Topmed medicine benefits: 2017

By Staff Writer -

Click here to compare medicine benefits across all schemes, or use the menu bar above for more options. Topmed home page.

Non income-limited plans

Income limited plans

Momentum Ingwe A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe Active Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R335 R335 R210
Children: Pay for all children
Income limit: R0-R650 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Pinnacle 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Some co-payments. Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 46 conditions covered
  • non-PMBs limited to R11,100 per person and R16,700 per family
  • non-PMBs above-threshold limited to R4,175 per family, subject to sub-limits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,328 R4,146 R1,476
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R12,816 R9,936 R3,528
Extended Fund: R3,197 R2,488 R886
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R17,913 R13,840 R4,874
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
  • Limited to R3,475 per family from above-threshold
3. Over-the-counter:
  • R200 per event>, from day-to-day benefit
  • Limited to R920 per person and R1,310 per family
  • Not payable from above-threshold benefit, and does not accumulate to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per person per month
6. Notes:

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Discovery KeyCare Plus A 2017: Medicine Benefits
In brief: Unlimited cover in KeyCare networks. Scheme pays out-of-hospital claims for: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R914 R914 R331
Children: Pay for maximum 3 children
Income limit: R0-R8,100 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Medicines on medicine list, if prescribed by KeyCare network GP: Covered
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • Medicines on medicine list, if prescribed by KeyCare network GP: Covered
5. Birth Control:
  • No benefit
6. Notes:

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Fedhealth Maxima EntryZone 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,326 R991 R446
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Momentum Ingwe B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe Active Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R911 R911 R342
Children: Pay for all children
Income limit: R651-R6,100 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Pinnacle ED 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Netcare hospitals. Some co-payments. Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 46 conditions covered
  • non-PMBs limited to R11,100 per person and R16,700 per family
  • non-PMBs above-threshold limited to R4,175 per family, subject to sub-limits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,452 R3,462 R1,242
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R10,656 R8,280 R2,952
(SP) Self Payment: R1,900 R1,416 R460
Threshold (S+SP): R15,226 R11,774 R4,158
Above Threshold: R8,700 pb
R17,400 pf		 17,400 pf

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
  • Limited to R3,475 per family from above-threshold
3. Over-the-counter:
  • R200 per event>, from day-to-day benefit
  • Limited to R920 per person and R1,310 per family
  • Not payable from above-threshold benefit, and does not accumulate to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per person per month
6. Notes:

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Discovery KeyCare Plus B 2017: Medicine Benefits
In brief: Unlimited cover in KeyCare networks. Scheme pays out-of-hospital claims for: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,280 R1,280 R358
Children: Pay for maximum 3 children
Income limit: R8,101-R11,550 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Medicines on medicine list, if prescribed by KeyCare network GP: Covered
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • Medicines on medicine list, if prescribed by KeyCare network GP: Covered
5. Birth Control:
  • No benefit
6. Notes:

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Sizwe Gomomo A 2017: Medicine Benefits
In brief: 100% scheme rate. Scheme pays out-of-hospital claims for: maternity. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,666 R1,546 R410
Children: Pay for all children
Income limit: R0-R10,112 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:maternity. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • R280 per family
4. On Discharge:
5. Birth Control:
  • No benefit
6. Notes:

View this plan

Fedhealth Maxima Core 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,616 R667
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Momentum Ingwe C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe Active Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R1,273 R1,273 R385
Children: Pay for all children
Income limit: R6,101-R8,200 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Dynamix 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 37 conditions covered
  • non-PMBs limited to R8,350 per person and R13,950 per family
  • non-PMBs above-threshold limited to R2,775 per family, subject to sub-limits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,014 R3,138 R1,122
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R7,200 R5,688 R2,016
Extended Fund: R2,408 R1,883 R673
(SP) Self Payment: R5,000 R3,878 R1,402
Threshold (S+SP): R14,608 R11,449 R4,091
Above Threshold: R5,800 pb
R11,600 pf		 11,600 pf

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
  • Limited to R2,800 per family from above-threshold
3. Over-the-counter:
  • R190 per event>, from day-to-day benefit
  • Limited to R800 per person and R1,200 per family
  • Not payable from above-threshold benefit, and does not accumulate to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per person per month
6. Notes:

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Compcare Networx ED A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private and public Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R330 R330 R330
Children: Pay for all children
Income limit: R0-R500 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Discovery KeyCare Plus C 2017: Medicine Benefits
In brief: Unlimited cover in KeyCare networks. Scheme pays out-of-hospital claims for: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,906 R1,906 R510
Children: Pay for maximum 3 children
Income limit: R11,551+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Medicines on medicine list, if prescribed by KeyCare network GP: Covered
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • Medicines on medicine list, if prescribed by KeyCare network GP: Covered
5. Birth Control:
  • No benefit
6. Notes:

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Sizwe Gomomo B 2017: Medicine Benefits
In brief: 100% scheme rate. Scheme pays out-of-hospital claims for: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,060 R1,623 R420
Children: Pay for all children
Income limit: R10,113+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • R280 per family
4. On Discharge:
5. Birth Control:
  • No benefit
6. Notes:

View this plan

Fedhealth Maxima Core Grid 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,716 R1,454 R600
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:post hospitalisation treatment (30 days), casualty visits, GP visit, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

View this plan

Momentum Ingwe D 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe Active Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R1,734 R1,734 R406
Children: Pay for all children
Income limit: R8,201-R11,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Dynamix ED 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Netcare hospitals. Some co-payments. Comprehensive cover with savings, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 37 conditions covered
  • non-PMBs limited to R8,350 per person and R13,950 per family
  • non-PMBs above-threshold limited to R2,775 per family, subject to sub-limits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,306 R2,580 R930
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R5,976 R4,680 R1,656
Extended Fund: R1,984 R1,548 R558
(SP) Self Payment: R5,000 R3,878 R1,402
Threshold (S+SP): R12,960 R10,106 R3,616
Above Threshold: R5,800 pb
R11,600 pf		 11,600 pf

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
  • Limited to R2,800 per family from above-threshold
3. Over-the-counter:
  • R190 per event>, from day-to-day benefit
  • Limited to R800 per person and R1,200 per family
  • Not payable from above-threshold benefit, and does not accumulate to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per person per month
6. Notes:

View this plan

Compcare Networx ED B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private and public Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R665 R632 R233
Children: Pay for all children
Income limit: R501-R4,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

View this plan

Discovery KeyCare Access A 2017: Medicine Benefits
In brief: Unlimited cover in state facilities, or Access network for some procedures. Scheme pays out-of-hospital claims for: maternity, specialists. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R644 R644 R281
Children: Pay for maximum 3 children
Income limit: R0-R5,050 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Full coverage for medicines on the medicine list, if prescribed by KeyCare network GP
  • From Overall Annual Limit (OAL)
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • Medicines on medicine list, if prescribed by KeyCare network GP: Covered
5. Birth Control:
  • No benefit
6. Notes:

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Sizwe Savings Care A 2017: Medicine Benefits
In brief: 100% scheme rate. Scheme pays out-of-hospital claims for: radiology, pathology, maternity. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • non-PMB: 11 additional conditions covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,015 R1,742 R490
Children: Pay for all children
Income limit: R0-R15,052 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medication, radiology, physio, pathology, standard dentistry, optometry, maternity. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,627 R3,136 R882

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

View this plan

Fedhealth Maxima EntrySaver 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,640 R1,181 R524
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,280 R1,008

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Momentum Ingwe E 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe Active Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R2,225 R2,225 R646
Children: Pay for all children
Income limit: R11,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Symmetry 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme offers extended fund once savings are depleted, and also pays for: specialised radiology, GPs (unlimited), medical appliances and preventative benefits. Limits apply.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 20 conditions covered
  • non-PMBs limited to R4,100 per person and R6,160 per family from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,186 R2,484 R900
Children: Pay for all children
Day-to-Day Benefit:
Scheme offers extended fund for claims once savings are depleted, and also pays for: specialised radiology, GPs, medical appliances and preventative benefits. Limits apply. All else paid from savings, fund or out of pocket.
Main: Adult: Child:
(S) Savings: R3,816 R2,952 R1,080
Extended Fund: R3,816 R2,952 R1,080

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • One script per day, and R170 per event>
  • R650 per person and R1,050 per family
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per month
6. Notes:

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Compcare Networx ED C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private and public Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R687 R652 R240
Children: Pay for all children
Income limit: R4,001-R5,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Discovery KeyCare Access B 2017: Medicine Benefits
In brief: Unlimited cover in state facilities, or Access network for some procedures. Scheme pays out-of-hospital claims for: maternity, specialists. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R859 R859 R309
Children: Pay for maximum 3 children
Income limit: R5,051-R8,100 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • Medicines on medicine list, if prescribed by KeyCare network GP: Covered
5. Birth Control:
  • No benefit
6. Notes:

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Sizwe Savings Care B 2017: Medicine Benefits
In brief:
1. Chronic:
  • non-PMB: 11 additional conditions covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,800 R2,243 R555
Children: Pay for all children
Income limit: R15,053+ (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R5,040 R4,037 R999

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Fedhealth Maxima Saver 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,079 R1,693 R600
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,744 R3,048 R1,080

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

View this plan

Momentum Ingwe Network A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe primary Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R335 R335 R210
Children: Pay for all children
Income limit: R0-R650 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Symmetry ED 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Netcare hospitals. Some co-payments. Scheme offers extended fund once savings are depleted, and also pays for: specialised radiology, GPs (unlimited), medical appliances and preventative benefits. Limits apply.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 20 conditions covered
  • non-PMBs limited to R4,100 per person and R6,160 per family from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,598 R2,022 R732
Children: Pay for all children
Day-to-Day Benefit:
Scheme offers extended fund for claims once savings are depleted, and also pays for: specialised radiology, GPs, medical appliances and preventative benefits. Limits apply. All else paid from savings, fund or out of pocket.
Main: Adult: Child:
(S) Savings: R3,118 R2,426 R878
Extended Fund: R3,118 R2,426 R878

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • One script per day, and R170 per event>
  • R650 per person and R1,050 per family
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per month
6. Notes:

View this plan

Compcare Networx ED D 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private and public Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R821 R779 R289
Children: Pay for all children
Income limit: R5,001-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Discovery KeyCare Access C 2017: Medicine Benefits
In brief: Unlimited cover in state facilities, or Access network for some procedures. Scheme pays out-of-hospital claims for: maternity, specialists. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,241 R1,241 R348
Children: Pay for maximum 3 children
Income limit: R8,101-R11,550 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • Medicines on medicine list, if prescribed by KeyCare network GP: Covered
5. Birth Control:
  • No benefit
6. Notes:

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Sizwe Primary Care A 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R407 R407 R407
Children: Pay for all children
Income limit: R0-R530 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Day-to-day limit: M =R5,390 M1 =R7,980 M2 =R9,330 M3 =R10,670 M4 =R12,020 M5 =R13,370 M6+ =R14,720
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R1,680 M1 =R3,030 M2 =R3,370 M3 =R3,820 M4 =R3,930 M5 =R4,150 M6+ =R4,490
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
  • Paid from R2,490 per family
6. Notes:

View this plan

Fedhealth Maxima Saver Grid 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,871 R1,524 R540
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,372 R2,748 R972

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

View this plan

Momentum Ingwe Network B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe primary Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R701 R701 R321
Children: Pay for all children
Income limit: R651-R6,100 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Mumed 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme offers fund for out-of-hospital claims, incl unlimited GP visits, Scheme also pays for specialised radiology, medical appliances and preventative benefits.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 10 conditions covered from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,532 R1,974 R714
Children: Pay for all children
Day-to-Day Benefit:
Scheme offers fund for out-of-hospital claims, incl unlimited GP visits, Scheme also pays for specialised radiology, medical appliances and preventative benefits.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R5,376 R3,372 R1,338

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • One script per day, and R160 per event>
  • R530 per person and R950 per family
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per month
6. Notes:

View this plan

Compcare Networx ED E 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private and public Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R859 R817 R301
Children: Pay for all children
Income limit: R6,001-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

View this plan

Discovery KeyCare Access D 2017: Medicine Benefits
In brief: Unlimited cover in state facilities, or Access network for some procedures. Scheme pays out-of-hospital claims for: maternity, specialists. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,863 R1,863 R503
Children: Pay for maximum 3 children
Income limit: R11,551+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • Medicines on medicine list, if prescribed by KeyCare network GP: Covered
5. Birth Control:
  • No benefit
6. Notes:

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Sizwe Primary Care B 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,907 R1,488 R480
Children: Pay for all children
Income limit: R531-R8,766 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Day-to-day limit: M =R5,390 M1 =R7,980 M2 =R9,330 M3 =R10,670 M4 =R12,020 M5 =R13,370 M6+ =R14,720
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R1,680 M1 =R3,030 M2 =R3,370 M3 =R3,820 M4 =R3,930 M5 =R4,150 M6+ =R4,490
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
  • Paid from R2,490 per family
6. Notes:

View this plan

Fedhealth Maxima Basis 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,501 R2,129 R754
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,500 R3,828 R1,356

