SAB MEDICAL AID BENEFITS - 2021 Your guide to - mymembership
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You r gu i d e t o SAB MEDICAL AID BENEFITS 2021
Content s
3 How the Scheme works
What’s the difference between traditional medical schemes and new-
generation medical schemes? And where does SAB Medical Aid fit into the
mix? We explain it all.
4 Essential vs Comprehensive
SAB Medical Aid offers two Options: Essential and Comprehensive. But how
do you choose the right Option? Our comparison table can help you make
an informed decision.
6-17 What we cover
Medical schemes are complex by nature, but that doesn’t mean they have to
confuse you. Here we unpack all of the benefits available to you.
7 Chronic Benefits
If there’s medicine you need to take every day, you may have a chronic
condition. Find out if your condition is on our list and if so, how to register,
which service providers to use, what reference pricing means and how to
choose a network pharmacy.
Prescribed Minimum Benefits (PMB) and the Chronic Disease List (CDL)
Chronic Care Management
1
Reference pricing and medicine management
Choosing a network pharmacy
reatment baskets for Prescribed Minimum Benefit (PMB) Chronic
T
Disease List (CDL) Conditions.
6 Day-to-day Benefits
We explain more about your Day-to-day Benefits, which relate to all out-of-
hospital benefits such as consultations with doctors, dentists, specialists,
optometrists, and acute medication.
11 Patient Advocacy
As a consumer and a member of SAB Medical Aid, you’re allowed to
negotiate prices with your Healthcare Providers – and to shop around if
they’re unaffordable. We show you how and explain why.
12 SAB Medical Aid Provider Networks
Getting the right treatment is critical, but so is getting it at the right cost –
otherwise you’re wasting the money you need for other things. We explain
about the Provider Networks, the group of medical service providers whose
fees we’ve already negotiated on your behalf.
Content s
15-18 Benefit options
Find out how your Benefit Option has you covered for day-to-day and Major
Medical Benefits.
20-21 The Wellness Benefit
Here we show you how to proactively manage your health (via the
Early Detection Programmes and Immunisations) and make your benefits
last longer.
22 Other areas we can help with
We want to help you if you’re pregnant, undergoing cancer treatment,
are HIV-positive or if you’re faced with a medical emergency. Find out S outh Afric an
Me dic al S cheme s
how we can support you.
Maternity Management Programme
Oncology Management Programme There are two types of medical schemes, differentiated as follows:
Netcare 911
Traditional
Aid for AIDS Programme
Out-of-Hospital DTP PMB.
These are usually closed corporate medical schemes. Contributions from all members are
pooled and all medical claims are paid using funds from the medical scheme’s pool of
money. The size of the pool determines what benefits can be covered for all members.
23 Benefit Exclusions
2
Limits start fresh each year, so if you don’t use a particular benefit in a particular year, 3
As with all medical schemes, there are certain procedures and treatments we
it doesn’t carry over to the next year.
do not cover. Find out what these are so that you’re a well-informed member.
In essence, traditional cover generally means that most of your medical expenses are
covered from the medical scheme’s pool of money within the rules and benefits of the
24 Admin How-to’s medical scheme and up to certain limits.
How to claim? You’ve seen a doctor and now you’d like to be refunded for
your claim. But what’s claimable? And when will the money be reimbursed?
We’ll explain.
New Generation
These are open medical schemes like Discovery Health Medical Scheme, Momentum
27 Admin Information Health, Bonitas Medical Scheme and others. They generally cover major medical costs
Who’s covered? And how do you get cover? Like all medical schemes, we like hospitalisation and chronic medicine from the medical scheme’s pool of money, but
have to be firm about who we cover and when, so that we can keep your day-to-day expenses, like visits to a GP, dentist, optometrist, X-rays, and medicine come
contributions as low as possible. You can find all the details here. out of the member’s own savings account. If savings aren’t fully used, they carry over to
the next year.
29 Q & A: Provider Networks
These Networks consist of providers who charge pre-negotiated rates.
How the S cheme Work s
Learn about these Networks.
