Inpatient Benefits

INPATIENT BENEFITS	COMPREHENSIVE	FLEXIBLE PLAN
Overall Annual Limit (OAL)	2 500 000 per beneficiary per annum	750 000 per beneficiary per annum
Travelling Expenses	1 200 per family per annum	900 per annum
Accommodation expenses	500 per night, limited to 2 nights per family per annum	375 per night, limited to 2 nights per family per annum
Blood and blood products	100% of ORHE tariff and Subject to Overall IP Limit	100% of ORHE tariff and Subject to Overall IP Limit
Consultations and Visits – (General Practitioners, Specialist and Nurse Practitioners)	100% of ORHE tariff and Subject to Overall IP Limit	100% of ORHE tariff and Subject to Overall IP Limit
Maxillofacial Surgeon	100% of ORHE tariff and Subject to Overall IP Limit	100% of ORHE tariff and Subject to Overall IP Limit
Hospitalisation In-Patient (Accommodation – General ward, Theatre fees, medicines, Material and Equipment)	100% of ORHE tariff and Subject to Overall IP Limit	100% of ORHE tariff and Subject to Overall IP Limit
TTO's	7 days	7 days
Alternative to Hospitalisation (Step Down nursing facilities, Private nursing, Frail care, Hospice and Physical Rehabilitation	17 480 per family	17 480 per family
Mental Health (in and out of Hospital)	15 170 per family	9 290 per family
Non-Surgical Procedures	100% of ORHE tariff and Subject to Overall IP Limit	100% of ORHE tariff and Subject to Overall IP Limit
Organ Transplant (for pathology and Radiology the separate benefit limits apply)	186 000 per family	152 000 per family
Oncology Radiotherapy & Chemotherapy (including medicine, radiology, and pathology)	278 000 per family	207 000 per family
Brachytherapy (within oncology limit above)	44 600 per family	44 600 per family
Pathology & Medical Technology	41 600 per family	20 700 per family
Physiotherapy and Biokinetics	2 310 M0 4 560 M1 6 820 M2+	780 M0 1 520 M1 2 410 M2+
Pregnancy/Confinement
Hospitalisation (Accommodation, theatre fees, Labour ward fees, drugs, dressings, medicines, and materials) Physio will only apply to post caesarean cases during hospital stay. Abnormal Vaginal delivery will be considered for physiotherapy on application & authorisation	33 100 per family	31 300 per family
Global fee for delivery within Maternity limit above	6 450 per family	6 140 per family
Prosthesis Internal External	57 200 per family 37 000 per family	26 800 per family No Benefit
Renal Dialysis Acute & Chronic – pathology and Radiology the separate benefit limits apply	101 000 per family	69 000 per family
Radiology & Radiography In Hospital (general & specialised – including CT scans, MRI Scans etc)	24 500 per family	16 200 per family
PET Scan and PET-CT scan Bone densitometry within Radiology limit	1 per family per annum	1 per family per annum
Surgical Procedures	100% of ORHE tariff and Subject to Overall IP Limit	100% of ORHE tariff and Subject to Overall IP Limit
Emergency Room Benefit	3 000 per beneficiary per Annum	2 000 per beneficiary per Annum
Ambulance Service (Emergency only)	15 170 per family	12 120 per family
Appliances – Medical and Surgical	12 230 per family	5 000 per beneficiary per annum

 

Outpatient Benefits

INPATIENT BENEFITS	COMPREHENSIVE	FLEXIBLE PLAN
Alcoholism and drug dependency	1940 per family	Subject to available Savings
Alternative health care Practitioners & Paramedical Services (audiology, biokinetics, chiropractors (including X-Rays), dieticians, Genetic Counselling, hearing aid acousticians, homeopathy, naturopathy (including medicines), occupational therapy, Orthoptic, physiotherapy, podiatry & speech therapy)	5460 per family	Subject to available Savings
Consultations – (General Practitioners, Specialist and Nurse Practitioners)	6 350 M0 7 240 M1 8 450 M2+	Subject to available Savings
Advanced Dentistry/Oral Surgery (Inlays, crowns, Bridges, Study models, Metal base, Oral medicines by: Orthodontists, Periodontists, Prosthodontists, and dental technicians)	5 250 M0 8 970 M1 12 440 M2+ 5 250 per beneficiary	Subject to available Savings
Basic/ Ordinary & Restorative (Including Plastic Dentures, Dental Technicians & Dental Therapist) Joint limit with Advanced Dentistry	2 150 M0 3 930 M1 5 560 M2+ 2 150 per beneficiary	Subject to available Savings
Osseo integrated Implants (Including hospitalisation, Dental practitioner, Anaesthetist) Joint limit with Advanced Dentistry	subject to clinical protocols	No benefit
Immune Deficiency (related to HIV/AIDS)	subject to clinical protocols	subject to clinical protocols
Chronic Medication Only cover for: asthma, allergic rhinitis, epilepsy, GORD, Hypertension, Diabetes (Type 1 &2), hyperlipidaemia Subject to registration	3 510 M0 6 510 M1 8 870 M2+	1 150 M0 2 360 M1 2 940 M2+
Acute Medication	4 620 M0 9 030 M1 12 750 M2+	Subject to available Savings
Pharmacy Advised Therapy (OTC) Within acute medicine limit Schedule 0,1,2 only	1 150 M0 2 150 M1 3090 M2+ 220 per script	Subject to available Savings 220 per script
Contraceptives Within acute medication limit	100 per script	Subject to available Savings 100 per script
Optometry Frames, Lenses, Readers One in 24 months claiming period	3 880 M0 5 580 M1 6 400 M2+ 3 880 per beneficiary	Subject to available Savings
Eye Examination	One per Beneficiary per year	Subject to available Savings
Refractive Surgery (Radial Keratotomy/Excimer Laser)	2 940 per family	No Benefit
Pathology & Medical Technology	6 140 per family	Subject to available Savings
Pregnancy/Confinement Services (Consultants, Visits & Scans) Ante-natal consults are from the consultation benefit and scans are from the radiology benefit and scans are limited to two	4 x post-natal midwife consultation per pregnancy	4 x post-natal midwife consultation per pregnancy Subject to available Savings
Radiology & Radiography Out of Hospital Within In-Hospital Radiology	3 990 per family	Subject to available Savings

 

 

Monthly Premium Rates

	COMPREHENSIVE		FLEXIBLE PLAN
	1-20 members	21- 499 members	1-20 members	21- 499 members	Additional Contributions for Savings for Flexible Plan
M0	2 800	2 661	1 048	996	Level 0	0
M1	3 943	3 747	1 475	1 401	Level 1	236
M2	4 403	4 182	1 646	1 564	Level 2	354
M3	4 628	4 398	1 731	1 644	Level 3	472
M4	4 736	4 501	1 771	1 683	Level 4	941
M5	5 043	4 791	1 886	1 792	Level 5	1410
Parent	1 432	1 360	1 048	996

	COMPREHENSIVE		FLEXIBLE PLAN
Private Members	<60 years	>=60 years	<60 years	>=60 years
Principal Member	2 862	8 584	1 139
Adult Dependant	1 432	4 293	570	1 708
Child Dependant	717	2 147	285	855
Parent	3 577	4 293	1 424	1 708

 

This Plan is subject to underwriting as per the Scheme Rules. Underwriting will be done at application stage. NPL: Medscheme Eswatini Price List NHRPL (SA): National Health Reference Price List (inside South Africa) SAOA: South African Optometrists Association