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

View this plan

Momentum Ingwe Network C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe primary Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R892 R892 R334
Children: Pay for all children
Income limit: R6,101-R8,200 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Mumed ED 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Netcare hospitals. Some co-payments. Scheme offers fund for out-of-hospital claims, incl unlimited GP visits, Scheme also pays for specialised radiology, medical appliances and preventative benefits.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 10 conditions covered from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,054 R1,600 R572
Children: Pay for all children
Day-to-Day Benefit:
Scheme offers fund for out-of-hospital claims, incl unlimited GP visits, Scheme also pays for specialised radiology, medical appliances and preventative benefits.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R5,376 R3,372 R1,338

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • One script per day, and R160 per event>
  • R530 per person and R950 per family
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per month
6. Notes:

View this plan

Compcare Networx ED F 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private and public Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R978 R931 R343
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

Compare with these plans:

2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

View this plan

Discovery KeyCare Core A 2017: Medicine Benefits
In brief: Unlimited cover in KeyCare networks. Scheme pays out-of-hospital claims for: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R731 R731 R190
Children: Pay for maximum 3 children
Income limit: R0-R8,100 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:

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Sizwe Primary Care C 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,326 R1,519 R480
Children: Pay for all children
Income limit: R8,767+ (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Day-to-day limit: M =R5,390 M1 =R7,980 M2 =R9,330 M3 =R10,670 M4 =R12,020 M5 =R13,370 M6+ =R14,720
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R1,680 M1 =R3,030 M2 =R3,370 M3 =R3,820 M4 =R3,930 M5 =R4,150 M6+ =R4,490
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
  • Paid from R2,490 per family
6. Notes:

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Fedhealth Maxima Basis Grid 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,251 R1,916 R679
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, GP visits, specialised radiology, contraceptives, some dentistry and maternity, optometry, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,056 R3,444 R1,224

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Momentum Ingwe Network D 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe primary Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R1,241 R1,241 R365
Children: Pay for all children
Income limit: R8,201-R11,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Unisave 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments, incl R3,500 for each hospital admission. Over and above the savings fund, scheme pays out-of-hospital claims for): specialised radiology, maternity, appliances, preventative benefits. Limits apply.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,974 R1,680 R594
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, appliances, preventative benefits. Limits apply. . Limits apply. All else paid out of savings or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R5,904 R5,040 R1,800

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • One script per day, and R150 per event>
  • R500 per person and R900 per family
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per month
6. Notes:

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Compcare Networx ED G 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private and public Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R1,037 R987 R364
Children: Pay for all children
Income limit: R9,001-R10,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Discovery KeyCare Core B 2017: Medicine Benefits
In brief: Unlimited cover in KeyCare networks. Scheme pays out-of-hospital claims for: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R912 R912 R224
Children: Pay for maximum 3 children
Income limit: R8,101-R11,550 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:

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Sizwe Affordable Care A 2017: Medicine Benefits
In brief:
1. Chronic:
  • non-PMB: 13 additional conditions covered
  • R4,940 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,733 R2,511 R630
Children: Pay for all children
Income limit: R0-R15,052 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Day-to-day limit: M =R9,330 M1 =R13,370 M2 =R15,390 M3 =R16,740 M4 =R18,760 M5 =R20,790 M6+ =R22,690
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R3,250 M1 =R4,940 M2 =R5,840 M3 =R6,290 M4 =R7,190 M5 =R7,420 M6+ =R7,640
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
  • Paid from R2,490 per family
6. Notes:

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Fedhealth Maxima Standard 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 14 conditions covered
  • R5,120 per person, and R10,200 per family. Thereafter only PMBs are covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,032 R2,583 R907
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R6,552 R5,580 R1,956
(SP) Self Payment: R4,648 R3,020 R924
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

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2. Acute (presrcibed) medication:
  • R5,120 per person and R10,200 per family, from day-to-day benefit
3. Over-the-counter:
  • Paid from savings benefit only and does not add up to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Medihelp Dimension Prime 1 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), GP, specialists, physio, medication, maternity, infant paediatrics, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,608 R1,320 R486
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GP, specialists, physio, medication, maternity, infant paediatrics, medical appliances. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • M =R1,050 and M+ =R2,100
  • Shared with GPs, specialists, physio, acute medicine and over the counter medication
3. Over-the-counter:
  • M= R1,000 and M+= R2,000
  • Shared with GP benefit
4. On Discharge:
  • R320 per admission
5. Birth Control:
  • See "Acute Medicine" benefit, above
6. Notes:
  • PMBs chronic: only 40% of the reference price is paid if medicine is outside the formulary and/or obtained from non-network provider
  • For acute and non-PMBs chronic medicines:
    • 80% of scheme rate where no generic is available
    • 70% of MMAP (maximum medical aid price) for voluntary use of original medicine where generic is available

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Medihelp Unify 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments.Scheme pays out-of-hospital claims for: specialised radiology (co-payment). Limits apply. All else paid from savings or from out-of-pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,944 R1,602 R588
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment). Limits apply. All else paid from savings or from out-of-pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R5,832 R4,824 R1,800

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Medihelp Necesse A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Plan aimed at students. Network hospitals only. Income based plan. Scheme pays out-of-hospital claims for: specialised radiology, maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances, radiology and pathology. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from network pharmacy and according to formulary
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R438 R438 R438
Children: Pay for all children
Income limit: R0-R400 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances, radiology and pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • If dispensed by GP: 100% of scheme rate
  • Paid from pharmacy: 100% of MMAP
3. Over-the-counter:
  • R100 per event, R260 per person per year
4. On Discharge:
  • R320 per admission
5. Birth Control:
6. Notes:

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Hosmed Essential A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. In-hospital, PMBs only. Scheme pays out-of-hospital claims for: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
PMBs only
Contributions:
Main: Adult: Child:
Total Cost: R1,196 R1,092 R410
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
  • R950 per person, and R2,650 per family if obtained from pharmacy
3. Over-the-counter:
  • R210 per family, with a maximum of R80 per script
4. On Discharge:
  • 5 days
5. Birth Control:
  • R55 per person, limited to R660 per family per year
6. Notes: Medicines paid at reference price, subject to formulary

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Genesis Private Choice 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R50,000 in-hospital limit for cancer, stroke, motor-neuron disease and organ transplant. Scheme pays out-of-hospital claims for: dentistry. Limits apply. All else paid out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,000 R1,000 R325
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:
  • Scheme pays 100% of cost for medicines on the formulary

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Bonitas Essential 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme pays out-of-hospital claims for: maternity and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,473 R1,127 R432
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • R340 per person per admission
5. Birth Control:
  • No benefit
6. Notes:
  • For PMBs chronic medication, there is a 40% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Bonitas BonFit 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Over and above the savings fund, scheme pays out-of-hospital claims for: maternity, infant paediatrics, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,789 R1,385 R535
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,228 R2,496 R960

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • R340 per person per admission
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • For PMBs chronic medication, there is a 40% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Momentum Custom (Any provider for chronic) 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Chronic benefits at any provider. Scheme pays out-of-hospital claims for: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,059 R1,653 R735
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Momentum Incentive (Any provider for chronic) 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Chronic benefits at any provider. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs chronic: additional 6 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,794 R2,270 R389
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,288 R3,288 R2,724

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Momentum Extender (Any provider for chronic) 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Chronic benefits from any provider. Comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs chronic: additional 36 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,308 R4,235 R1,665
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
Main: Adult: Child:
(S) Savings: R15,924 R12,705 R4,995
(SP) Self Payment: R1,176 R2,095 R105
Threshold (S+SP): R17,100 R14,800 R5,100
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, R15,100 per person and R28,400 per family
3. Over-the-counter:
  • Paid from day-to-day benefit
    • , but does not accumulate to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Momentum Access 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,842 R1,842 R552
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Some medication covered
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Keyhealth Essence 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Some co-payments. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), maternity, medical appliances, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • R450
5. Birth Control:
  • No benefit
6. Notes:
  • Chronic medicine: 30% co-payment where non-DSP pharmacy is used
  • Reference pricing

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Discovery Executive 2017: Medicine Benefits
In brief: 300% scheme rate for specialists. Comprehensive cover with savings, extended fund, and unlimited above threshold benefits that cover most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 23 conditions covered, up to a pre-set limit including an exclusive list of brand medicines.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,544 R5,544 R1,055
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R16,632 R16,632 R3,156
(SP) Self Payment: R28 R28 R
Threshold (S+SP): R16,660 R16,660 R3,150
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Schedule 3 and above
  • Paid from day-to-day benefit, up to the limits below
Main M1 M2 M3+
R33,000 R38,700 R44,300 R49,950
3. Over-the-counter:
  • Paid from day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Classic Comprehensive 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Comprehensive cover with savings, extended fund, and unlimited above threshold benefits that cover most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 23 conditions covered, up to a pre-set limit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,506 R4,264 R898
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R13,512 R12,792 R2,688
(SP) Self Payment: R1,988 R2,708 R262
Threshold (S+SP): R15,500 R15,500 R2,950
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Schedule 3 and above
  • Paid from day-to-day benefit, up to the limits below
  • If you are in the Self Payment Gap, Discovery will still pay for the medicine, up to the limits below
Main M1 M2 M3
R26,650 R31,300 R36,350 R41,450
3. Over-the-counter:
  • Paid from day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Classic Priority 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,968 R2,337 R1,187
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,904 R7,008 R3,552
(SP) Self Payment: R4,246 R2,842 R748
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

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2. Acute (presrcibed) medication:
  • Schedule 3 and above, from day-to-day benefit, up to the limits below
Main M1 M2 M3
R17,200 R20,850 R25,150 R27,450
3. Over-the-counter:
  • Paid from day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Classic Saver 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Over and above the savings fund, scheme pays out-of-hospital claims for: GP consults, maternity, kids' casualty if savings run out. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,577 R2,029 R1,031
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP consults, maternity, kids' casualty if savings run out. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,728 R6,084 R3,084

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Classic Smart 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: GP consults, acute meds, eye and dental check up and sport related injuries, specialised radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,535 R1,209 R612
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP consults, acute meds, eye and dental check up and sport related injuries, specialised radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Cover for a defined list of medicine, with a R10 co-payment for each medicine item
  • Limited to 12 prescriptions per year per person from network pharmacies
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Classic Core 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Most day-to-day claims paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,918 R1,510 R767
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Most claims paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Topmed Essential 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Hospital plan. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), maternity, scopes, alternatives to hospital, extended rehab benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,458 R1,174 R592
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, scopes, alternatives to hospital, extended rehab benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Topmed Network A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Covered if dispensed by Network GP or pharmacy, according to formulary
3. Over-the-counter:
  • R216 per family per year, with a maximum of R72 per script
4. On Discharge:
  • No benefit
5. Birth Control:
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Medimed Alpha 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays in and out of hospital benefits, but with a 25% or 40% co-payment from member for most claims. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme on authorisation
  • Extended chronic conditions: R3,000 per person and R6,000 per family, paid at 75% scheme rate
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,020 R1,020 R400
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: out-of-hospital claims but with a 25% or 40% co-payment from member. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • R3,300 per person, R7,900 per family
  • 60% scheme rate, member pays balance
3. Over-the-counter:
  • R120 per prescription and R1,200 per family, subject to acute medicine limit (see above) and a 40% co-payment
4. On Discharge:
5. Birth Control:
6. Notes:

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Medimed Essential A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Income based plan. Over and above the savings, scheme pays out-of-hospital claims for: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme on authorisation
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,110 R1,110 R380
Children: Pay for all children
Income limit: R0-R7,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R1,332 R1,332 R456

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2. Acute (presrcibed) medication:
  • Unlimited if prescribed by GP according to formulary
  • Paid by scheme
3. Over-the-counter:
  • R100 per prescription, and R400 per family
  • Paid from day-to-day benefit
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • For acute medicine not on the formulary: if there is a generic equivalent on the formulary, scheme will pay maximum of formulary generic alternative. If there is no generic equivalent, the member pays full amount out-of-pocket.