31 Contact Us As you know, health is unpredictable and the costs of quality healthcare in South Africa
This is where you can find the info to contact us, compliment us or complain are rising all the time. Even if you take good care of yourself and your health, you don’t
about us. Hopefully more of the first two; less of the last. Either way, we’re want to be caught off guard by an accident, an unforeseen illness or even the high costs
at your service of a pregnancy, appendectomy or X-rays.
Remember
Complaints and Appeals In our country, the Medical Schemes Act (131 of 1998) regulates all medical schemes.
Benefits and contributions for
Since the healthcare industry is constantly evolving and undergoing changes, so does
Contact Information. 2021 are subject to approval by
SAB Medical Aid undergo changes to ensure that it stays abreast of industry
the Council of Medical Schemes.
developments. This allows members to make the most informed and most
appropriate choices possible within SAB Medical Aid.
W hat ab out S A B Me dic al A id ? Choosing the right benefit Option
SAB Medical Aid is a closed corporate medical scheme. higher than the Scheme Rate). We also offer our members The table below gives you a brief summary of the different benefits and inclusions we offer on the Essential and the
We aim to give our members the best of both worlds. something unique: both Options have a wellness component Comprehensive Options. See at a glance the benefits offered for each Option to help you make an informed decision.
The Essential Option is considered a traditional medical to them, which encourages health awareness and provides
scheme option. The Comprehensive Option is also a peace of mind via preventative care and early detection.
traditional medical scheme option with a savings element. Review the Option comparison on page 5 so that you can E S S E NT I A L COM P RE H E NS IVE
These savings are used for co-payments and discretionary easily identify the Option with the benefits that will suit you OVERALL ANNUAL An overall annual limit applies Unlimited
medical spend (such as over-the-counter medicine and fees and your budget. LIMIT R426 055 per family*
MEDICAL SAVINGS No savings 10% savings
ACCOUNT This always remains the members’
Acute Hospital Network Hospital of choice
Specialist Network (if you use a non-network specialist, pecialist Network (if you use a non-network specialist,
S
you may have to pay for out-of-pocket expenses) you may have to pay for out-of-pocket expenses)
MAJOR MEDICAL
BENEFITS
Refractive surgery
Various sub-limits
for day-to-day medical Specialised dentistry benefits, subject to limits
expenses
Subject to pre-authorisation, limits and patient advocacy
(see page 5)
26 Prescribed Minimum Benefit (PMB) Chronic Disease 6 Prescribed Minimum Benefit (PMB) Chronic
2
Major Medical Risk Pool List (CDL) conditions Disease List (CDL) conditions + 28 additional non
pays for hospitalisation and other major PMB CDL conditions
medical expenses
Network Providers – SABMAS Pharmacy Network
CHRONIC BENEFIT
(20% co-payment if you use a non-Network Provider) Network Providers – SABMAS Pharmacy Network
(20% co-payment if you use a non-Network Provider)
Wellness
WellnessBenefit
Benefit
(see pages 20-21)
(see page 16) Subject to medicine reference pricing and approval
ubject to overall annual limit with certain sub-limits
S Subject to Routine Benefit
(GPs, specialists, dentists, acute medicine, physiotherapy
Essential Option and biokinetics, remedial and other therapies)
Subject to certain sub-limits
(GPs, specialists and dentists)
No Routine Benefit
10% savings
4 No savings 5
DAY-TO-DAY
20% co-payment payable from savings or deducted
BENEFIT
20% co-payment deducted from salary, or is deducted from salary, or is deducted by debit order if you are
by debit order if you are a self-paying member a self-paying member
Limited Optical Benefit Enhanced Optical Benefit
Medical
Savings Account
Unused benefits are not carried over to the next year Unused savings balances are carried over each year
(10%)
Unused benefits are not carried over to the next year
or your chosen GP or 3 consultations with a different
F 0% of the lower of cost or Scheme Rate R4 857**
8
Day-to-day
GP: 80% of the lower of cost or Scheme Rate R2 203 per beneficiary including minor procedures and
covers your routine day-to- CONSULTATIONS
Es sential v s
per beneficiary including minor procedures and consumables.
