cost based on a restriction to select hospital providers.

DAY-TO-DAY BENEFITS

Very comprehensive: paid up to 3 x MSR

  • Primary Care Benefit Limit is dependent on income band and family size
  • At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to-Day limit (thereafter, accumulated savings can be used):
    • GPs and specialists
    • Specified doctor’s room procedures
    • Dentistry
    • Radiology
    • Pathology
    • Psychology
    • Auxiliary services
    • Optical benefits (eye tests, spectacles, frames, contact lenses and readers (including fitting consultation for contact lenses)
  • Prescribed (acute) Medicines: At 100% of MMAP or medicine price, whichever is the lesser, from PMSA. Once PMSA is depleted, from PCB at 100% of MMAP or medicine price, whichever is the lesser. Thereafter, accumulated savings can be used
  • Pharmacy-Advised Therapy (PAT): At 100% of MMAP or medicine price, whichever is the lesser, from PMSA. Once PMSA is depleted, from PCB at 100% of MMAP or medicine price, whichever is the lesser. (Medicine exclusion list may apply.) Thereafter, accumulated savings can be used

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

  • Comprehensive with unlimited overall annual limit (subject to certain sub-limits)
  • Unlimited Prescribed Minimum Benefits (PMB) if obtained from a Designated Service Provider (DSP)
  • Oncology covered within ICON Enhanced Protocols (higher benefit sub-limit)

Note: Under the SELECT Plan, members’ choice of hospitals is restricted

SUPPLEMENTARY BENEFITS

Comprehensive, paid at 1 x MSR

  • Maternity benefits
  • Ultrasound scans in and out of hospital (other than for pregnancy) combined benefit limit: R7 480 per family per benefit year
  • Specialised Radiology in and out of hospital (including MRI, CT and Radio-isotope Scans and Nuclear Medicine) – combined benefit limit: R18 200 per family per benefit year, with a co-payment of R1 500 per authorisation
  • Dental implants: R15 200 per family per benefit year
  • Medical appliances: R10 100 per family per benefit year, subject to approval
  • Foot orthotics: R4 570 per family and included in the appliance limit of R10 100 per family above
  • Hearing aids and repairs:
    • R18 000 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.
    • The benefit excludes consultations and associated tests
  • Refractive procedures: 1 x MSR or cost, whichever is the lesser, up to a sublimit of R16 000 per beneficiary per benefit year
  • Mental Health Programme: R11 000 per beneficiary per benefit year
  • Back and Neck Rehabilitation Programme

CHRONIC BENEFITS

Comprehensive

  • Non-PMB conditions: A limit of R15 300 per family per benefit year, subject to chronic medicine benefit, chronic disease lists and approval
  • PMB conditions: Universal Healthcare Comprehensive Formulary will apply

MATERNITY BENEFITS

  • All pregnant beneficiaries have to register on the Mother and Baby Care Programme
  • Antenatal classes: R2 100 per family per benefit year
  • Antenatal visits: R5 270 per pregnancy
  • Ultrasound scans: Two 2-D scans per beneficiary
  • Out-of-hospital pathology tests: R3 260 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

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
  • 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 the 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.

  1. Home
  2.  | 
  3. PLANS
  4.  | TRADITIONAL PLUS SELECT

TRADITIONAL PLUS SELECT

The most comprehensive medical cover solution, with the highest day-to-day benefits, fully comprehensive, unlimited in-hospital cover, comprehensive chronic and supplementary benefits and standard wellness benefits. Get all this cover at a lower cost based on a restriction to select hospital providers.

DAY-TO-DAY BENEFITS

Very comprehensive: paid up to 3 x MSR

  • Primary Care Benefit Limit is dependent on income band and family size
  • At 100% of cost from PMSA, then at 3 x MSR from PCB, up to overall Day-to-Day limit (thereafter, accumulated savings can be used):
  • GP Consultation
  • Virtual Consultations covered by the Fund
  • Specialist’s consultations (subject to a GP referral and authorisation)
  • Specified doctor’s room procedures
  • Dentistry
  • Radiology
  • Pathology
  • Psychology
  • Auxiliary services
  • Optical benefits (eye tests, spectacles, frames, contact lenses and readers (including fitting consultation for contact lenses)
    • Prescribed (acute) Medicines: At 100% of MMAP or medicine price, whichever is the lesser, from PMSA. Once PMSA is depleted, from PCB at 100% of MMAP or medicine price, whichever is the lesser. Thereafter, accumulated savings can be used
    • Vitamins paid at 100% of cost or Medicine Price whichever is the lesser, paid from PMSA only and excluded from PCB. (refer to page 56 for more information).
    • Pharmacy-Advised Therapy (PAT): At 100% of MMAP or medicine price, whichever is the lesser, from PMSA. Once PMSA is depleted, from PCB at 100% of MMAP or medicine price, whichever is the lesser. (Medicine exclusion list may apply.) Thereafter, accumulated savings can be used

    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

      • Comprehensive with unlimited overall annual limit (subject to certain sub-limits)
      • Unlimited Prescribed Minimum Benefits (PMB) if obtained from a Designated Service Provider (DSP)
      • Oncology covered within ICON Enhanced Protocols (higher benefit sub-limit)
      • Quro Medical – The technology-enabled Hospital at Home (HAH) gives patients the option to receive active   treatment for a specified period at home instead of a general hospital ward, without compromising on the quality of care. Subject to referral from treating doctor.

      Note: Under the SELECT Plan, members’ choice of hospitals is restricted

      SUPPLEMENTARY BENEFITS

      Comprehensive paid at 1 x MSR

      • Maternity benefits
      • Ultrasound scans in and out of hospital (other than for pregnancy) combined benefit limit: R7 800 per family per benefit year
      • Specialised Radiology in and out of hospital (including MRI, CT, and Radio-isotope Scans and Nuclear Medicine) – combined benefit limit: R19 000 per family per benefit year, with a co-payment of R1 500 per authorisation
      • Dental implants: R15 900 per family per benefit year
      • Medical appliances: R10 500 per family per benefit year, subject to approval
      • Foot orthotics: R4 770 per family and included in the appliance limit of R10 100 per family above
      • Hearing aids and repairs:
        • R18 800 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.
        • The benefit excludes consultations and associated tests
      • Refractive procedures: 1 x MSR or cost, whichever is the lesser, up to a sublimit of R16 700per beneficiary per benefit year
      • Mental Health Programme: R11 500 per beneficiary per benefit year
      • Back and Neck Rehabilitation Programme

      CHRONIC BENEFITS

      Comprehensive

      • Non-PMB conditions: A limit of R16 000 per family per benefit year, subject to chronic medicine benefit, chronic disease lists and approval
      • PMB conditions: Universal Healthcare Comprehensive Formulary will apply

      MATERNITY BENEFITS

      • All pregnant beneficiaries have to register on the Mother and Baby Care Programme
      • Antenatal classes: R2 190 per family per benefit year
      • Antenatal visits: R5 500 per pregnancy
      • Ultrasound scans: Two 2-D scans per beneficiary
      • Out-of-hospital pathology tests: R3 400 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

      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 260 per beneficiary per benefit year. R2 050 sub-limit per beneficiary for oral contraceptives.
        • Non-pharmacy based benefits consist of one pap smear and mammogram per female beneficiary per benefit year and 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 – see the green note on page 65 for more information.
        • 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.
        • *NEW! 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.
        • *NEW! 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.

        *COVID-19 Vaccine: 1 vaccination per eligible adult beneficiary.

        WANT TO KNOW MORE?

        Click here for the full membership guide.

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