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Medimed Standard A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Income based plan. Over and above the savings and extended fund, scheme pays out-of-hospital claims for: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R9,000 per family) or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Extended chronic conditions: R1,600 per person and R3,200 per family paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,660 R1,660 R390
Children: Pay for all children
Income limit: R0-R8,500 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R9,000 per family) or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R9,480 R9,480 R1,170
Extended Fund: R4,500 pp R9,000 pf R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R150 per prescription, R1,500 per family
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:

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Medimed Max A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Income based plan. Over and above the savings and extended fund, scheme pays out-of-hospital claims for: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R10,000 per family) or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Extended chronic conditions: R3,200 per person and R6,400 per family paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,810 R2,810 R500
Children: Pay for all children
Income limit: R0-R10,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R10,000 per family) or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R13,430 R13,430 R1,500
Extended Fund: R5,000 pp R10,000 pf R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R150 per prescription, R1,500 per family
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:

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Bestmed Beat 1 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme pays out-of-hospital claims for: wound care, specialised radiology, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: unlimited
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R1,257 R976 R529
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Wound care, specialised radiology, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Bestmed Pace 1 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 7 conditions covered at 85% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: R5,200 per person and R10,450 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,055 R2,145 R711
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,332 R5,148 R1,848
Extended Fund: R8,500 (main) R17,000 (family) R

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2. Acute (presrcibed) medication:
  • Limited to M1= R1,850 and M1+ =R3,800
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit, limited to R525
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Bestmed Pulse 1 A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: GP and specialist consults, dentistry, optometry, maternity, radiology and pathology, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,131 R1,075 R679
Children: Pay for maximum 4 children
Income limit: R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, maternity, radiology and pathology, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
  • R300 per family
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Spectramed Aqua 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,208 R1,099 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 5 days supply
5. Birth Control:
  • No benefit
6. Notes:
  • All medication must be on formulary, otherwise no benefit
  • All medication must be obtained from DSP, otherwise 40% co-payment

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Fedhealth Blue Door A: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R776 R644 R369
Children: Pay for all children
Income limit: R0-R5,200 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Resolution Hospital 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,565 R1,335 R585
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Reference and GRP pricing apply

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Resolution Fundation A 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R907 R907 R273
Children: Pay for all children
Income limit: R0-R4,600 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Limited to network providers and formularies
3. Over-the-counter:
  • Limited to network providers and formularies
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Reference and GRP pricing apply

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Cape Medical Premium 2017: Medicine Benefits
In brief:
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,548 R1,548 R271
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:
  • Medicines are paid at cost to a maximum of Single Exit price plus dispensing fee

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Suremed Shuttle 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: specialised radiology, preventative care, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,320 R980 R540
Children: Pay for all children
Day-to-Day Benefit:
Scheme pays out-of-hospital claims for: specialised radiology, preventative care, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:

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Suremed Explorer A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: medication, appliances, dentistry, GPs and specialists, maternity, optometry, pathology, radiology, specialised radiology, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R860 R770 R400
Children: Pay for all children
Income limit: R0-R7,500 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: medication, appliances, dentistry, GPs and specialists, maternity, optometry, pathology, radiology, specialised radiology, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if prescribed by nominated provider, limited to R70 per event
3. Over-the-counter:
  • R230 per person and R265 per family
4. On Discharge:
  • R300 per event
5. Birth Control:
6. Notes:

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Medshield MediPhila 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R1,000,000 per family limit. Scheme pays out-of-hospital claims for: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
R500,000 per person, R1 million per family for non-PMB
Contributions:
Main: Adult: Child:
Total Cost: R1,041 R1.041 R261
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,500 per family R R

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2. Acute (presrcibed) medication:
  • R1,135 per family, from day-to-day benefit
3. Over-the-counter:
  • Shared with Acute medicine benefit, and limited to M= R285 and M1+= R395 with R60 limit per script
4. On Discharge:
  • R150 per admission
5. Birth Control:
  • R96 per monthly script
6. Notes:
  • PMB: Basic formulary
  • Out of formulary PMB or obtained from non-network provider: 40% co-payment
  • PMB: reimbursed at Maximum Generic Price

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Commed Roots A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some-co-payments. Network hospitals. Annual limit of R400k per person and R800k per family. Scheme pays out-of-hospital claims for:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Paid at formulary reference price
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R822 R822 R342
Children: Pay for all children
Income limit: R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:
  • PMBs: Single exit price t plus dispensing fee
  • Otherwise, subject to formulary reference price

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Commed Shina A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some-co-payments. Network hospitals. Annual limit of R600,000 per person and R1,200,000 per family. Scheme pays out-of-hospital claims for: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Paid at formulary reference price
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R1,498 R1,274 R300
Children: Pay for all children
Income limit: R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R1,798 R1,529 R360

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:
  • PMBs: Single exit price t plus dispensing fee
  • Otherwise, subject to formulary reference price

View this plan

Commed Standard A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some-co-payments. Network hospitals. Annual limit of R760,000 per person and R1,460,000 per family. Scheme pays out-of-hospital claims for: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Paid at formulary reference price
Overall Annual Limit (OAL):
R730k per person, R1,460,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R2,946 R2,413 R591
Children: Pay for all children
Income limit: R0-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,419 R3,620 R887

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:
  • PMBs: Single exit price t plus dispensing fee
  • Otherwise, subject to formulary reference price

View this plan

Commed Deluxe 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Comprehensive cover with savings, self-payment gap and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
1. Chronic:
  • No. of chronic conditions covered by scheme: 27 CDLs and PMBs
  • Overall limit for chronic paid by scheme:R4,500 per person and R8,000 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,802 R4,742 R1,158
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive cover with savings, self-payment gap and limited above threshold benefits that cover most out-of-hospital benefits (with limits).
Main: Adult: Child:
(S) Savings: R10,440 R8,532 R2,088
(SP) Self Payment: R7,830 R6,399 R1,566
Threshold (S+SP): R18,270 R14,931 R3,654
Above Threshold: 2,610 2,133 522

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2. Acute (presrcibed) medication:
  • R3,500 per person and R9,000 per family
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R1,750 per family
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:

View this plan

Makoti Primary A 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
PMBs only, in state hospitals
Contributions:
Main: Adult: Child:
Total Cost: R225 R225 R147
Children: Pay for all children
Income limit: R0-R3,000 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
6. Notes:

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Makoti Comprehensive A 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,469 R1,266 R488
Children: Pay for all children
Income limit: R0-R9,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
6. Notes:

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Selfmed Selfnet Essential 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R850 R850 R300
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Otherwise, 40% co-payment

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Momentum Ingwe Network E 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe primary Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R1,758 R1,758 R518
Children: Pay for all children
Income limit: R11,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Axis 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Most out-of-hospital benefits covered only if PMBs.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,734 R1,734 R534
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per month
6. Notes:

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Compcare Networx ED H 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private and public Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R1,908 R1,718 R669
Children: Pay for all children
Income limit: R10,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Discovery KeyCare Core C 2017: Medicine Benefits
In brief: Unlimited cover in KeyCare networks. Scheme pays out-of-hospital claims for: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,408 R1,408 R318
Children: Pay for maximum 3 children
Income limit: R11,551+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, GP consults, specialists, casualty visits, acute meds, pathology and radiology. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:

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Sizwe Affordable Care B 2017: Medicine Benefits
In brief:
1. Chronic:
  • non-PMB: 13 additional conditions covered
  • R4,940 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,843 R2,610 R660
Children: Pay for all children
Income limit: R15,053-R18,444 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Day-to-day limit: M =R9,330 M1 =R13,370 M2 =R15,390 M3 =R16,740 M4 =R18,760 M5 =R20,790 M6+ =R22,690
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R3,250 M1 =R4,940 M2 =R5,840 M3 =R6,290 M4 =R7,190 M5 =R7,420 M6+ =R7,640
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
  • Paid from R2,490 per family
6. Notes:

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Fedhealth Maxima Standard Elect 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 14 conditions covered
  • R5,120 per person, and R10,200 per family. Thereafter only PMBs are covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,316 R1,974 R694
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits (with 20% co-payment) that can be used for most out-of-hospital claims.
Main: Adult: Child:
(S) Savings: R5,004 R4,260 R1,500
(SP) Self Payment: R6,196 R4,340 R1,380
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit, with 20% co-payment No limit, with 20% co-payment No limit, with 20% co-payment

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2. Acute (presrcibed) medication:
  • R5,120 per person and R10,200 per family, from day-to-day benefit
3. Over-the-counter:
  • Paid from savings benefit only and does not add up to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Momentum Ingwe State A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. State hospitals. Network hospitals. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe primary Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R335 R335 R210
Children: Pay for all children
Income limit: R0-R650 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Axis ED 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Netcare hospitals. Some exclusions apply. Most out-of-hospital benefits covered only if PMBs.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,260 R1,260 R396
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

2. Acute (presrcibed) medication:
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R120 per month
6. Notes:

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Compcare Networx ED Plus A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R283 R279 R154
Children: Pay for all children
Income limit: R0-R500 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Sizwe Affordable Care C 2017: Medicine Benefits
In brief:
1. Chronic:
  • non-PMB: 13 additional conditions covered
  • R4,940 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,657 R3,251 R730
Children: Pay for all children
Income limit: R18,445+ (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Day-to-day limit: M =R9,330 M1 =R13,370 M2 =R15,390 M3 =R16,740 M4 =R18,760 M5 =R20,790 M6+ =R22,690
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R3,250 M1 =R4,940 M2 =R5,840 M3 =R6,290 M4 =R7,190 M5 =R7,420 M6+ =R7,640
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
  • Paid from R2,490 per family
6. Notes:

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Fedhealth Maxima Advanced 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 25 conditions covered
  • R4,240 per person, and R7,620 per family. Thereafter only PMBs are covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,251 R2,756 R968
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: post hospitalisation treatment (30 days), casualty visits, specialised radiology, contraceptives, some medication, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,900 R3,312 R1,164

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Momentum Ingwe State B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. State hospitals. Network hospitals. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe primary Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R560 R560 R302
Children: Pay for all children
Income limit: R651-R6,100 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Networx ED Plus B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R413 R405 R204
Children: Pay for all children
Income limit: R501-R4,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Sizwe Full Benefit A 2017: Medicine Benefits
In brief:
1. Chronic:
  • non-PMB: 33 additional conditions covered
  • R10,400 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,210 R3,825 R860
Children: Pay for all children
Income limit: R0-R18,879 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Day-to-day limit: M =R15,390 M1 =R20,790 M2 =R23,370 M3 =R26,060 M4 =R28,770 M5 =R31,460 M6+ =R34,150
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R4,380 M1 =R7,750 M2 =R8,990 M3 =R10,230 M4 =R10,890 M5 =R11,460 M6+ =R12,020
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
  • Paid from R2,490 per family
6. Notes:

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Fedhealth Maxima Exec 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Comprehensive plan with extended fund and threshold benefits that can be used for most out-of-hospital claims.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 26 conditions covered
  • R6,430 per person, and R11,900 per family. Thereafter only PMBs are covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,302 R3,666 R1,284
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits that can be used for most out-of-hospital plans.
Main: Adult: Child:
(S) Savings: R3,768 R3,216 R1,128
Extended Fund: R5,390 R4,200 R700
(SP) Self Payment: R2,042 R1,184 R1,052
Threshold (S+SP): R11,200 R8,600 R2,880
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • R6,430 per person and R11,900 per family, from day-to-day benefit
3. Over-the-counter:
  • Paid from savings benefit only and does not add up to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Momentum Ingwe State C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. State hospitals. Network hospitals. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe primary Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R641 R1,282 R950
Children: Pay for all children
Income limit: R6,101-R8,200 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Sizwe Full Benefit B 2017: Medicine Benefits
In brief:
1. Chronic:
  • non-PMB: 33 additional conditions covered
  • R10,400 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,885 R4,441 R960
Children: Pay for all children
Income limit: R18,880+ (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Day-to-day limit: M =R15,390 M1 =R20,790 M2 =R23,370 M3 =R26,060 M4 =R28,770 M5 =R31,460 M6+ =R34,150
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R4,380 M1 =R7,750 M2 =R8,990 M3 =R10,230 M4 =R10,890 M5 =R11,460 M6+ =R12,020
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
  • Paid from R2,490 per family
6. Notes:

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Fedhealth Maxima Plus 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Comprehensive plan with extended fund and threshold benefits that can be used for most out-of-hospital claims.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 26 conditions covered
  • R13,600 per person, and R25,400 per family. Thereafter only PMBs are covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,740 R5,733 R2,021
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits that can be used for most out-of-hospital plans.
Main: Adult: Child:
(S) Savings: R4,452 R3,780 R1,332
Extended Fund: R7,850 R5,670 R1,740
(SP) Self Payment: R736 R578 R405
Threshold (S+SP): R13,038 R10,028 R3,477
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • R8,980 per person and R17,800 per family, from day-to-day benefit
3. Over-the-counter:
  • Paid from savings benefit only and does not add up to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Momentum Ingwe State D 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. State hospitals. Network hospitals. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe primary Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R748 R748 R324
Children: Pay for all children
Income limit: R8,201-R11,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Networx ED Plus D 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R529 R502 R251
Children: Pay for all children
Income limit: R5,001-R6,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Fedhealth Ultimax 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Comprehensive plan with extended fund and threshold benefits that can be used for most out-of-hospital claims.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 40 conditions covered
  • R25,400 per person, and R42,300 per family. Thereafter only PMBs are covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R9,215 R7,829 R2,765
Children: Pay for all children
Day-to-Day Benefit:
Comprehensive plan with extended fund and threshold benefits that can be used for most out-of-hospital plans.
Main: Adult: Child:
(S) Savings: R5,748 R4,884 R1,728
Extended Fund: R2560 (main) R4,010 (family) R
(SP) Self Payment: R4,942 R3,747 R
Threshold (S+SP): R13,250 R10,081 R3,360
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • R8,980 per person and R17,800 per family, from day-to-day benefit
3. Over-the-counter:
  • Paid from savings benefit only and does not add up to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Devices and medicine: paid by scheme, including IUDs
  • Consultations: from day-to-day benefit
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Momentum Ingwe State E 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. State hospitals. Network hospitals. R1,190,000 per family limit. Income based plan. Scheme pays out-of-hospital claims for: dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Chronic benefits from Ingwe primary Primary Care Network
Overall Annual Limit (OAL):
R1,190,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R1,291 R1,291 R389
Children: Pay for all children
Income limit: R11,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: std dentistry, GPs, specialists, optometry, pathology, std radiology, medicine, maternity, alternatives to hospitalistion, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Compcare Networx ED Plus F 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R631 R599 R300
Children: Pay for all children
Income limit: R8,001-R9,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Compcare Networx ED Plus G 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R668 R636 R318
Children: Pay for all children
Income limit: R9,001-R10,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Compcare Networx ED Plus H 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some exclusions apply. Private Network hospitals. Annual limit of R1,100,000 per family. Scheme pays for: GPs, medicine, radiology, pathology, maternity and preventative benefits. Limits apply. All else paid from out of fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 1 condition covered
Overall Annual Limit (OAL):
R1,100,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R1,318 R1,186 R585
Children: Pay for all children
Income limit: R10,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, medicine, radiology, pathology, maternity and preventative benefits. All else paid from out of fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R2,800 (main) R4,170 (family) R

