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  4.  | TRADITIONAL SELECT

TRADITIONAL SELECT

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

DAY-TO-DAY BENEFITS

Comprehensive

  • At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to-Day limit (thereafter, accumulated savings can be used):
    • GP and specialist consultations
    • Specified procedures in general practitioners’ and specialists’ rooms
    • Pathology
    • Radiology
    • Acute medicine paid at 100% of MMAP or medicine price, whichever is the lesser.
    • Pharmacy-Advised Therapy (PAT)
    • Basic and advanced Dentistry
    • Psychology
    • Physiotherapy
    • Auxiliary services
    • Optometry

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)
  • Sub-limits apply
  • 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 R12 800 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
  • Doula (birthing coach) as part of maternity benefits in hospital: R2 500 per pregnancy

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
  • 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
  • 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

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 SELECT

TRADITIONAL SELECT

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

DAY-TO-DAY BENEFITS

Comprehensive

  • At 100% of cost from PMSA, then at 1 x MSR from PCB, up to overall Day-to-Day limit (thereafter, accumulated savings can be used):
  • GP consultations
  • uConsult Virtual Consultation
  • Specialist consultations (subject to GP referral and authorization)
  • Specified procedures in general practitioners’ and specialists’ rooms
  •  Pathology
  •  Radiology
  • Acute medicine paid at 100% of MMAP or medicine price, whichever is the lesser.
  • Vitamins paid at 100% of cost or Medicine Price whichever is the lesser, paid from PMSA only and excluded from PCB.
  • Pharmacy-Advised Therapy (PAT)
  • Basic and advanced Dentistry
  •  Psychology
  •  Physiotherapy
  • Auxiliary services
  • Optometry

MANAGED CARE BENEFITS

  • 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)
  • Sub-limits apply
  • 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 500 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 700 per 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 R13 400 per family per benefit year, subject to chronic medicine benefit, Chronic Disease Lists and approval.
  • PMB conditions:Unlimited, subject to the Universal Healthcare comprehensive formulary and approval.

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
  • Doula (birthing coach) as part of maternity benefits in hospital: subject to a limit of R2 610 per pregnancy, specifically for the confinement (delivery). No post-natal follow-ups.

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
    • 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
    • Health Risk assessment – limited to 1 test per beneficiary per benefit year. Only for services rendered by a registered healthcare practitioner (for example, 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: 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.

    IMPORTANT: 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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