day medical expenses AND VISITS WITH
consumables. For a GP who has not been chosen, where
A GP (OUT-OF-
3 consultations have been depleted: 60% of the lower
HOSPITAL)
Comprehensi ve
of cost or Scheme Rate R2 203 per beneficiary including
Major Medical Risk Pool
minor procedures and consumables
pays for hospitalisation and other major
medical expenses CONSULTATION
If referred by GP: 80% of the lower of cost or Scheme 0% of the lower of cost or Scheme Rate R4 857**
8
AND VISITS WITH Rate R2 147 beneficiary. If not referred by GP: 60% of the per beneficiary including minor procedures and
Changing between Options SPECIALISTS lower of cost or Scheme Rate R2 147 per beneficiary consumables.
Wellness Benefit (OUT-OF-
(see pages 20-21) HOSPITAL)
Please note that you can only change between the
WELLNESS A basket of early detection and preventative tests paid from the Scheme’s risk pool, which helps your Day-to-day Benefit last
Comprehensive and Essential Options at the end of the year
BENEFIT longer and keeps you on track with your health status
for the following year. Specific dates for the Option change
Comprehensive Option 100% of the agreed rate for the diagnosis, treatment and 100% of the agreed rate for the diagnosis, treatment and
window period are published online at www.sabmas.co.za. PRESCRIBED
care costs of PMB conditions, if those services are obtained care costs of PMB conditions, if those services are obtained
During this time, you can change either from Essential to MINIMUM
from a Network Provider. Benefits may be subject to pre- from a Network Provider. Benefits may be subject to
BENEFITS (PMB)
Comprehensive, or vice versa. Please remember that Option authorisation and/or managed care protocols preauthorisation and/or managed care protocols
changes take effect on 1 January each year.
MONTHLY Lower, as there are limited benefits and restricted access igher, as there are richer benefits and more freedom
H
CONTRIBUTIONS of choice
*
All claims accumulate to this limit. Once the available sub-limit and/or annual limit has been reached, you will only have cover for PMB treatment.
**
This is a shared limit for GP and Specialist Out-of-hospital consultations.
2. Chronic Benefits
Prescribed Minimum Benefits (PMB) and the Chronic Disease List (CDL)
All medical scheme members have access to a certain Please refer to page 14 for the list of hospitals within the
minimum level of health services. PMBs are defined in the Acute Hopsital Network and visit www.sabmas.co.za to
Regulations to the Medical Schemes Act as the level of search for a Healthcare Provider.
minimum benefits available to all members and their
As part of PMBs, 26 chronic conditions, excluding HIV/AIDS,
dependants.
on the CDL are covered, as well as any chronic condition
To ensure that you have full cover for the treatment of included in the 270 PMBs. The 270 PMB conditions are
your PMB condition in hospital, we have created a Hospital linked to a specific diagnosis and treatment guideline known
Network for PMBs. The Acute Hospital Network will serve as Diagnosis and Treatment pairs. Members will receive
as the Scheme’s PMB Hospital Network for both the treatment for conditions on this list, subject to registration,
Comprehensive and Essential Option. approval, formularies and use of a Network Provider.
When you make use of the Acute Hospital Network along To view the complete list of DTPMB conditions, please visit
with a Healthcare Provider in the SABMAS Provider Network, www.medicalschemes.com
your entire PMB hospital event will be covered in full.
The 26 CDL conditions, (excluding HIV/AIDS and Diabetes type 1 and
type 2) covered on the Essential and Comprehensive Options are:
W hat we cover E S S E NT I A L
1. Addison’s disease
COM P R E H E NS I V E
14. Dysrhythmias
2. Asthma 15. Epilepsy
1. Day-to-day Benefits
3. Bipolar mood disorder 16. Glaucoma
4. Bronchiectasis 17. Haemophilia
We are one of the very few medical schemes to offer you both a savings account (on the Comprehensive
5. Cardiac failure 18. Hyperlipidaemia
Option) and routine benefits. The value of the Routine Benefits will differ depending on your family size.
