Suremed Explorer A medical aid plan: 2017

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. Pay for all children. Income-limited plan: R0-R7,500pm only

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
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-

Compare with these plans:
Hospital Choice:
  • Network
Specialised Radiology:
  • 2 scans per family,in and out of hospital
Supplementary Services: (Physio, etc)
  • Physiotherapy: R3,300 per family
Transplants:
Co-payments: none
Alternatives to hospitals:
  • Private nursing and step down facilities: R12,500 per family
  • Hospice: R20,000 per family

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • 12 consults per person
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-

Compare with these plans:

Specialists consultations:
  • R3,000 per person, if referred
Pathology:
  • Unlimited if referred by GP
General radiology:
  • Unlimited if referred by GP
Specialised radiology:
  • 2 scans per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

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MATERNITY BENEFITS:
Hospital stay:
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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Consultations:
  • 2 consults, and one paediatric consult. Paid by scheme.
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
Note: All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
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-

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: unlimited, through Prime Cure provider
  • Specialised dentistry: 1 set of acrylic dentures. Every 2 years, limited to R3,150 and paid at 80%
  • In-hospital: no benefit
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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Orthodontics:
Maxillo Facial Surgery:

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MEDICATION:
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-

Compare with these plans:
Acute (presrcibed) medication:
  • Unlimited if prescribed by nominated provider, limited to R70 per event
Over-the-counter:
  • R230 per person and R265 per family
Birth Control:
On Discharge:
  • R300 per event
Notes:

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OPTOMETRY:
Optometry:
  • Eye test
  • One pre-selected frame every 2 years
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-

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
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-

Compare with these plans:


Out-of-hospital:

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OTHER BENEFITS:
General Appliances:
  • R3,700 per family, at preferred provider in and out of hospital
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-

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport: ER24
International Coverage:
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
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-

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
Child Immunisation:
Pap Smear:
Mammogram:
PAS Test:
HIV Test:

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PROSTHESIS:
Overal Limit:
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-

Compare with these plans:
Sub-limits:

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