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2. Acute (presrcibed) medication:
  • Paid by scheme
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply and R 280 per discharge
5. Birth Control:
  • R95 per month
6. Notes:
  • Meds must be prescribed by a Universal Network provider and dispensed by network pharmacy
  • Only formulary is covered, unless otherwise authorised
  • Reference pricing

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Medihelp Dimension Prime 1 Network 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), GP, specialists, physio, medication, maternity, infant paediatrics, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,260 R1,026 R378
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GP, specialists, physio, medication, maternity, infant paediatrics, medical appliances. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • M =R1,050 and M+ =R2,100
  • Shared with GPs, specialists, physio, acute medicine and over the counter medication
3. Over-the-counter:
  • M= R1,000 and M+= R2,000
  • Shared with GP and Acute medicine benefit
  • paid by scheme
4. On Discharge:
  • R320 per admission
5. Birth Control:
  • See "Acute Medicine" benefit, above
6. Notes:
  • PMBs chronic: only 40% of the reference price is paid if medicine is outside the formulary and/or obtained from non-network provider
  • For acute and non-PMBs chronic medicines:
    • 80% of scheme rate where no generic is available
    • 70% of MMAP (maximum medical aid price) for voluntary use of original medicine where generic is available

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Medihelp Plus 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: radiology, pathology, GPs, specialists, supplementary services, psychologists, medicine, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs chronic medicine: R15,600 per person. 100% of MMAP if generic.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,936 R6,936 R1,728
Children: Pay for all children.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, medical appliances, GPs, specialists, psychologists, supplementary health, medication, radiology and pathology, dentistry and optometry. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • R5,350 per person, pooled per family.
3. Over-the-counter:
  • See "Acute Medicine" benefit
4. On Discharge:
  • R510 per admission
5. Birth Control:
  • See "Acute Medicine" benefit, above
6. Notes:
  • PMBs chronic: only 40% of the reference price is paid if medicine is outside the formulary and/or obtained from non-network provider
  • For acute and non-PMBs chronic medicines:
    • 80% of scheme rate where no generic is available
    • 70% of MMAP (maximum medical aid price) for voluntary use of original medicine where generic is available

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Medihelp Necesse B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals only. Income based plan. Scheme pays out-of-hospital claims for: specialised radiology, maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances, radiology and pathology. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from network pharmacy and according to formulary
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,404 R1,110 R600
Children: Pay for all children
Income limit: R401-R5,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances, radiology and pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • If dispensed by GP: 100% of scheme rate
  • Paid from pharmacy: 100% of MMAP
3. Over-the-counter:
  • R100 per event, R260 per person per year
4. On Discharge:
  • R320 per admission
5. Birth Control:
6. Notes:

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Hosmed Essential B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. In-hospital, PMBs only. Scheme pays out-of-hospital claims for: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
PMBs only
Contributions:
Main: Adult: Child:
Total Cost: R1,460 R1,333 R368
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
  • R950 per person, and R2,650 per family if obtained from pharmacy
3. Over-the-counter:
  • R210 per family, with a maximum of R80 per script
4. On Discharge:
  • 5 days
5. Birth Control:
  • R55 per person, limited to R660 per family per year
6. Notes: Medicines paid at reference price, subject to formulary

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Genesis Private 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R50,000 in-hospital limit for cancer, stroke, motor-neuron disease and organ transplant. Scheme pays out-of-hospital claims for: dentistry. Limits apply. All else paid out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,500 R1,500 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:
  • Scheme pays 100% of cost for medicines on the formulary

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Bonitas Primary 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Over and above the fund, scheme pays out-of-hospital claims for: GPs, mental health, specialised radiology, optometry, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from fund or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,924 R1,505 R613
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, mental health, specialised radiology, optometry, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Fund:
Main M+1 M+2 M+3 M4+
R1,900 R3,400 R4,000 R4,300 R4,650
Specialists, medicine, radiology, pathology, etc
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit, limited to R440 per person and R1,290 per family
4. On Discharge:
  • R340 per person per admission
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • For PMBs chronic medication, there is a 40% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Bonitas BonSave 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Over and above the savings fund, scheme pays out-of-hospital claims for: specialised radiology, mental health, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered by scheme: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
  • Other chronic meds: paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,135 R1,654 R640
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, mental health, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,104 R3,180 R1,236

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • R340 per person per admission
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • For PMBs chronic medication, there is a 40% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Momentum Custom Associate (and any provider for chronic) 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Chronic benefits at any provider. Scheme pays out-of-hospital claims for: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from any provider
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,742 R1,374 R614
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Momentum Incentive Network hospital (and any provider for chronic) 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Network hospitals. Chronic benefits at any provider. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs chronic: additional 6 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,529 R2,034 R826
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,035 R3,035 R2,441

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Momentum Extender Network hospital (and any provider for chronic) 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Network hospitals. Chronic benefits from any provider. Comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs chronic: additional 36 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,671 R3,728 R1,465
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
Main: Adult: Child:
(S) Savings: R14,013 R11,184 R4,395
(SP) Self Payment: R3,087 R3,616 R705
Threshold (S+SP): R17,100 R14,800 R5,100
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, R15,100 per person and R28,400 per family
3. Over-the-counter:
  • Paid from day-to-day benefit
    • , but does not accumulate to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Momentum Summit 2017: Medicine Benefits
In brief: 300% scheme rate. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs: Additional 36 conditions covered, from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R7,637 R6,108 R1,754
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R22,300 R22,300 R22,300

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2. Acute (presrcibed) medication:
  • R17,400 per person and R28,500 per family from day-to-day benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Keyhealth Equilibrium 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Some co-payments. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), dentistry, maternity, medical appliances, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 3 conditions for children under 21 (Acne, ADD/ADHD, Rhinitis), 10% co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,817 R1,096 R556
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R1,584 R960 R480
Extended Fund: R2,070 R1,150 R625

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • R450
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • Chronic medicine: 30% co-payment where non-DSP pharmacy is used
  • Reference pricing

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Discovery Classic Delta Comprehensive 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Network hospitals. Comprehensive cover with savings, extended fund, and unlimited above threshold benefits that cover most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 23 conditions covered, up to a pre-set limit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,059 R3,842 R807
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,168 R11,520 R2,412
(SP) Self Payment: R3,332 R3,980 R538
Threshold (S+SP): R15,500 R15,500 R2,950
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Schedule 3 and above
  • Paid from day-to-day benefit, up to the limits below
  • If you are in the Self Payment Gap, Discovery will still pay for the medicine, up to the limits below
Main M1 M2 M3
R26,650 R31,300 R36,350 R41,450
3. Over-the-counter:
  • Paid from day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Essential Priority 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Comprehensive cover with savings, extended fund, and limited above threshold benefits that cover most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,551 R2,004 R1,012
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits) with limited above threshold benefit. Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,584 R3,600 R1,824
(SP) Self Payment: R8,566 R6,250 R2,476
Threshold (S+SP): R13,150 R9,850 R4,300
Above Threshold: 11,150 7,950 3,850

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2. Acute (presrcibed) medication:
  • Schedule 3 and above, from day-to-day benefit, up to the limits below
Main M1 M2 M3
R12,250 R14,500 R17,150 R20,850
3. Over-the-counter:
  • Paid from day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Classic Delta Saver 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Network Hospitals. Over and above the savings fund, scheme pays out-of-hospital claims for: GP consults, maternity, kids' casualty if savings run out. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,058 R1,623 R826
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP consults, maternity, kids' casualty if savings run out. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R6,168 R4,860 R2,472

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Essential Smart 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: GP consults, eye and dental check up. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,100 R1,100 R1,100
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP consults, eye and dental check up. Limits and co-payments apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Cover for a defined list of medicine, with a R10 co-payment for each medicine item
  • Limited to 12 prescriptions per year per person from network pharmacies
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Classic Delta Core 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Network hospitals. Most day-to-day claims paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,535 R1,209 R612
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Most claims paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Topmed Active Saver 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: maternity, scopes, extended rehab benefits, birth control, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,512 R1,512 R500
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, scopes, extended rehab benefits, birth control, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,904 R960

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid by scheme
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Topmed Network B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R915 R915 R331
Children: Pay for all children
Income limit: R1,000-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Covered if dispensed by Network GP or pharmacy, according to formulary
3. Over-the-counter:
  • R216 per family per year, with a maximum of R72 per script
4. On Discharge:
  • No benefit
5. Birth Control:
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Medimed Essential B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Income based plan. Over and above the savings, scheme pays out-of-hospital claims for: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme on authorisation
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,200 R1,200 R390
Children: Pay for all children
Income limit: R7,001-R8,500 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R1,440 R1,440 R468

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2. Acute (presrcibed) medication:
  • Unlimited if prescribed by GP according to formulary
  • Paid by scheme
3. Over-the-counter:
  • R100 per prescription, and R400 per family
  • Paid from day-to-day benefit
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • For acute medicine not on the formulary: if there is a generic equivalent on the formulary, scheme will pay maximum of formulary generic alternative. If there is no generic equivalent, the member pays full amount out-of-pocket.

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Medimed Standard B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Income based plan. Over and above the savings and extended fund, scheme pays out-of-hospital claims for: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R9,000 per family) or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Extended chronic conditions: R1,600 per person and R3,200 per family paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,760 R1,760 R410
Children: Pay for all children
Income limit: R8,501-R13,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R9,000 per family) or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R9,780 R9,780 R1,230
Extended Fund: R4,500 pp R9,000 pf R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R150 per prescription, R1,500 per family
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:

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Medimed Max B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Income based plan. Over and above the savings and extended fund, scheme pays out-of-hospital claims for: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R10,000 per family) or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Extended chronic conditions: R3,200 per person and R6,400 per family paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,050 R3,050 R530
Children: Pay for all children
Income limit: R10,001-R17,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R10,000 per family) or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,150 R14,150 R1,590
Extended Fund: R5,000 pp R10,000 pf R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R150 per prescription, R1,500 per family
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:

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Bestmed Beat 1 Network 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Some co-payments. Scheme pays out-of-hospital claims for: wound care, specialised radiology, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: unlimited
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R1,131 R879 R476
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Wound care, specialised radiology, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Bestmed Pace 2 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine, trauma rehab and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 18 conditions covered at 85% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: R7,150 per person and R14,300 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,315 R4,231 R951
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, specialised radiology, contraceptives, medicine, trauma rehab and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,764 R7,620 R1,716
Extended Fund: R12,000 (main) R24,000 (family) R

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2. Acute (presrcibed) medication:
  • Limited to M1= R3,800 and M1+ =R7,600
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit, limited to R525
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Bestmed Pulse 1 B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: GP and specialist consults, dentistry, optometry, maternity, radiology and pathology, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,357 R1,290 R814
Children: Pay for maximum 4 children
Income limit: R6,001-R10,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, maternity, radiology and pathology, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
  • R300 per family
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Spectramed Cyan A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMB: 2 more conditions, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,730 R1,669 R692
Children: Pay for maximum 3 children
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,904 R2,808 R1,164

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 5 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • All medication must be on formulary, otherwise no benefit
  • All medication must be obtained from DSP, otherwise 40% co-payment

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Fedhealth Blue Door B: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R984 R813 R475
Children: Pay for all children
Income limit: R5,201-R8,500 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Resolution Progressive Flex 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,154 R2,017 R666
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • From limit below
  • Limit shared with supplementary health, std radiology and pathology, physio, mental health, speech therapy and audiology, acute medication
MM1+
R2,268R2,878
3. Over-the-counter:
  • From limit below, with following sub limits: M =R623 and M+ =R873
  • Limit shared with supplementary health, std radiology and pathology, physio, mental health, speech therapy and audiology, acute medication
MM1+
R2,268R2,878
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R1,496 per female, from preventative benefit limit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Reference and GRP pricing apply