6 6. Cardiomyopathy 19. Hypertension 7
7. Chronic renal disease 20. Hypothyroidism
1. There’s an 80/20 co-payment structure
8. Chronic obstructive 21. Multiple sclerosis
When you claim for a doctor or dentist consultation, the Scheme pays 80% of the Scheme Rate. The other 20% is first paid from pulmonary disease 22. Parkinson’s disease
your available savings if you’re on the Comprehensive Option, otherwise it comes off your salary, or is deducted by debit order
9. Coronary artery disease 23. Rheumatoid arthritis
if you are a self-paying member.
10. Crohn’s disease 24. Schizophrenia
11. Diabetes insipidus 25. Systematic lupus erythematosus
2. There are set limits and sub-limits 12. Diabetes mellitus type 1 26. Ulcerative colitis
Please refer to page 15, which will take you through the limits and sub-limits of certain benefits so that your savings (if 13. Diabetes mellitus type 2
you’re on the Comprehensive Option) can go further.
In addition, the following non-CDL conditions are covered by the
If you are on the Essential Option, and have depleted your limits, you will need to pay from your own pocket.
Comprehensive Option only:
COM P R E H E NS I V E
1. Acne 15. Endocarditis
2. A
ttention Deficit Hyperactivity 16. Gastro-oesophageal
Disorder (ADHD) reflux disease
3. Allergic rhinitis 17. Gout
4. Alzheimers 18. Heart valve disease
5. Ankylosing spondylitis 19. Hepatomegaly and splenomegaly
6. Benign prostatic hypertrophy 20. Hypoparathyroidism
7. Carcinoid syndrome 21. Menopause
8. Cardiac dysrhythmias 22. Osteoarthritis
REMEMBER
9. Cerebral palsy 23. Osteoporosis
If your doctor charges more than the Scheme Rate, you will 10. Cerebrovascular disease 24. Paraplegia/quadriplegia
need to pay the extra amount above the Scheme Rate. This
11. Congenital malformation of heart 25. Polycystic ovarian syndrome
amount above the Scheme Rate can be funded from your
12. Depression 26. Psoriasis
available savings (Comprehensive Option).
13. Deep vein and other thrombosis 27. Pulmonary hypertension
14. Eczema 28. Stroke
Advanced Illness Benefit (AIB) and Compassionate Care Benefit (CCB)
Through the Advanced Illness Benefit (AIB), SABMAS will ensure that members with advanced cancer have access to comprehensive
palliative care that offers quality care in the comfort of their own home, with minimum disruption to normal routine and family
life. In the same way, the Compassionate Care Benefit (CCB) will offer these additional benefits to members who have advanced
diseases, other than cancer.
Choosing a pharmacy
Chronic Care Management
1 | Remember that if you use a pharmacy in our Network your 3 | When the pharmacist dispenses medicine, feel free
out-of-pocket expenses can be reduced. More than 90% of to ask if there’s a less expensive generic or alternative.
The Scheme applies clinical guidelines to assess each Our chronic medicine application process is telephonic pharmacies in South Africa are part of our Network. Visit Pharmacists are qualified and required by law to
chronic application and ensure the suggested medicines are and real-time. Ask your doctor to contact the Customer www.sabmas.co.za and look under Pharmacy Network substitute with alternatives, unless otherwise mentioned
appropriate, correctly prescribed and cost effective. You will Care Centre on 0860 002 133 and speak to a pharmacist where you will find a list of SABMAS Network Providers. on your prescription.
need to apply for all Chronic Benefits. to approve your medicine.
2 | If you choose not to use a pharmacy in our network, 4 | Question any co-payments (amounts you have to
you should shop around. Ask each pharmacy what their pay from your own pocket) and find out the reason
Reference Price and Medicine Management dispensing fee is (in short, how much they add to the cost behind the co-payment – like Reference Pricing and
of the medicine for giving it to you). dispensing fees.
