Option A Overview
This option is for you if you need higher than average healthcare needs for yourself and your family.
Substantial in and out of hospital for everyday benefits.
Extensive chronic medication cover.
CONTRIBUTIONS FROM 1 JANUARY 2025 | |||
Income | Member | Adult Dependant | Child Dependant |
All income | R8 787 | R8 430 | R2 052 |
Please note
- Adult dependants include spouses/partners, registered children age 21 and older (except children who are approved by the Scheme and who are full-time students registered at a recognised tertiary institution), parents and siblings dependant on the member;
- Your portion of the contribution will depend on your subsidy;
- If you are unsure of your subsidy, please check with your Human Resources Department.
BENEFIT OVERVIEW
Prescribed Minimum Benefit (PMB)
Chronic disease list – This is a list of the PMB conditions covered by the Scheme in terms of
legislation governing all medical schemes
- Addison’s disease
- Asthma
- Bipolar mood disorder
- Bronchiectasis
- Cardiac failure
- Cardiomyopathy disease
- Chronic renal disease
- Chronic obstructive pulmonary disease (emphysema)
- Coronary artery disease (anginapectoris and ischaemic heart disease)
- Crohn’s disease
- Diabetes insipidus
- Diabetes mellitus type Iand II
- Dysrythmias
- Epilepsy
- Glaucoma
- Haemophilia
- Hiv/aids
- Hyperlipidaemia
- Hypertension (high blood pressure)
- Hypothyroidism
- Multiple sclerosis
- Parkinson’s disease
- Rheumatoid arthritis
- Schizophrenia
- Systemic lupus erythematosus
- Ulcerative colitis
Extended Chronic Disease List
In addition to the diseases on the PMB list, members will also be covered for the following conditions
- Allergic rhinitis
- Alzheimer’s disease
- Ankylosing spondylitis
- Anti-migraine
- Atopic dermatitis
- Attention deficit syndrome
- Benign prostatic hypertrophy (BPH)
- Chronic anaemia
- Chronic urinary tract infection
- Cystic fibrosis
- Deep vein thrombosis
- Depression/mood disorder
- Dry eye syndrome
- Eczema
- Enuresis/incontinence
- Erythematosus
- Gastro-oesophageal reflux disorder (GORD)
- Gout/hyperuricaemia
- Hypoparathyroidism
- Meniere’s disease (anti- vertigo)
- Menopause (hormonereplacement therapy)
- Motor neuron disease
- Myasthenia gravis
- Osteoarthritis
- Osteoporosis
- Paget’s disease
- Pancarditis
- Para/quadriplegia
- Pemphigus
- Peptic ulcer
- Peripheral vascular disease
- Pituitary adenomas
- Post-bowel surgery
- Post-stroke treatment
- Psoriasis
- Scleroderma
- Sjogren’s syndrome
- Thrombocytopaenia
- Tourette’s syndrome
- Zollinger-ellison syndrome
Option A: Day-to-day benefits
The following table reflects the overall annual day-to-day benefits with sub-limits on Option A.
Service | Benefit limit |
OVERALL DAY-TO-DAY LIMITS | |
This benefit limit depends on family size; All sub-limits are subject to the overall annual day-to-day limit | Maximum annual limits: R9 500 per member R9 500 per adult dependant R1 830 per child dependant |
General practitioners (GPs) | |
Visits, consultations and outpatient visits | Subject to the overall day-to-day limit |
Network GP | 100% of negotiated rate |
Non-network GP (non-DSP) | 80% of cost or MSR, whichever is less Members are encouraged to make use of the GP network to minimise possible co-payments |
Specialists | |
Visits, consultations and outpatient visits | Subject to the overall annual day- to-day limit Benefits are only covered if: • a member was referred by a GP • AND Pre-authorisation was obtained from the Scheme for the first consultation at a given Specialist |
Preferred specialist | Paid at 100% of cost or 110% MSR, of the negotiated rate, whichever is less. Members are encouraged to make use of a preferred specialist provider to minimise short payments or co-payments. |
Non-preferred specialist | Paid at 100% of cost or MSR, whichever is less |
Acute medication | |
Prescribed (acute) medication | Subject to the overall day-to-day limit; 100% of medicine price and limited to: Member: R4 750 Adult dependant: R4 750 Child dependant: R920 |
Pharmacist-advised therapy (PAT) Medication will be subject to generic and/ or formulary reference pricing; If a member chooses to purchase a medication that is not on the Scheme`s formulary, the member will be required to pay the difference between the cost of the medication as a co-payment at the point of service | 100% of medicine price and limited to R1 920 per family per year Members are encouraged to make use of the Scheme’s pharmacy network to minimise possible co-payments |
Auxiliary services | |
Occupational therapy, speech therapy, physiotherapy, psychology, social workers, audiometry, chiropractors, dieticians | Paid at 100% of cost or MSR, whichever is less and limited to R3 140 per family per year; Subject to the overall day-to-day limit (Service must be obtained by an approved and registered paramedical and auxiliary service provider) |
No benefit for: Biokineticist, chiropody, orthoptists, orthotic consultations, remedial therapy, reflexology, homeopaths, naturopaths, acupuncturists, osteopaths, phytotherapists, ayuverdic practitioners,aromatherapists, therapeutic massage therapists and Chinese medicine | |
Palliative Care Programme | |
Alignd palliative care | Paid at 100% of cost or MSR, whichever is less. Payable from major medical expense benefit subject to the Overall Annual Limit |
OVERALL OPTICAL BENEFITS | |
Overall optical benefits every two years Includes frames, all prescription lenses/ add-ons, clear single vision, clear Aquity, flat- top bifocal, clear Aquity multifocal lenses, contact lenses and eye tests | Subject to R5 070 per beneficiary every two years, including a frame sub-limit of R1 600 |
OVERALL DENTISTRY BENEFITS | |
Basic dentistry Includes routine prophylaxis (prevention and treatment) scaling and polishing (cleaning), fluoride application, fillings, non-surgical tooth extraction and root canal treatment | 100% of cost or MSR, whichever is less; Subject to a maximum limit of R10 930 per family per year |
Advanced dentistry and dental implants Includes dentures, inlays/onlays, periodontal surgery, crowns and bridges as well as orthodontic treatment and dental implants All dentistry benefits are subject to the Scheme`s managed care protocols and benefits; All specialised/advanced dentistry procedures, including orthodontic services and dental implants, are subject to prior approval, except for plastic dentures; In- hospital dentistry is subject to prior approval and pre-authorisation; Refer to Annexure E for details of dental benefits and exclusions that are applicable | 100% of cost or MSR, whichever is less; Subject to a maximum limit of R20 370 per family per year |
PRIMARY CARE BENEFIT (PCB) (Out of hospital) | |
Radiology | Limited to R2 270 per family per year; Subject to MME |
Pathology | Subject to the Overall Day-to-Day Limit |
Contact Us
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Tel: 0860 100 078
Fax: 086 566 1372
Email: enquiries@medipos.co.za
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pre-authorisation & ICON)
0860 100 078
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Tel: 0800 112 811
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DISCLAIMER : The material and other information provided on this website is for educational, communication and informational purposes only and does not by any means supersede the rules of the Scheme. Please note that the scope of the Scheme and all terms and conditions are set out in detail in the rules of the Scheme. In the event of any discrepancy between this website and the rules of the Scheme, the rules of the Schemes always take precedence.