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Resolution Fundation B 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,056 R1,056 R364
Children: Pay for all children
Income limit: R4,601-R7,100 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Limited to network providers and formularies
3. Over-the-counter:
  • Limited to network providers and formularies
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Reference and GRP pricing apply

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Cape Medical Silver 2017: Medicine Benefits
In brief:
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,704 R1,704 R258
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,000 R3,000 R456

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2. Acute (presrcibed) medication:
  • R440 per family. Thereafter from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from acute medicine benefit
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • Medicines are paid at cost to a maximum of Single Exit price plus dispensing fee

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Suremed Navigator 2017: Medicine Benefits
In brief: 125% scheme rate for specialists. Scheme pays out-of-hospital claims for: medication, appliances, dentistry, GPs and specialists, maternity, non surgical procedures, optometry, supplementary services, pathology, radiology, specialised radiology, preventative care, alternative to hospitals. Limits apply. All else paid out of savings or out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,400 R1,900 R720
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: medication, appliances, dentistry, GPs and specialists, maternity, non surgical procedures, optometry, supplementary services, pathology, radiology, specialised radiology, preventative care, alternative to hospitals. Limits apply. All else paid out of savings or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,960 R3,180 R1,200
Extended Fund: R8,500 pp R17,680 pf R

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2. Acute (presrcibed) medication:
  • Paid from savings first. Thereafter R2,640 per person from overall day-to-day benefit
3. Over-the-counter:
  • R140 per prescription per month, limited to R1,250 per family per year
  • Included in acute medicine benefit
4. On Discharge:
  • R500 per person per admission
5. Birth Control:
6. Notes:

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Suremed Explorer B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: medication, appliances, dentistry, GPs and specialists, maternity, optometry, pathology, radiology, specialised radiology, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,080 R960 R480
Children: Pay for all children
Income limit: R7,501-R11,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: medication, appliances, dentistry, GPs and specialists, maternity, optometry, pathology, radiology, specialised radiology, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if prescribed by nominated provider, limited to R70 per event
3. Over-the-counter:
  • R230 per person and R265 per family
4. On Discharge:
  • R300 per event
5. Birth Control:
6. Notes:

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Medshield MediValue 2017: Medicine Benefits
In brief: 100% scheme rate. Scheme pays out-of-hospital claims for: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,521 R1,323 R414
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: RM= R4,815
M1= R5,240
M2= R5,900
M3= R6,660
M4+ =R7,600		 R R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R185 per script. Limited to R400 per person and R600 per family. Paid from day-to-day benefit
4. On Discharge:
  • R400 per admission
5. Birth Control:
  • R140 per monthly script
  • Mirena: one per female every four years. Includes consultation, insertion if done in rooms.
6. Notes:
  • PMB: Restrictive formulary
  • Out of formulary PMB or obtained from non-network provider: 40% co-payment
  • PMB: reimbursed at Maximum Generic Price

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Commed Roots B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some-co-payments. Network hospitals. Annual limit of R400k per person and R800k per family. Scheme pays out-of-hospital claims for:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Paid at formulary reference price
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R950 R950 R458
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:
  • PMBs: Single exit price t plus dispensing fee
  • Otherwise, subject to formulary reference price

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Commed Shina B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some-co-payments. Network hospitals. Annual limit of R600,000 per person and R1,200,000 per family. Scheme pays out-of-hospital claims for: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Paid at formulary reference price
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R1,803 R1,532 R361
Children: Pay for all children
Income limit: R6,001-R18,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,164 R1,838 R433

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:
  • PMBs: Single exit price t plus dispensing fee
  • Otherwise, subject to formulary reference price

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Commed Standard B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some-co-payments. Network hospitals. Annual limit of R760,000 per person and R1,460,000 per family. Scheme pays out-of-hospital claims for: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Paid at formulary reference price
Overall Annual Limit (OAL):
R730k per person, R1,460,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R3,181 R2,607 R638
Children: Pay for all children
Income limit: R6,001-R7,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,772 R3,911 R957

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:
  • PMBs: Single exit price t plus dispensing fee
  • Otherwise, subject to formulary reference price

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Makoti Primary B 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
PMBs only, in state hospitals
Contributions:
Main: Adult: Child:
Total Cost: R239 R239 R159
Children: Pay for all children
Income limit: R3,001-R6,450 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
6. Notes:

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Makoti Comprehensive B 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,699 R1,415 R554
Children: Pay for all children
Income limit: R9,251-R12,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
6. Notes:

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Selfmed Selfnet 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,185 R1,185 R418
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Covered if prescribed by Network GP and part of formulary
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Otherwise, 40% co-payment

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Medihelp Dimension Prime 2 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs: paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,136 R1,746 R642
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,096 R2,520 R936

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2. Acute (presrcibed) medication:
3. Over-the-counter:
  • M= R1,000 and M+= R2,000
  • Shared with GP and Acute medicine benefit
  • paid by scheme
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • See "Acute Medicine" benefit, above
6. Notes:
  • PMBs chronic: only 40% of the reference price is paid if medicine is outside the formulary and/or obtained from non-network provider
  • For acute and non-PMBs chronic medicines:
    • 80% of scheme rate where no generic is available
    • 70% of MMAP (maximum medical aid price) for voluntary use of original medicine where generic is available

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Medihelp Necesse C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals only. Income based plan. Scheme pays out-of-hospital claims for: specialised radiology, maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances, radiology and pathology. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from network pharmacy and according to formulary
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,464 R1,170 R660
Children: Pay for all children
Income limit: R5,001-R7,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances, radiology and pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • If dispensed by GP: 100% of scheme rate
  • Paid from pharmacy: 100% of MMAP
3. Over-the-counter:
  • R100 per event, R260 per person per year
4. On Discharge:
  • R320 per admission
5. Birth Control:
6. Notes:

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Hosmed Essential C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. In-hospital, PMBs only. Scheme pays out-of-hospital claims for: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
PMBs only
Contributions:
Main: Adult: Child:
Total Cost: R1,826 R1,666 R707
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
  • R950 per person, and R2,650 per family if obtained from pharmacy
3. Over-the-counter:
  • R210 per family, with a maximum of R80 per script
4. On Discharge:
  • 5 days
5. Birth Control:
  • R55 per person, limited to R660 per family per year
6. Notes: Medicines paid at reference price, subject to formulary

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Genesis Private Plus 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R50,000 in-hospital limit for cancer, stroke, motor-neuron disease and organ transplant. Scheme pays out-of-hospital claims for: dentistry. Limits apply. All else paid out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,900 R1,900 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,140 R4,140 R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • Scheme pays 100% of cost for medicines on the formulary

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Bonitas BonComplete 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Over and above the savings/threshold fund, scheme pays out-of-hospital claims for: specialised radiology, mental health, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from savings, or from above threshold benefit or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,923 R2,340 R794
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, mental health, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from savings, or from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R5,256 R4,200 R1,428
(SP) Self Payment: R1,568 R1,326 R336
Threshold (S+SP): R6,824 R5,526 R1,764
Above Threshold: R4,150 R2,450 R1,060

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • R370 per person per admission
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • For PMBs chronic medication, there is a 40% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Bonitas Standard 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Over and above the fund, scheme pays out-of-hospital claims for: GPs, specialised radiology, mental health, medical appliances, hearing aids, optometry, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from fund or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 17 conditions
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit:R8,650 per person and R17,350 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,998 R2,600 R880
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialised radiology, mental health, medical appliances, hearing aids, optometry, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Fund:
Main M+1 M+2 M+3 M4+
R5,232 R7,970 R9,214 R10,062 R10,966
Specialists, medicine, radiology, pathology, etc
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit, limited to R700 per person and R2,121 per family
4. On Discharge:
  • R420 per person per admission
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • For PMBs chronic medication, there is a 40% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Momentum Custom (Network for chronic) 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Chronic benefits at Network provider. Scheme pays out-of-hospital claims for: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from Network provider
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,899 R1,483 R689
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Momentum Incentive (Network provider for chronic) 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Chronic benefits at Network provider. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from Network provider
  • non-PMBs chronic: additional 6 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Momentum Extender (Network provider for chronic) 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Chronic benefits from Network provider. Comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
1. Chronic:
  • PMB chronic: paid by scheme, from Network provider
  • non-PMBs chronic: additional 36 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,776 R3,813 R1,495
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
Main: Adult: Child:
(S) Savings: R14,328 R11,439 R4,485
(SP) Self Payment: R2,772 R3,361 R615
Threshold (S+SP): R17,100 R14,800 R5,100
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, R15,100 per person and R28,400 per family
3. Over-the-counter:
  • Paid from day-to-day benefit
    • , but does not accumulate to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Keyhealth Silver 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, preventative benefits. Limits apply. All else paid from fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 3 conditions for children under 21 (Acne, ADD/ADHD, Rhinitis), 10% co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,977 R1,601 R620
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, preventative benefits. Limits apply. All else paid from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R6,485 R4,710 R1,305

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Limited to R1,400 per family
  • Paid from day-to-day benefit
4. On Discharge:
  • R450
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • Chronic medicine: 30% co-payment where non-DSP pharmacy is used
  • Reference pricing

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Discovery Classic Comprehensive Zero MSA 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Comprehensive cover with no savings, a self-payment gap and unlimited above threshold benefits that cover most out-of-hospital benefits (with sub limits). All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 23 conditions covered, up to a pre-set limit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,380 R3,199 R674
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Comprehensive cover with no savings, a self-payment gap and unlimited above threshold benefits that cover most out-of-hospital benefits (with sub limits). All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
(SP) Self Payment: R#VALUE! R#VALUE! R#VALUE!
Threshold (S+SP): R15,500 R15,500 R2,950
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Schedule 3 and above
  • Paid from day-to-day benefit, up to the limits below
Main M1 M2 M3
R26,650 R31,300 R36,350 R41,450
3. Over-the-counter:
  • Not covered
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Essential Saver 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Over and above the savings fund, scheme pays out-of-hospital claims for: GP consults if savings run out. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,047 R1,536 R819
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP consults if savings run out. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,684 R2,760 R1,464

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Essential Core 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Most day-to-day claims paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,648 R1,234 R661
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Most claims paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Topmed Limited 2017: Medicine Benefits
In brief: R1,000,000 limit per person in private hospitals. Unlimited in public hospitals. Co-payment for private hospital stays, and 20% co-payment for all healthcare providers. Scheme pays most out-of-hospital benefits with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs and non-PMBs: R10,884 per family. Thereafter, only PMBs are covered
  • 20% co-payment for non-PMBs
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Main: Adult: Child:
Total Cost: R2,245 R600 R260
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • R7,440 per family
  • 20% co-payment
3. Over-the-counter:
4. On Discharge:
  • 7 days supply
5. Birth Control:
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Topmed Network C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,282 R1,282 R359
Children: Pay for all children
Income limit: R8,001-R11,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Covered if dispensed by Network GP or pharmacy, according to formulary
3. Over-the-counter:
  • R216 per family per year, with a maximum of R72 per script
4. On Discharge:
  • No benefit
5. Birth Control:
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Medimed Essential C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Income based plan. Over and above the savings, scheme pays out-of-hospital claims for: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme on authorisation
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,390 R1,390 R400
Children: Pay for all children
Income limit: R8,501-R13,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R1,668 R1,668 R480

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2. Acute (presrcibed) medication:
  • Unlimited if prescribed by GP according to formulary
  • Paid by scheme
3. Over-the-counter:
  • R100 per prescription, and R400 per family
  • Paid from day-to-day benefit
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • For acute medicine not on the formulary: if there is a generic equivalent on the formulary, scheme will pay maximum of formulary generic alternative. If there is no generic equivalent, the member pays full amount out-of-pocket.

