Home | PLANS | TRADITIONAL PLUS

TRADITIONAL PLUS

The most comprehensive medical cover solution, with the highest day-to-day benefits, fully unlimited in-hospital cover, all-inclusive chronic and supplementary benefits and standard wellness benefits.

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 140 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: R17 400 per family per benefit year, with a co-payment of R1 500 per authorisation
  • Dental implants: R14 500 per family per benefit year
  • Medical appliances: R9 660 per family per benefit year, subject to approval
  • Foot orthotics: R4 360 per family and included in the appliance limit of R9 660 per family above
  • Hearing aids and repairs:
    • R17 200 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 R15 300 per beneficiary per benefit year
  • Mental Health Programme: R10 500 per beneficiary per benefit year
  • Back and Neck Rehabilitation Programme

CHRONIC BENEFITS

Comprehensive

  • Non-PMB conditions: A limit of R14 600 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 010 per family per benefit year
  • Antenatal visits: R5 030 per pregnancy
  • Ultrasound scans: Two 2-D scans per beneficiary
  • Out-of-hospital pathology tests: R3 110 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: R2 990 per beneficiary per benefit year. R1 880 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
  • 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.

Home | PLANS | TRADITIONAL PLUS

TRADITIONAL PLUS

The most comprehensive medical cover solution, with the highest day-to-day benefits, fully unlimited in-hospital cover, all-inclusive chronic and supplementary benefits and standard wellness benefits.

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 140 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: R17 400 per family per benefit year, with a co-payment of R1 500 per authorisation
  • Dental implants: R14 500 per family per benefit year
  • Medical appliances: R9 660 per family per benefit year, subject to approval
  • Foot orthotics: R4 360 per family and included in the appliance limit of R9 660 per family above
  • Hearing aids and repairs:
    • R17 200 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 R15 300 per beneficiary per benefit year
  • Mental Health Programme: R10 500 per beneficiary per benefit year
  • Back and Neck Rehabilitation Programme

CHRONIC BENEFITS

Comprehensive

  • Non-PMB conditions: A limit of R14 600 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 010 per family per benefit year
  • Antenatal visits: R5 030 per pregnancy
  • Ultrasound scans: Two 2-D scans per beneficiary
  • Out-of-hospital pathology tests: R3 110 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: R2 990 per beneficiary per benefit year. R1 880 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
  • 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.