The Reference Price is the maximum price that the Scheme Pricing structure, looking at new medicine that has emerged,
will pay for a group of medicines within the same therapeutic medicine discontinuations, medicine enhancements, clinical
Treatment baskets for the Prescribed
class. If you claim for a medicine that is more expensive than literature, price changes and other factors.
the Reference Price, you’ll have to pay in the difference out of Minimum Benefit (PMB) Chronic
To search for the Reference Pricing page on our website, log
your own pocket at the pharmacy.
in to www.sabmas.co.za and then click on Health and then
Disease List (CDL) conditions
When we set the Reference Price, we always make sure that Chronic Illness Benefit. In the diagram below, we unpack
there’s a choice of clinically appropriate drugs at or below Reference Pricing, Network Providers and dispensing fees to Members who are registered with a chronic condition that
the Reference Price. We also regularly review the Reference help you save money when obtaining your chronic medicine. falls within the Chronic Disease List conditions listed as
Prescribed Minimum Benefits, will now be eligible for a new
8
chronic medicine basket. This includes defined tests and a 9
limited number of specialist consultations, all of which are
covered up to the Scheme Rate for each year.
To view the document on treatment baskets that lists
EXAMPLE A EXAMPLE B the procedures, investigations and specialist consultations
we cover for your approved PMB CDL conditions, visit
Member has hyperlipidaemia (high cholesterol) Member has hyperlipidaemia (high cholesterol) www.sabmas.co.za.
and requires chronic medicine. They do NOT use and requires chronic medicine. Member uses a
a Network pharmacy and refuse to try Network Provider and takes the less expensive The number of tests and consultations are calculated based
a less expensive alternative. alternative that the Scheme pays for. on the number of months left in the year at the time we approve
cover for your condition. If you have cover for the same
procedures or tests from more than one basket, we limit funding
to the basket that gives you the most procedures or tests.
It is important that the correct ICD-10 code is used when your
Medicine: Lipitor costs: R280.85 (incl. dispensing fee) claim is submitted to the Scheme. This is to make sure we pay
Medication: Therapeutic alternative Atorvastatin costs:
from the correct benefit.
Cost of less expensive alternative covered by Scheme: R45.99 (incl. dispensing fee)
R45.99 (The member must pay R234.86 to the pharmacy) If you need more cover than what is included in the
As the pharmacy is part of the Network, the Scheme
treatment basket, your doctor may follow an appeals process
A member who uses a non-network pharmacy will will pay the claim in full to the amount of R45.99.
to request extra funding for the tests, procedures and
have an additional 20% co-payment of R9.19, which he
consultations you need. Your doctor needs to complete a
or she must pay to the pharmacy at the point of sale,
form titled: Request for additional cover for approved Chronic
i.e. final cost covered by the Scheme will be R36.80
Disease List conditions, which can be downloaded from
(R45.99 less R9.19) if a non-network pharmacy is used.
our website at www.sabmas.co.za and sent back to us for
review. It is important to note that an appeals process does
FINAL COSTS FINAL COSTS
not guarantee approval for the additional cover.
Paid by Scheme: R36.80 Paid by Scheme: R45.99
Paid by member: R244.05 Paid by member: R0.00
Note that the rand values given above are provided purely for illustration – medicine prices may fluctuate from time to time.
3 . Major Me dic al Benef it s 4 . P atient
It probably won’t surprise you to hear that hospitalisation is the most expensive benefit we provide. All those Ad voc ac y
scans, surgeries and specialists cost a fortune in hospital. The Major Medical Benefit gives you cover for
hospitalisation and certain out-of-hospital procedures. These procedures can be performed in a doctor’s room, SAB Medical Aid is consistently at work to add a large range
a registered day clinic or an outpatient facility, if treatment is clinically appropriate and pre-authorised. of Healthcare Providers to our SABMAS Provider Networks
for your convenience. Our SABMAS Provider Networks
have been contracted to the Scheme to provide you with
Pre-authorisation quality healthcare at negotiated rates. Negotiated rates
are paid in full by the Scheme, protecting you from out-of-
pocket expenses and therefore saving you money. It is each
You need to get pre-authorisation for planned admissions,
member’s responsibility to ensure that you are consulting
before being admitted to hospital, as well as for certain out-
of-hospital procedures. But in an emergency, when there’s no with a provider in the Network.
time to think about these things, we make an exception – so Visit www.sabmas.co.za to search for a Healthcare Provider
you can get authorisation afterwards. This must be done within
in your area.
