Home | PLANS | 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

  • 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 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 R12 200 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 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

  • 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 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 R12 200 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.