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Medimed Standard C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Income based plan. Over and above the savings and extended fund, scheme pays out-of-hospital claims for: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R9,000 per family) or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Extended chronic conditions: R1,600 per person and R3,200 per family paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,050 R2,050 R440
Children: Pay for all children
Income limit: R13,001-R17,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R9,000 per family) or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R10,650 R10,650 R1,320
Extended Fund: R4,500 pp R9,000 pf R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R150 per prescription, R1,500 per family
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:

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Medimed Max C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Income based plan. Over and above the savings and extended fund, scheme pays out-of-hospital claims for: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R10,000 per family) or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Extended chronic conditions: R3,200 per person and R6,400 per family paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,210 R3,210 R560
Children: Pay for all children
Income limit: R17,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R10,000 per family) or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,630 R14,630 R1,680
Extended Fund: R5,000 pp R10,000 pf R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R150 per prescription, R1,500 per family
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:

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Bestmed Beat 2 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme pays out-of-hospital claims for: preventative dentistry, wound care, specialised radiology, contraceptives and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: unlimited
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R1,554 R1,208 R655
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, wound care, specialised radiology, contraceptives and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,168 R2,460 R1,332

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Bestmed Pace 3 A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine, trauma rehab and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 18 conditions covered at 85% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: R11,500 per person and R23,000 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,243 R3,394 R725
Children: Pay for maximum 4 children
Income limit: R0-R8,208 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, specialised radiology, contraceptives, medicine, trauma rehab and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,632 R6,108 R1,416
Extended Fund: R15,000 (main) R31,000 (family) R

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2. Acute (presrcibed) medication:
  • Limited to M1= R1,200 and M1+ =R3,000
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit, limited to R525
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Bestmed Pulse 1 C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: GP and specialist consults, dentistry, optometry, maternity, radiology and pathology, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,630 R1,466 R814
Children: Pay for maximum 4 children
Income limit: R10,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, maternity, radiology and pathology, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
  • R300 per family
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Spectramed Cyan B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMB: 2 more conditions, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,396 R2,296 R960
Children: Pay for maximum 3 children
Income limit: R8,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,020 R3,852 R1,608

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 5 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • All medication must be on formulary, otherwise no benefit
  • All medication must be obtained from DSP, otherwise 40% co-payment

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Fedhealth Blue Door C: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,380 R1,145 R522
Children: Pay for all children
Income limit: R8,501-R10,500 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Resolution Progressive Flex Plus 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,369 R2,219 R733
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • From limit below
  • Limit shared with supplementary health, std radiology and pathology, physio, mental health, speech therapy and audiology, acute medication
MM1+
R2,268R2,878
3. Over-the-counter:
  • From limit below, with following sub limits: M =R623 and M+ =R873
  • Limit shared with supplementary health, std radiology and pathology, physio, mental health, speech therapy and audiology, acute medication
MM1+
R2,268R2,878
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R1,496 per female, from preventative benefit limit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Reference and GRP pricing apply

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Resolution Fundation C 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,338 R1,338 R427
Children: Pay for all children
Income limit: R7,101-R9,700 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Limited to network providers and formularies
3. Over-the-counter:
  • Limited to network providers and formularies
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Reference and GRP pricing apply

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Cape Medical Select 2017: Medicine Benefits
In brief:
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,998 R4,998 R809
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R3,600 R3,600 R586
Extended Fund: R4,800 R4,800 R1,200

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • Medicines are paid at cost to a maximum of Single Exit price plus dispensing fee

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Suremed Challanger 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: medication, appliances, dentistry, GPs and specialists, maternity, non surgical procedures, optometry, supplementary services, pathology, radiology, specialised radiology, preventative care, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • Some non-PMB conditions are also covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,000 R3,000 R800
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: medication, appliances, dentistry, GPs and specialists, maternity, non surgical procedures, optometry, supplementary services, pathology, radiology, specialised radiology, preventative care, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • R5,500 per person and R19,550 per family
  • 20% co-payment once R3,100 per person is reached
3. Over-the-counter:
  • R140 per prescription per month, limited to R1,350 per family per year
  • Included in acute medicine benefit
4. On Discharge:
  • R500 per person per admission
5. Birth Control:
6. Notes:

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Suremed Explorer C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: medication, appliances, dentistry, GPs and specialists, maternity, optometry, pathology, radiology, specialised radiology, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,720 R1,720 R500
Children: Pay for all children
Income limit: R11,001-R15,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: medication, appliances, dentistry, GPs and specialists, maternity, optometry, pathology, radiology, specialised radiology, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if prescribed by nominated provider, limited to R70 per event
3. Over-the-counter:
  • R230 per person and R265 per family
4. On Discharge:
  • R300 per event
5. Birth Control:
6. Notes:

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Medshield MediCore 2017: Medicine Benefits
In brief: Up to 200% scheme rate for specialists. This is hospital plan. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), alternatives to hospitalisation, some non-surgical procedures including scopes, maternity, preventative benefits, in-hospital dentistry for under 6yr olds. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,926 R1,623 R438
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • R300 per admission
5. Birth Control:
  • R140 per monthly script
6. Notes:
  • PMB: Basic formulary
  • Out of formulary PMB or obtained from non-network provider: 40% co-payment
  • PMB: reimbursed at Maximum Generic Price

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Commed Roots C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some-co-payments. Network hospitals. Annual limit of R400k per person and R800k per family. Scheme pays out-of-hospital claims for:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Paid at formulary reference price
Overall Annual Limit (OAL):
R400k per person, R800k per family
Contributions:
Main: Adult: Child:
Total Cost: R1,454 R1,454 R620
Children: Pay for all children
Income limit: R18,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some:GPs, specialits, dentistry, medicine, optometry, radiology, pathology, external applianes, alternative to hopitalisation. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:
  • PMBs: Single exit price t plus dispensing fee
  • Otherwise, subject to formulary reference price

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Commed Shina C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some-co-payments. Network hospitals. Annual limit of R600,000 per person and R1,200,000 per family. Scheme pays out-of-hospital claims for: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Paid at formulary reference price
Overall Annual Limit (OAL):
R600k per person, R1,200,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R2,441 R2,075 R488
Children: Pay for all children
Income limit: R18,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,929 R2,490 R586

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:
  • PMBs: Single exit price t plus dispensing fee
  • Otherwise, subject to formulary reference price

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Commed Standard C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some-co-payments. Network hospitals. Annual limit of R760,000 per person and R1,460,000 per family. Scheme pays out-of-hospital claims for: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Paid at formulary reference price
Overall Annual Limit (OAL):
R730k per person, R1,460,000 per family
Contributions:
Main: Adult: Child:
Total Cost: R3,434 R2,815 R690
Children: Pay for all children
Income limit: R7,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Alternative to hopitalisation, mammogram and external appliances. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R5,151 R4,223 R1,035

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:
  • PMBs: Single exit price t plus dispensing fee
  • Otherwise, subject to formulary reference price

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Makoti Primary C 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
PMBs only, in state hospitals
Contributions:
Main: Adult: Child:
Total Cost: R530 R438 R195
Children: Pay for all children
Income limit: R6,451-R9,000 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
6. Notes:

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Makoti Comprehensive C 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R1,832 R1,537 R594
Children: Pay for all children
Income limit: R12,251-R16,250 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
6. Notes:

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Selfmed MexXXI 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,599 R1,592 R818
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R1,500 per family
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Otherwise, 40% co-payment

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Medihelp Dimension Prime 2 Network 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Some co-payments. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs: paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,668 R1,368 R498
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), GPs, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,448 R2,016 R720

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2. Acute (presrcibed) medication:
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • See "Acute Medicine" benefit, above
6. Notes:
  • PMBs chronic: only 40% of the reference price is paid if medicine is outside the formulary and/or obtained from non-network provider
  • For acute and non-PMBs chronic medicines:
    • 80% of scheme rate where no generic is available
    • 70% of MMAP (maximum medical aid price) for voluntary use of original medicine where generic is available

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Medihelp Necesse D 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals only. Income based plan. Scheme pays out-of-hospital claims for: specialised radiology, maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances, radiology and pathology. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from network pharmacy and according to formulary
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,656 R1,290 R726
Children: Pay for all children
Income limit: R7,001-R11,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances, radiology and pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • If dispensed by GP: 100% of scheme rate
  • Paid from pharmacy: 100% of MMAP
3. Over-the-counter:
  • R100 per event, R260 per person per year
4. On Discharge:
  • R320 per admission
5. Birth Control:
6. Notes:

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Hosmed Access 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R1,250,000 per family limit. Scheme pays out-of-hospital claims for: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
R1,250,000
Contributions:
Main: Adult: Child:
Total Cost: R2,124 R1,829 R413
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
  • R1,700 per person, and R4,200 per family if obtained from pharmacy
3. Over-the-counter:
  • R475 per family, with a maximum of R85 per script
4. On Discharge:
  • 5 days
5. Birth Control:
  • R70 per person, limited to R840 per family per year
6. Notes: Medicines paid at reference price, subject to formulary

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Genesis Private Comprehensive 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. R50,000 in-hospital limit for cancer, stroke, motor-neuron disease and organ transplant. Scheme pays out-of-hospital claims for: dentistry, consults, medicine. Limits apply. All else paid out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,200 R2,200 R365
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: dentistry, consults and medicine. Limits apply. All else paid from out of savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R1,740 R1,740 R

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2. Acute (presrcibed) medication:
  • R3,900 per adult
  • Balance from day-to-day benefit
3. Over-the-counter: See Acute Medicine benefit, above
4. On Discharge: See Acute Medicine benefit, above
5. Birth Control: See Acute Medicine benefit, above
6. Notes:
  • Scheme pays 100% of cost for medicines on the formulary

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Bonitas Standard Select 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Over and above the fund, scheme pays out-of-hospital claims for: GPs, specialised radiology, mental health, medical appliances, hearing aids, optometry, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from fund or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 17 conditions
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit:R8,650 per person and R17,350 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,597 R2,247 R760
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialised radiology, mental health, medical appliances, hearing aids, optometry, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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day-to-day funds
Main M+1 M+2 M+3 M4+
R5,232 R7,970 R9,214 R10,062 R10,966
Specialists, medicine, radiology, pathology, etc
2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit, limited to R700 per person and R2,121 per family
4. On Discharge:
  • R420 per person per admission
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • For PMBs chronic medication, there is a 40% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Bonitas BonClassic 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Over and above the savings fund, scheme pays out-of-hospital claims for: specialised radiology, mental health, medical appliances, hearing aids, optometry, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 17 conditions
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit:R10,200 per person and R21,100 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,648 R3,132 R900
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, mental health, medical appliances, hearing aids, optometry, dentistry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R6,192 R5,316 R1,524

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • R470 per person per admission
5. Birth Control:
6. Notes:
  • For PMBs chronic medication, there is a 40% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Momentum Custom Associate (and Network provider for chronic) 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Chronic benefits at Network provider. Scheme pays out-of-hospital claims for: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from Network provider
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,573 R1,219 R556
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Momentum Incentive Network hospital (and Network provider for chronic) 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Network hospitals. Chronic benefits at Network provider. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from Network provider
  • non-PMBs chronic: additional 6 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,323 R1,848 R949
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,788 R2,788 R2,218

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Momentum Extender Network hospital (and Network provider for chronic) 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Network hospitals. Chronic benefits from Network provider. Comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
1. Chronic:
  • PMB chronic: paid by scheme, from Network provider
  • non-PMBs chronic: additional 36 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,304 R3,433 R1,352
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
Main: Adult: Child:
(S) Savings: R12,912 R10,299 R4,056
(SP) Self Payment: R4,188 R4,501 R1,044
Threshold (S+SP): R17,100 R14,800 R5,100
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, R15,100 per person and R28,400 per family
3. Over-the-counter:
  • Paid from day-to-day benefit
    • , but does not accumulate to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Keyhealth Gold 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Limited to R1,710 per family
  • Paid from day-to-day benefit
4. On Discharge:
  • R450
5. Birth Control:
6. Notes:
  • Chronic medicine: 15% co-payment where non-DSP pharmacy is used
  • Reference pricing

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Discovery Essential Comprehensive 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Comprehensive cover with savings, extended fund, and unlimited above threshold benefits that cover most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 23 conditions covered, up to a pre-set limit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,787 R3,580 R762
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R6,816 R6,444 R1,368
(SP) Self Payment: R8,684 R9,056 R1,582
Threshold (S+SP): R15,500 R15,500 R2,950
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Schedule 3 and above
  • Paid from day-to-day benefit, up to the limits below
Main M1 M2 M3
R17,200 R20,850 R21,150 R27,450
3. Over-the-counter:
  • Paid from day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Essential Delta Saver 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Over and above the savings fund, scheme pays out-of-hospital claims for: GP consults if savings run out. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,634 R1,230 R655
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP consults if savings run out. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,940 R2,208 R1,176

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Essential Delta Core 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Most day-to-day claims paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,317 R989 R528
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Most claims paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Topmed Savings 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,317 R1,850 R698
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,452 R3,552 R1,344

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Topmed Network D 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,734 R1,734 R464
Children: Pay for all children
Income limit: R11,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Covered if dispensed by Network GP or pharmacy, according to formulary
3. Over-the-counter:
  • R216 per family per year, with a maximum of R72 per script
4. On Discharge:
  • No benefit
5. Birth Control:
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Medimed Essential D 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Income based plan. Over and above the savings, scheme pays out-of-hospital claims for: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme on authorisation
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,660 R1,660 R420
Children: Pay for all children
Income limit: R13,001-R17,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R1,992 R1,992 R504

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2. Acute (presrcibed) medication:
  • Unlimited if prescribed by GP according to formulary
  • Paid by scheme
3. Over-the-counter:
  • R100 per prescription, and R400 per family
  • Paid from day-to-day benefit
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • For acute medicine not on the formulary: if there is a generic equivalent on the formulary, scheme will pay maximum of formulary generic alternative. If there is no generic equivalent, the member pays full amount out-of-pocket.