48 hours of admission to avoid penalties. (Also, please see the
Netcare 911 information on page 20).
Medical procedures
To get pre-authorisation, call 0860 002 133 and have
the following information on hand: Medical procedures often include services from more than
Membership number one Healthcare Provider. Please contact our Customer Care
Name of admitting doctor Centre on 0860 002 133 to determine if the Healthcare Provider
involved in your procedure form part of the Network. You will
Name of hospital
benefit from using specialists on this Network, as they charge
Diagnosis
the agreed reimbursement rate, therefore the claim will be
The diagnostic code/s (called the ICD-10 code) settled in full by the Scheme without any co-payments payable
Procedure to be performed – with relevant tariff codes. by the member.
If you do not use Healthcare Providers that form part of the
10 You will get this information from the Healthcare Provider Network, please ensure that you negotiate reduced rates 11
referring you to hospital. Pre-authorisation is given once prior to the procedure, as you will be liable for the shortfall
benefits have been checked and the Scheme Rules have been
between the rates charged and the Scheme’s Rate.
applied. As an example, if you are on the Essential Option, we
check to see whether you have used all your benefits. If a hospital A little preparation will go a long way to curb exorbitant
or a doctor obtains authorisation on your behalf, you are medical costs, making sure you get the right quality
responsible for obtaining the information that has been treatment at the right cost.
given to your hospital or doctor.
We asked one of our customer care agents how
Patient Advocacy has helped save a member money.
Here’s her story:
There are so many
‘A member called in asking for pre-authorisation for
things in life that you
shoulder surgery. I asked if she had discussed the costs
with her doctor upfront. She hadn’t, so I advised her
spend ages deciding
to get a breakdown of the costs of the procedure. She
received a written quote from her doctor.
to buy. You shop
We looked at the quote, and found that the around. You ask
anaesthetist’s charge was very high. I advised her to
call her doctor to discuss this cost. questions. You quiz
It turned out that the anaesthetist was happy to negotiate,
which ended up saving her thousands of rands.
the salesperson.
All members should feel free to discuss costs with their
doctors – just as they would with a builder or painter.
So, talk to your
PLEASE NOTE: If you don’t feel comfortable, get a second opinion.’
Healthcare
If you do not get pre-authorisation for
a planned procedure, you may have to Provider too!
pay the full account yourself.
5. S
A B Me dic al A id Prov ider Net work s
Below is an example of how the Specialist Network works:
General Practitioner
Network
A B C
Our GP Network consists of 1 | The specialist is not on the SABMAS 1 | The specialist of your choice is not 1|Y
ou meet with the non-network
Preferred Providers who have Specialist Network. You request the on the SABMAS Specialist Network. specialist who takes you through
contracted with the Scheme in order details of a specialist who is. You decide not to switch to a provider the procedure.
to provide you with quality care at an who is.
affordable rate.
2 | You visit the new specialist to discuss 2|Y
ou meet with the specialist, who 2|Y
ou contact our Customer Care
If you visit a medical practitioner the procedure. You are prepared takes you through the procedure. Centre. The agent takes you
who forms part of our GP Network, with questions: What will be done? through the Patient Advocacy
the provider will not charge more How long will I stay in hospital? Who process, see page 10 for more
than the contracted rate. That means is the anaesthetist you partner with? information.
the only co-payment you may incur Are they on the SABMAS Specialist
is the 20% co-payment, as per the Network? If not, can you choose one
Scheme Rules. who is? (Remember, you are the
Please be aware that if you do not consumer).
use a provider who is part of the 3 | Now that you have all the details 3|Y
ou contact the Customer Care Centre 3|Y
ou go back to the non-network
GP Network, you will still only be of your procedure (not just a weird to get your authorisation number. specialist and discuss the costs.
reimbursed at 80% of the Scheme code), you contact the Customer Care They give you authorisation for the You try to negotiate on rates or
Rate and therefore may have co- Centre and check if all the costs will procedure and inform you of the a discount for payment upfront.
payments greater than 20% if the be covered. portion of costs you have to pay. You ask questions such as how
provider charges more than the In addition, you’ll receive an email long it will take, what’s involved,
Scheme Rate. or an SMS to confirm all your the anaesthetist and their rates,
authorised benefits. etc.
