

Full cover and total peace of mind
The most comprehensive medical cover solution, with the highest day-to-day benefits, all-inclusive, unlimited in-hospital cover, full chronic and supplementary benefits and enhanced wellness benefits.
Day-to-day Benefits
- PMSA is used to pay for day-to-day medical services such as GPs, dentistry, acute medicine etc.
- Paid from Personal Medical Savings Account at cost; then from PCB at 3 x MSR.
- Unused PMSA carries over to the new benefit year and becomes accumulated savings.
- Primary Care Benefit (PCB) is used similar to the PMSA when you’ve run out of PMSA.
- Any unused PCB does not carry over.
- PMSA can be used to purchase vitamins.
- Accumulated Savings can be used for frail care from registered frail care facilities.
- Members are required to consult with their GP first, to obtain a referral to a specialist.
- Specialist claims without a referral will have 25% co-payment levied on the total specialist bill. This will exclude the following practice types: Ophthalmologist; Psychiatrist; Gynaecologist; Oncologist; Haematologist; Urologist (for lives > 40 years); Paediatrician (for lives < 2 years).
E-mail for specialist referral and authorisation: spec.auth@omsmaf.co.za
Managed Care Benefits
Members have access to treatment plans and chronic medication for the medical management of their PMB conditions.
- Chronic Medicine Benefits.
- Mental Health Programme.
- Back and Neck Rehabilitation Programme.
- Oncology Programme.
- HIV/AIDS Management Programme.
- Active Disease Risk Management Programme.
- Mother and Baby Care Programme.
Hospital Benefits
Unlimited overall annual limit (subject to certain sub-limits.)
- Basic pathology: Subject to the Overall Annual Limit and Managed Care protocols.
- Basic radiology: Subject to the Overall Annual Limit and Managed Care protocols.
- Physiotherapy: Subject to the Overall Annual Limit and Managed Care protocols.
- Quro (home-based monitoring service) Medical benefit. This benefit allows you to return home from hospital sooner. Member can recover in their own home while still being closely monitored 24 hours-a-day by a team of medical professionals.
Supplementary Benefits
(Paid from Risk and not from your Day-to-Day Benefits.)
- Medical Appliance overall limit of R11 600 pfpa. (Comprehensive, paid at 3 x MSR)
- Foot Orthotics R5 260 pfpa (subject to overall limit).
- Hearing Aids R20 700 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.
- Specialised Radiology R21 000 pfpa.
- Ultrasound scans (non-pregnancy) R8 610 pfpa.
- Refractive Procedures sub-limit of R18 500 per beneficiary per benefit year.
- Maternity Benefits refer to member guide for full benefit structure.
- Dental implants R17 500 pfpa.
Maternity Benefits
- All pregnant beneficiaries have to register on the Mother and Baby Care Programme.
- Antenatal classes: R2 420 per family per benefit year.
- Antenatal visits: 12 visits per pregnancy, paid at MSR.
- Ultrasound scans: Two 2-D scans per beneficiary.
- Out-of-hospital pathology tests: R3 750 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.
- A Doula (birthing coach): as part of the in-hospital maternity benefit, subject to a limit of R2 890 per pregnancy for delivery only.
Chronic Benefits
Subject to Enhanced Formulary
- 27 PMB chronic conditions PLUS 10 additional DTP chronic conditions.
- Additional 27 non-PMB chronic conditions covered up to R17 700 pfpa.
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 600 per beneficiary per benefit year. R2 260 sub-limit per beneficiary for oral contraceptives.
- Non-pharmacy based benefits:
- One Pap smear, Mammogram, Syphilis and Chlamydia infection screening, limited to 1 test per female beneficiary, including consultation with a Gynaecologist or General Practitioner. (Please note for the Pap smear, Mammogram and Syphilis and Chlamydia screening, only one Gynaecologist consultation per benefit year will be funded from the Screening Benefit.)
- 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.
- 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: 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.
- 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.
- Dental caries (prevention and oral fluoride supplementation) – limited to beneficiaries up to age 6 years, subject to Managed Care Protocols, including oral-hygienist consultation.
- COVID-19 Vaccine: Vaccinations for all eligible beneficiaries in accordance with the Department of Health recommendation.
- Dermatologist Consultation – limited to 1 consultation for cancer screening per beneficiary every 2 years, for beneficiaries 35-years and older.
- Bone Density Scan – limited to 1 bone density scan per beneficiary, per annum.
What are my monthly contributions?
Offers Comprehensive Benefits for a variety of Healthcare Services including Hospital Benefits, Day-to-day, a wide-range of Chronic conditions, an extensive Supplementary Benefit and Wellness Screenings.
Ready to make a decision?
Download and email your completed form to
membership@omsmaf.co.za or call 0860 100 076 for assistance.