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Medimed Standard D 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Income based plan. Over and above the savings and extended fund, scheme pays out-of-hospital claims for: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R9,000 per family) or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • Extended chronic conditions: R1,600 per person and R3,200 per family paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,230 R2,230 R470
Children: Pay for all children
Income limit: R17,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, preventative benefits, some medication. Limits apply. All else paid from savings, extended fund (max R9,000 per family) or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R11,190 R11,190 R1,410
Extended Fund: R4,500 pp R9,000 pf R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R150 per prescription, R1,500 per family
  • Paid from day-to-day benefit
4. On Discharge:
5. Birth Control:
6. Notes:

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Bestmed Beat 2 Network 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Some co-payments. Scheme pays out-of-hospital claims for: preventative dentistry, wound care, specialised radiology, contraceptives and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: unlimited
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R1,399 R1,087 R589
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, wound care, specialised radiology, contraceptives and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,856 R2,220 R1,220

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Bestmed Pace 3 B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine, trauma rehab and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 18 conditions covered at 85% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: R11,500 per person and R23,000 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,097 R4,066 R853
Children: Pay for maximum 4 children
Income limit: R8,209+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, specialised radiology, contraceptives, medicine, trauma rehab and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R9,180 R7,320 R1,536
Extended Fund: R28,000 (main) R45,100 (family) R

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2. Acute (presrcibed) medication:
  • Limited to M1= R1,200 and M1+ =R3,000
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit, limited to R525
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Bestmed Pulse 2 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, some medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 16 conditions covered at 85% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit:R5,450 per person and R10,800 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,902 R3,902 R927
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP and specialist consults, dentistry, optometry, appliances, wound care, maternity, radiology and pathology, specialised radiology, medication, contraceptives and preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R11,350 (main) R22,550 (family) R

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2. Acute (presrcibed) medication:
  • M =R3,600 and M1+ =R7,200
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R525 per family
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Spectramed Capri 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,003 R1,609 R909
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,400 R1,932 R1,092

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 5 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • All medication must be on formulary, otherwise no benefit
  • All medication must be obtained from DSP, otherwise 40% co-payment

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Fedhealth Blue Door D: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Resolution Millennium 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs: Additional 10 conditions covered
  • M= R2,649 and M+= R5,310. Thereafter, only PMBs covered.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,200 R3,598 R979
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R10,092 R8,628 R2,340
(SP) Self Payment: R3,479 R2,629 R633
Threshold (S+SP): R13,571 R11,257 R2,973
Above Threshold: 5,544 4,728 774

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, subject to sub limits below
MM1M2+
R5,899R8,137R9,673
3. Over-the-counter:
  • Shared with acute medicine limit, subject to sub limits below
MM1M2+
R1,748R2,438R2,872
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R1,496 per female, from preventative benefit limit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Reference and GRP pricing apply

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Resolution Fundation D 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,022 R2,022 R694
Children: Pay for all children
Income limit: R9,701+ (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Limited to network providers and formularies
3. Over-the-counter:
  • Limited to network providers and formularies
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Reference and GRP pricing apply

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Suremed Explorer D 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: medication, appliances, dentistry, GPs and specialists, maternity, optometry, pathology, radiology, specialised radiology, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,920 R1,920 R600
Children: Pay for all children
Income limit: R15,000+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: medication, appliances, dentistry, GPs and specialists, maternity, optometry, pathology, radiology, specialised radiology, alternative to hospitals. Limits apply. All else paid out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if prescribed by nominated provider, limited to R70 per event
3. Over-the-counter:
  • R230 per person and R265 per family
4. On Discharge:
  • R300 per event
5. Birth Control:
6. Notes:

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Medshield MediPlus 2017: Medicine Benefits
In brief: 100% scheme rate. Scheme pays out-of-hospital claims for: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 14 conditions covered
  • R5,385 per person and R10,775 per family, thereafter unlimited for PMBs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,544 R1,797 R558
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes,preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: RM=R6,750
M1 =R9,420
M2 =R10,600
M3 = R11,910
M4+ +R13,050		 R R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R535 per person and R985 per family limited to R185 per script. From day-to-day benefit
4. On Discharge:
  • R500 per admission
5. Birth Control:
  • R140 per monthly script
  • Mirena: one per female every four years. Includes consultation, insertion if done in rooms.
6. Notes:
  • PMB: Restrictive formulary
  • Out of formulary PMB or obtained from non-network provider: 40% co-payment
  • PMB: reimbursed at Maximum Generic Price

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Makoti Primary D 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
PMBs only, in state hospitals
Contributions:
Main: Adult: Child:
Total Cost: R569 R461 R210
Children: Pay for all children
Income limit: R9,001-R12,000 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
6. Notes:

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Makoti Comprehensive D 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
PMBs only, in private hospitals
Contributions:
Main: Adult: Child:
Total Cost: R2,008 R1,722 R653
Children: Pay for all children
Income limit: R16,251+ (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
6. Notes:

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Selfmed Selfsure 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,456 R2,451 R836
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R1,500 per family
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Otherwise, 40% co-payment

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Medihelp Dimension Prime 3 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme pays out-of-hospital claims for: radiology (co-payment), pathology, GPs, specialists, supplementary services, medicine, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,730 R2,316 R798
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Shared with the GP, specialists, mental health, supplementary services
Main M1 M2 M3+
R5,700 R9,550 R11,700 R12,600
3. Over-the-counter:
  • See "Acute medicine" benefit
4. On Discharge:
  • R320 per admission
5. Birth Control:
  • See "Acute Medicine" benefit, above
6. Notes:
  • PMBs chronic: only 40% of the reference price is paid if medicine is outside the formulary and/or obtained from non-network provider
  • For acute and non-PMBs chronic medicines:
    • 80% of scheme rate where no generic is available
    • 70% of MMAP (maximum medical aid price) for voluntary use of original medicine where generic is available

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Medihelp Necesse E 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals only. Income based plan. Scheme pays out-of-hospital claims for: specialised radiology, maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances, radiology and pathology. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from network pharmacy and according to formulary
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,932 R1,506 R834
Children: Pay for all children
Income limit: R11,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances, radiology and pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • If dispensed by GP: 100% of scheme rate
  • Paid from pharmacy: 100% of MMAP
3. Over-the-counter:
  • R100 per event, R260 per person per year
4. On Discharge:
  • R320 per admission
5. Birth Control:
6. Notes:

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Hosmed Value 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, mental health, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: R5,936 per person, and R11,980 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,964 R2,144 R482
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, mental health, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Overall out-of-hospital annual limit for : Acute medicine, advanced dentistry, alternative services, biokinetics, physio, remedial and other therapies and mental health:
Main M+1 M+2 M+3
R8,500 R17,950 R19,525 R21,625
2. Acute (presrcibed) medication:
  • R3,040 per person, and R6,170 per family
3. Over-the-counter:
  • R600 per family, with a maximum of R135 per script
4. On Discharge:
  • 7 days
5. Birth Control:
  • R100 per person, limited to R1,200 per family per year
6. Notes: Medicines paid at reference price, subject to formulary

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Bonitas BonComprehensive 2017: Medicine Benefits
In brief: 300% scheme rate. Over and above the savings/threshold benefit, scheme pays out-of-hospital claims for: specialised radiology, mental health, refractive surgery, medical appliances, hearing aids, optometry, maternity, infant paediatrics and preventative benefits. Limits apply. Unlimited threshold with a self payment gap and sub-limits. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 35 conditions
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit:R12,450 per person and R24,800 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,254 R4,956 R1,069
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, mental health, refractive surgery, medical appliances, hearing aids, optometry, maternity, infant paediatrics and preventative benefits. Limits apply. All else paid from savings, above threshold or from out of pocket.
Main: Adult: Child:
(S) Savings: R11,892 R11,220 R2,424
(SP) Self Payment: R3,600 R2,980 R1,370
Threshold (S+SP): R15,492 R14,200 R3,794
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • R490 per person per admission
5. Birth Control:
6. Notes:
  • For PMBs chronic medication, there is a 40% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Momentum Custom (State for chronic) 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Chronic benefits at State facilities. Scheme pays out-of-hospital claims for: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from State provider
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,610 R1,215 R590
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Momentum Incentive (State provider for chronic) 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Chronic benefits at State facilities. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from State provider
  • non-PMBs chronic: additional 6 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,088 R1,646 R984
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,506 R2,506 R1,975

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Momentum Extender (State provider for chronic) 2017: Medicine Benefits
In brief: 00% scheme rate. Chronic benefits from State provider. Comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
1. Chronic:
  • PMB chronic: paid by scheme, from State provider
  • non-PMBs chronic: additional 36 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,309 R3,507 R1,323
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
Main: Adult: Child:
(S) Savings: R12,927 R10,521 R3,969
(SP) Self Payment: R4,173 R4,279 R1,131
Threshold (S+SP): R17,100 R14,800 R5,100
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, R15,100 per person and R28,400 per family
3. Over-the-counter:
  • Paid from day-to-day benefit
    • , but does not accumulate to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Keyhealth Platinum 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. This is a comprehensive plan. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, oncology, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: R16,000 per person, and R32,600 per family with 10% co-payment. Paid by scheme.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,796 R4,764 R1,433
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
MainAdultChild
R7,520R3,410R1,670
3. Over-the-counter:
  • Limited to R2,560 per family
  • Paid from day-to-day benefit
4. On Discharge:
  • R450
5. Birth Control:
6. Notes:
  • Chronic medicine: 10% co-payment where non-DSP pharmacy is used
  • Reference pricing

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Discovery Essential Delta Comprehensive 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Comprehensive cover with savings, extended fund, and unlimited above threshold benefits that cover most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: additional 23 conditions covered, up to a pre-set limit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,410 R3,221 R684
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Comprehensive cover that covers most out-of-hospital benefits (with sub limits). Extended benefit covers some claims while in self-payment gap. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R6,132 R5,796 R1,224
(SP) Self Payment: R9,368 R9,704 R1,726
Threshold (S+SP): R15,500 R15,500 R2,950
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Schedule 3 and above
  • Paid from day-to-day benefit, up to the limits below
Main M1 M2 M3
R17,200 R20,850 R21,150 R27,450
3. Over-the-counter:
  • Paid from day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Coastal Saver 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Over and above the savings fund, scheme pays out-of-hospital claims for: GP consults if savings run out. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,007 R1,506 R808
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GP consults if savings run out. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,812 R3,612 R1,932

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • Paid from day-to-day benefit
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Discovery Coastal Core 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Most day-to-day claims paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,496 R1,122 R596
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Most claims paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • No benefit
5. Birth Control:
  • No benefit
6. Notes:
  • Discovery pays for medicine up to the scheme rate, which includes the dispensing fee
  • Use MedExpress to have medicines delivered for free

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Topmed Family 2017: Medicine Benefits
In brief: 150% scheme rate. Scheme pays out-of-hospital claims for: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. In addition, there is a limited above threshold benefit. Limits apply. All else paid from savings, or from above threshold(limited) or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: 8 extra conditions covered
  • Limited to R10,752 per family. Thereafter, only PMBs medication is unlimited.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,490 R2,790 R954
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, up to limits below
MM1M2M3M4
R4,596R5,760R6,900R9,156R12,324
3. Over-the-counter:
  • Paid from day-to-day benefit, up to acute medicine limits
  • Not payable from above-threshold benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Medimed Essential E 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Income based plan. Over and above the savings, scheme pays out-of-hospital claims for: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme on authorisation
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,990 R1,990 R440
Children: Pay for all children
Income limit: R17,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,388 R2,388 R528

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2. Acute (presrcibed) medication:
  • Unlimited if prescribed by GP according to formulary
  • Paid by scheme
3. Over-the-counter:
  • R100 per prescription, and R400 per family
  • Paid from day-to-day benefit
4. On Discharge:
  • See "Acute Medicine" benefit
5. Birth Control:
6. Notes:
  • For acute medicine not on the formulary: if there is a generic equivalent on the formulary, scheme will pay maximum of formulary generic alternative. If there is no generic equivalent, the member pays full amount out-of-pocket.

