Cape Medical Premium medical aid plan: 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

Premium
2018 Costs:
Total Cost pm:

Main member:

R

Adult:

R

Child:

R
2019 Costs:
Total Cost pm:

Main member:

R
(%)

Adult:

R

Child:

R
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In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Premium
Scheme Benefits: Gap Benefits:
Specialists: 2018 benefits coming soon. 2017 benefits:
  • Up to 500% of scheme rate
  • In case of admission related to accident:
    • R300 per day, for days 1-13
    • R600 per day for days 14-20
    • R1,200 per day for days 21-30
Hospital Choice: 2018 benefits coming soon. 2017 benefits:
  • Unlimited for non PMBs
  • PMBs: State or simialar facility, nominated by scheme
Specialised Radiology: 2018 benefits coming soon. 2017 benefits:
  • R10,220 per person with a R1,500 co-payment, in and out of hospital
Supplementary Services: (Physio, etc) 2018 benefits coming soon. 2017 benefits:
  • 100% scheme rate
Transplants: 2018 benefits coming soon. 2017 benefits:
  • PMB level of care
Co-payments: 2018 benefits coming soon. 2017 benefits:
  • Arthroscopy, appendectomy, inguinal hernia repair, gynaecological procedures, urology procedures, umbilical hernia repair, incisional hernia repair, ventral hernia repair, colectomy, colonoscopy, gastroscopy, hysteroscopy, sympathectomy, vaginal hysterectomy, cystoscopy: R1,000 co-payment
  • Gap covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Alternatives to hospitals: 2018 benefits coming soon. 2017 benefits:
  • PMBs only
Casualty: 2018 benefits coming soon. 2017 benefits:
  • No benefit, unless PMB
Other: n/a
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

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Our quote will include the right gap cover for this plan

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Premium
Scheme Benefits Gap benefits
Main: Adult: Child:
General info:
GP consultations: 2018 benefits coming soon. 2017 benefits:
  • GP consult: One per person
  • Paediatric consults: R 1,655 per child
Childcare:
  • No extra benefit available
Specialists consultations: 2018 benefits coming soon. 2017 benefits:
  • No benefit, unless PMB
Pathology: 2018 benefits coming soon. 2017 benefits:
  • Covered if Lancet or Pathcare is used
General radiology: 2018 benefits coming soon. 2017 benefits:
  • No benefit, unless PMB
Specialised radiology: 2018 benefits coming soon. 2017 benefits:
  • R10,220 per person with a R1,500 co-payment, in and out of hospital
Supplementary Services: (Physio, etc) 2018 benefits coming soon. 2017 benefits:
  • No benefit, unless PMB

No phone calls!
Our quote will include the right gap cover for this plan

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MATERNITY BENEFITS:
Premium
Scheme Benefits Gap benefits
Hospital stay: 2018 benefits coming soon. 2017 benefits:
  • 200% scheme rate
  • Elective caesarean: no benefit
Consultations: 2018 benefits coming soon. 2017 benefits:
  • Consults: R1,995 per family, including scans. Paid by scheme.
Scans: 2018 benefits coming soon. 2017 benefits:
  • R1,995 per family, including consults

No phone calls!
Our quote will include the right gap cover for this plan

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CANCER (ONCOLOGY):
Premium
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital): 2018 benefits coming soon. 2017 benefits:
  • PMBs only, at state or similar facilities
  • Subject to SAOC Tier 1 treatment guidelines

No phone calls!
Our quote will include the right gap cover for this plan

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DENTISTRY:
Premium
Scheme Benefits Gap benefits
Dentistry: 2018 benefits coming soon. 2017 benefits:
  • No benefit, unless PMB
Orthodontics: 2018 benefits coming soon. 2017 benefits:
  • No benefit
Maxillo Facial Surgery: 2018 benefits coming soon. 2017 benefits:
  • 120% scheme rate

No phone calls!
Our quote will include the right gap cover for this plan

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MEDICATION:
Premium
Scheme Benefits Gap benefits
Chronic: 2018 benefits coming soon. 2017 benefits:
  • No. of chronic conditions covered: 27 CDLs and PMBs
Acute (presrcibed) medication: 2018 benefits coming soon. 2017 benefits:
  • No benefit
Over-the-counter: 2018 benefits coming soon. 2017 benefits:
  • No benefit
Birth Control: 2018 benefits coming soon. 2017 benefits:
  • No benefit
On Discharge: 2018 benefits coming soon. 2017 benefits:
  • No benefit
Biological:

No phone calls!
Our quote will include the right gap cover for this plan

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OPTOMETRY:
Premium
Scheme Benefits Gap benefits
Optometry: 2018 benefits coming soon. 2017 benefits:
  • No benefit

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Our quote will include the right gap cover for this plan

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MENTAL HEALTH:
Premium
Scheme Benefits Gap benefits
In-hospital: 2018 benefits coming soon. 2017 benefits:
  • PMBs only, at state or similar facilities
Out-of-hospital: 2018 benefits coming soon. 2017 benefits:
  • PMBs only, at state or similar facilities
Trauma:

No phone calls!
Our quote will include the right gap cover for this plan

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OTHER BENEFITS:
Premium
Scheme Benefits Gap benefits
General Appliances: 2018 benefits coming soon. 2017 benefits:
  • No benefit
  • No benefit
1.1. Hearing Aids: 2018 benefits coming soon. 2017 benefits:
  • No benefit
  • No benefit
1.2. Wheelchairs: 2018 benefits coming soon. 2017 benefits:
  • No benefit
  • No benefit
Dialysis: 2018 benefits coming soon. 2017 benefits:
  • PMB level of care criteria
HIV: 2018 benefits will be posted soon!
  • No benefit
Emergency Transport: 2018 benefits will be posted soon!
  • No benefit
International Insurance: 2018 benefits will be posted soon!
  • No benefit
Other: 2018 benefits will be posted soon!

No phone calls!
Our quote will include the right gap cover for this plan

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WELLNESS/PREVENTATIVE BENEFITS:
Premium
Scheme Benefits Gap benefits
Flu vaccination: 2018 benefits will be posted soon!
  • No benefit
Pneumonia vaccines: 2018 benefits will be posted soon!
  • No benefit
Back Rehabilitation Programme: 2018 benefits will be posted soon!
  • No benefit
Biometric Screening: 2018 benefits will be posted soon!
  • No benefit
Child Immunisation: 2018 benefits will be posted soon!
  • No benefit
Pap Smear: 2018 benefits will be posted soon!
  • No benefit
Mammogram: 2018 benefits coming soon. 2017 benefits:
  • R1,320 with R300 co-payment, for women 49yrs+, once every two years
  • No benefit
PAS Test: 2018 benefits will be posted soon!
  • No benefit
HIV Test: 2018 benefits will be posted soon!
  • No benefit
Other:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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PROSTHETICS:
Premium
Scheme Benefits Gap benefits
Overal Limit:
Sub-limits:

No phone calls!
Our quote will include the right gap cover for this plan


    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised