Option B Overview
This option is for you if you need comprehensive healthcare cover for yourself and your family; some peace of mind.
Doctors’ bills for the kids, specialist visits for you and your spouse and savings account benefit.
Extended chronic cover and for unforeseen hospital incidents.
| PREMIUMS FROM 1 JANUARY 2025 | ||||||||||||
| OPTION B | Contribution | PMSA (included in contribution) | ||||||||||
| Income | Member | Adult Dependant | Child Dependant | Member | Adult Dependant | Child Dependant | ||||||
| R0 – R8 185 | R3 363 | R3 159 | R996 | R151 | R142 | R45 | ||||||
| R8 186 – R11 140 | R3 510 | R3 312 | R1 044 | R158 | R149 | R47 | ||||||
| R11 141 – R14 985 | R3 675 | R3 486 | R1 104 | R165 | R157 | R50 | ||||||
| R14 986+ | R 3 768 | R3 579 | R1 131 | R170 | R161 | R51 | ||||||
Please note
- Adult dependants include spouses/partners, registered children age 21 and older (except children who are younger than 25 years of age 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 (angina pectoris and ischaemic heart disease)
- Crohn’s disease
- Diabetes insipidus
- Diabetes mellitus type I and 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
- Acne
- Allergic rhinitis
- Atopic dermatitis
- Attention deficit syndrome
- Depression/mood disorder
- Eczema
- Gastro-oesophageal reflux disorder (GORD)
- Gout/hyperuricaemia
- Menopause (hormone replacement therapy)
- Osteoarthritis
- Osteoporosis
- Psoriasis
Option B: Day-to-day benefits
The following table reflects the overall annual day-to-day benefits with sub-limits on Option B
| 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: R5 580 per member R5 580 per adult dependant R1 080 per child dependant |
| General Practitioners (GPs) | |
| Visits, consultations and outpatient visits | Subject to the overall annual 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, whichever is less. Members are encouraged to make use of a preferred specialist provider to minimise possible 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: R2 800 Adult dependant: R2 800 Child dependant: R550 |
| 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 280 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 R1 850 per family per year Subject to the overall day-to-day limit (Service must be obtained by an approved and registered paramedical and auxiliary healthcare 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 BENEFIT | |
| 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 R3 760 per beneficiary every two years, including a frame sub-limit of R1 200 |
| 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 R8 990 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 R13 490 per family per year |
| PRIMARY CARE BENEFIT (PCB) (Out of hospital): | |
| Radiology | Limited to R1 800 per family per year; Subject to MME |
| Pathology | Subject to the Overall Day-to-Day Limit |
Option B: Personal Medical Savings Account
MEDiPOS Medical Scheme offers an additional personal medical savings account (PMSA) benefit which is only available for Option B members. This benefit can be used for those unexpected medical costs. The benefit is provided to you annually and is available to you on 01 January every year.
Personal Medical Savings Account (PMSA) | ||
Your PMSA benefit is available in advance giving an annual upfront credit to be utilised in respect of the following medical services and supplies | ||
Copayments | Non-, non-DSP hospital, late authorisation copayments and medication reference price | |
Benefit exceeded | Any benefits were your limits have been exceeded | Advanced Savings |
Shortfalls | Tariffs above the MEDiPOS Scheme rate | |
Rejections | Specialist consultation not referred by a GP Benefits and authorisation that have been declined Non-oral contraceptives (patches, injectables, devices) | |
Waiting periods and certain exclusions including optical tints and hardening | Positive Savings Balance | |
Advanced savings
Total annual savings benefit of 12 months made available to you upfront on 01 January.
Positive savings
The monthly accumulated savings benefit that is carried forward every month.
Negative savings
Should you utilise your advanced savings before the end of the benefit year, you will have a negative savings balance and thus owe the Scheme. As we receive your monthly contributions for the remainder of the year, this will reduce your negative saving balance.
Contact Us
Client Services
Tel: 0860 100 078
Fax: 086 566 1372
Email: enquiries@medipos.co.za
Managed Care Services (including hospital
pre-authorisation & ICON)
0860 100 078
MEDiPOS Anti-fraud Hotline
Tel: 0800 112 811
24 Hour Pre-Auth Guide
Walk-in Centres
POPIA
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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.