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Bestmed Beat 3 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme pays out-of-hospital claims for: preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 5 conditions covered at 75% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: R2,700 per person and R5,450 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,359 R1,676 R911
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,812 R3,420 R1,860

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Bestmed Pace 4 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: optometry, maternity, specialised radiology, trauma rehab, some medication, contraceptives and preventative benefits. Limits apply. All else paid from extended fund, from savings or out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 26 conditions covered at 85% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: R15,550 per person and R31,150 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,096 R6,096 R1,428
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Optometry, maternity, specialised radiology, trauma rehab, medication, contraceptives and preventative benefits. Limits apply. All else paid from extended fund, from savings or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R996 R996 R516

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2. Acute (presrcibed) medication:
  • Limited to M1= R6,950 and M1+ =R10,800 with 10% co-payment
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from savings
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Spectramed Azure A 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMB: 4 more conditions, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,371 R1,875 R1,016
Children: Pay for max 3 children, with 2nd child=R616 and 3rd child=R415pm
Income limit: R0-R8,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,488 R4,164 R2,256

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 5 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • All medication must be on formulary, otherwise no benefit
  • All medication must be obtained from DSP, otherwise 40% co-payment

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Fedhealth Blue Door E: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Scheme pays out-of-hospital claims for: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,378 R2,061 R895
Children: Pay for all children
Income limit: R12,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
6. Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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Resolution Millennium Select 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs: Additional 10 conditions covered
  • M= R2,649 and M+= R5,310. Thereafter, only PMBs covered.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,819 R3,271 R890
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R9,180 R7,848 R2,124
(SP) Self Payment: R4,391 R3,409 R849
Threshold (S+SP): R13.571 R11,257 R2,973
Above Threshold: 5,544 4,728 774

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, subject to sub limits below
MM1M2+
R5,899R8,137R9,673
3. Over-the-counter:
  • Shared with acute medicine limit, subject to sub limits below
MM1M2+
R1,748R2,438R2,872
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R1,496 per female, from preventative benefit limit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Reference and GRP pricing apply

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Medshield MediSaver 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), alternatives to hospitalisation, some non-surgical procedures including scopes, maternity, preventative benefits, dentistry. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,571 R2,151 R615
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), alternatives to hospitalisation, some non-surgical procedures including scopes, maternity, preventative benefits, dentistry. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R6,192 R5,184 R1,476

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • R185 per script from day-to-day benefit
4. On Discharge:
  • R600 per admission
5. Birth Control:
  • R140 per monthly script
  • Mirena: one per female every four years. Includes consultation, insertion if done in rooms.
6. Notes:
  • PMB: Restrictive formulary
  • Out of formulary PMB or obtained from non-network provider: 40% co-payment
  • PMB: reimbursed at Maximum Generic Price

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Makoti Primary E 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
PMBs only, in state hospitals
Contributions:
Main: Adult: Child:
Total Cost: R611 R490 R223
Children: Pay for all children
Income limit: R12,001-R16,000 (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
6. Notes:

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Medihelp Dimension Prime 3 Network 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Some co-payments. Scheme pays out-of-hospital claims for: radiology (co-payment), pathology, GPs, specialists, supplementary services, medicine, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
>
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,184 R1,848 R636
Children: Pay for maximum 2 children under 18yrs.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, GPs, specialists, supplementary health and medication, dentistry, optometry, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Shared with the GP, specialists, mental health, supplementary services
Main M1 M2 M3+
R5,700 R9,550 R11,700 R12,600
3. Over-the-counter:
  • See "Acute medicine" benefit
4. On Discharge:
  • R320 per admission
5. Birth Control:
  • See "Acute Medicine" benefit, above
6. Notes:
  • PMBs chronic: only 40% of the reference price is paid if medicine is outside the formulary and/or obtained from non-network provider
  • For acute and non-PMBs chronic medicines:
    • 80% of scheme rate where no generic is available
    • 70% of MMAP (maximum medical aid price) for voluntary use of original medicine where generic is available

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Hosmed Plus 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, mental health, supplementary services, maternity benefits, preventative benefits, Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs chronic: R12,600 per person, and R24,060 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,184 R3,115 R700
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: GPs, specialists, medicine, pathology, radiology, specialised radiology, optometry, dentistry, appliances, mental health, supplementary services, maternity benefits, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Overall out-of-hospital annual limit for : Acute medicine, advanced dentistry, alternative services, biokinetics, physio, remedial and other therapies and mental health:
Main M+1 M+2 M+3
R10,960 R23,090 R25,200 R27,750
2. Acute (presrcibed) medication:
  • R4,800 per person, and R9,400 per family
3. Over-the-counter:
  • R975 per family, with a maximum of R191 per script
4. On Discharge:
  • 7 days
5. Birth Control:
  • R120 per person, limited to R1,440 per family per year
6. Notes: Medicines paid at reference price, subject to formulary

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Momentum Custom Associate (and State provider for chronic) 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. State hospitals. Chronic benefits at State facilities. Scheme pays out-of-hospital claims for: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from State provider
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,266 R957 R448
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: maternity, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • No benefit
3. Over-the-counter:
  • No benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • No benefit
6. Notes:

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Momentum Incentive Network hospital (and State provider for chronic) 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Network hospitals. Chronic benefits at State facilities. Scheme pays out-of-hospital claims for: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme, from State provider
  • non-PMBs chronic: additional 6 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,700 R1,333 R883
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,040 R2,040 R1,600

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Momentum Extender Network hospital (and State provider for chronic) 2017: Medicine Benefits
In brief: 200% scheme rate for specialists. Network hospitals. Chronic benefits from State provider. Comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
1. Chronic:
  • PMB chronic: paid by scheme, from State provider
  • non-PMBs chronic: additional 36 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,732 R2,805 R1,149
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: comprehensive plan, with out of hospital benefits paid by scheme from threshold (with sub-limits), once savings run out and self payment gap has been paid.
Main: Adult: Child:
(S) Savings: R11,196 R8,415 R3,447
(SP) Self Payment: R5,904 R6,385 R1,653
Threshold (S+SP): R17,100 R14,800 R5,100
Above Threshold: No limit No limit No limit

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, R15,100 per person and R28,400 per family
3. Over-the-counter:
  • Paid from day-to-day benefit
    • , but does not accumulate to threshold
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:

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Topmed Executive 2017: Medicine Benefits
In brief: 200% scheme rate fro specialists. Scheme pays most out-of-hospital claims for: maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of-pocket unless PMB. Sub-limits apply.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: paid by scheme
  • Limited to R8,650 per person and R17,350 per family. Thereafter, only PMBs medication is unlimited.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, limited to R10,644 per person and R21,084 per family
3. Over-the-counter:
  • Paid from day-to-day benefit, up to acute medicine limits
  • Not payable from above-threshold benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit, up to acute medicine limits
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Bestmed Beat 3 Network 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Network hospitals. Some co-payments. Scheme pays out-of-hospital claims for: preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 5 conditions covered at 75% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: R2,700 per person and R5,450 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, but sub-limits can apply
Contributions:
Main: Adult: Child:
Total Cost: R2,123 R1,509 R820
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, wound care, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,332 R3,084 R1,668

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Spectramed Azure B 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMB: 4 more conditions, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,501 R2,206 R1,137
Children: Pay for max 3 children, with 2nd child=R865 and 3rd child=R604pm
Income limit: R8,001- R11,500 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R7,776 R4,896 R2,520

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 5 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • All medication must be on formulary, otherwise no benefit
  • All medication must be obtained from DSP, otherwise 40% co-payment

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Resolution Supreme 2017: Medicine Benefits
In brief:
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs: Additional 28 conditions covered
  • M= R5,488 and M+= R10,964. Thereafter, only PMBs covered.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,565 R4,345 R1,130
Children: Pay for all children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Limit below shared with supplementary health, std radiology and pathology, physio, mental health, speech therapy and audiology, acute medication
MM1M2+
R7,424R13,067R14,191
3. Over-the-counter:
  • Paid from limit below, with these sub limits: M =R2,248; M1 =R3,873; M2+ =R4,229
  • Limit below shared with supplementary health, std radiology and pathology, physio, mental health, speech therapy and audiology, acute medication
MM1M2+
R7,424R13,067R14,191
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • R1,496 per female, from preventative benefit limit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Reference and GRP pricing apply

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Medshield MediBonus 2017: Medicine Benefits
In brief: Up to 200% scheme rate. Scheme pays out-of-hospital claims for: specialised radiology, maternity, alternative to hospitalisation, optometry, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 54 conditions covered
  • R11,910 per person and R23,815 per family, thereafter unlimited for PMBs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,119 R2,829 R819
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, optometry, preventative benefits. Limits apply. All else paid from extended fund or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: RM =R9,300
M1 = R13,040
M2 =R14,460
M3 = R15,930
M4 = R17,240		 R R

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Limited to M= R725 and M1+= R1,245 with R185 limit per script. From day-to-day benefit.
4. On Discharge:
  • R700 per admission
5. Birth Control:
  • R140 per monthly script
  • Mirena: one per female every four years. Includes consultation, insertion if done in rooms.
6. Notes:
  • PMB: Comprehensive formulary within limits, then Restrictive formulary
  • Out of formulary PMB or obtained from non-network provider: 40% co-payment
  • PMB: reimbursed at Maximum Generic Price

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Makoti Primary F 2017: Medicine Benefits
In brief:
1. Chronic:
Overall Annual Limit (OAL):
PMBs only, in state hospitals
Contributions:
Main: Adult: Child:
Total Cost: R656 R510 R235
Children: Pay for all children
Income limit: R16,001+ (other limits)
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
3. Over-the-counter:
4. On Discharge:
5. Birth Control:
6. Notes:

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Selfmed 80% 2017: Medicine Benefits
In brief:
1. Chronic:
  • 20% co-payment and R23,300 per person and R45,400 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,335 R5,485 R1,100
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • 20% co-payment and R5,800 per person and R17,200 per family
3. Over-the-counter:
  • 20% co-payment and R1,500 per family
  • Shared with acute medicine and birth control benefit
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • 20% co-payment and R1,500 per family
  • Shared with acute medicine and OTC benefit
6. Notes:
  • Chronic meds: Must be obtained from DSP. Formularies apply. Otherwise, 40% co-payment

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Medihelp Dimension Elite 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme pays out-of-hospital claims for: radiology (co-payment), pathology, GPs, specialists, supplementary services, psychologists, medicine, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMBs: 100% of MMAP up to limits below for generic medicines
Main M1 M2 M3+
R3,650 R5,500 R7,400 R7,950
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,972 R3,714 R1,080
Children: Pay for all children.
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: radiology (co-payment), pathology, GPs, specialists, supplementary services, psychologists, medicine, optometry, dentistry, maternity, infant paediatrics, medical appliances. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
Main M1 M2 M3+
R3,530 R5,870 R7,170 R7,730
3. Over-the-counter:
  • See "Acute Medicine" benefit
4. On Discharge:
  • R330 per admission
5. Birth Control:
  • See "Acute Medicine" benefit, above
6. Notes:
  • PMBs chronic: only 40% of the reference price is paid if medicine is outside the formulary and/or obtained from non-network provider
  • For acute and non-PMBs chronic medicines:
    • 80% of scheme rate where no generic is available
    • 70% of MMAP (maximum medical aid price) for voluntary use of original medicine where generic is available

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Topmed Comprehensive 2017: Medicine Benefits
In brief: 300% scheme rate. Scheme pays most out-of-hospital claims for: maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit (paid at 80% scheme rate) or out-of-pocket, unless PMB. Sub-limits apply.
1. Chronic:
  • PMBs chronic: covered
  • non-PMBs:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
3. Over-the-counter:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
  • Vitamins and Minerals: M= R2,460, Adult= R2,028 and child=R564
4. On Discharge:
  • 7 days supply
5. Birth Control:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
6. Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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Bestmed Beat 4 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Some co-payments. Scheme pays out-of-hospital claims for: preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
1. Chronic:
  • No. of chronic conditions covered: 27 CDLs and PMBs plus 5 conditions covered at 85% scheme rate
  • Co-payment if out of formulary: 40% co-payment
  • Overall limit: R5,900 per person and R11,800 per family. Once depleted, only CDL and PMBs will continue to be covered by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,618 R2,988 R895
Children: Pay for maximum 4 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: Preventative dentistry, optometry, maternity, specialised radiology, contraceptives, some medicine and preventative benefits. Limits apply. All else paid from savings, from extended fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R6,516 R5,376 R1,608
Extended Fund: R10,000 (main) R20,000 (family) R

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2. Acute (presrcibed) medication:
  • Limited to M1 =R2,250 and M1+ =R4,550
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit, limited to R525
4. On Discharge:
  • 7 days
5. Birth Control:
  • R1,800 per family per year, paid by scheme
6. Notes:

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Spectramed Azure C 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMB: 4 more conditions, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,651 R2,582 R1,282
Children: Pay for max 3 children, with 2nd and 3rd child=R1,175pm
Income limit: R11,500+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,100 R5,736 R2,844

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 5 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • All medication must be on formulary, otherwise no benefit
  • All medication must be obtained from DSP, otherwise 40% co-payment

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Medshield Premium Plus 2017: Medicine Benefits
In brief: Up to 200% scheme rate. Scheme pays out-of-hospital claims for: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
1. Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 54 conditions covered
  • R11,910 per person and R23,815 per family, thereafter unlimited for PMBs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit, with R185 script limit
4. On Discharge:
  • R700 per admission
5. Birth Control:
  • R140 per monthly script
  • Mirena: one per female every four years. Includes consultation, insertion if done in rooms.
6. Notes:
  • PMB: Comprehensive formulary within limits, then Restrictive formulary
  • Out of formulary PMB or obtained from non-network provider: 40% co-payment
  • PMB: reimbursed at Maximum Generic Price

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Spectramed Cobalt 2017: Medicine Benefits
In brief: 100% scheme rate for specialists. Scheme pays out-of-hospital claims for: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
1. Chronic:
  • PMB chronic: paid by scheme
  • non-PMB: 13 more conditions, paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R5,321 R4,831 R1,865
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: mental health, appliances, optometry, specialised dentistry and preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R14,688 R13,332 R5,148

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2. Acute (presrcibed) medication:
  • Paid from day-to-day benefit
3. Over-the-counter:
  • Paid from day-to-day benefit
4. On Discharge:
  • 5 days supply
5. Birth Control:
  • Paid from day-to-day benefit
6. Notes:
  • All medication must be on formulary, otherwise no benefit
  • All medication must be obtained from DSP, otherwise 40% co-payment

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Income limited plans

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