All members on the Essential Option Optometry Network
12 are required to choose a GP to visit. 4 | The Customer Care Centre may 4|Y
ou undergo the procedure. 4 | The non-network specialist agrees
13
If you see your chosen GP, are pay have one or two questions. on a discounted rate. You undergo
80% of the agreed or Scheme Rate, When you visit an optometrist on our Preferred Provider Optometry Network,
the procedure. You know what you
and the 20% will be the member you can now get a 20% discount on frames and lenses. You may still visit an
are in for. You have been a savvy
portion. If you see someone other optometrist who is not on the Network, however, you will then not benefit from
consumer and have taken control
than your chosen GP, we will pay the 20% discount.
of your healthcare.
60% of the agreed or Scheme Rate.
5 | You call the specialist to ask 5 | You get the bill from the specialist 5 | Next time, you look into the
The member portion will be 40%. SABMAS Pharmacy Network
questions. Everything is clarified; and the anaesthetist (oops, you forgot SABMAS Specialist Network first.
20% being a co-payment for not
you are good to go. In addition, you’ll about them!). Less hassle; less running around.
seeing your nominated GP and the
You are free to choose from the wide range of pharmacies in our Network. receive an email or an SMS to confirm
20% surcharge that applies to all
all your authorised benefits.
consultations. Refer to page 9 for more information.
6 | Your procedure did not result 6 | You may have to pay thousands
Specialist Network in nasty surprises. You were of rands. Why so much? Because you
an informed patient. used a specialist outside the Network,
whose rate was way above our
This is the group of specialists we’ve negotiated with to give you quality healthcare
Scheme Rate.
services at specified rates. If you decide to use a specialist who’s not on our
list, and who charges more than our Scheme Rate, you will have to pay for the
additional cost.
All members on the Essential Option are required to consult a GP before you see
Before you even make a Specialist, in order to get the fullest cover. If you go straight to the Specialist,
the appointment to see a SABMAS will only pay 60% of the Scheme Rate.
Healthcare Provider, you
can log in to our website
How things work
at www.sabmas.co.za and
use our self-help search
tool Find a HealthCare The below example has been done to explain how using a Network provider can
Professional, to identify help save you from out-of-pocket expenses.
a Network Provider in
your area.
Acute Hospital List
6 . Your Benef it Options 2021
Essential Option members are covered in full at hospitals in the Acute Hospital Network in accordance with your option benefits.
For planned admissions to any other private hospital, you must pay an upfront amount of R7 650. This does not apply in an emergency ESSENTIAL MONETARY LIMIT
BENEFITS ESSENTIAL OPTION
R426 055 OVERALL ANNUAL LIMIT PER FAMILY (M)
Remember that these private hospitals will also be the Scheme’s PMB Hospital Network for both the Comprehensive and Essential DAY-TO-DAY BENEFITS IS SUBJECT TO OVERALL ANNUAL LIMIT
Option. You will have full cover for your PMB condition when using any of these hospitals along with a Healthcare Provider in the
ROUTINE There are no Routine limits on this Option
SABMAS Provider Network. You also have access to more than 95 Day Clinics around the country. Please visit our website at Benefits are subject to the category sub-limits listed below, as
www.sabmas.co.za or call us on 0860 002 133 to find out more. well as the Overall Annual Limit
Member liable for a co-payment where applicable
ALTERNATIVE Acupuncture, naturopathy and osteopathy No benefit –
G GAUTENG F FREE STATE
HEALTHCARE SERVICES
Milpark (Cardiac electrophysiology
CONSULTATIONS AND Out-of-hospital (rooms or home) For your chosen GP or 3 consultations with a different GP: 80% M
centre of excellence – admissions VISITS WITH A GP OR of the lower of cost or Scheme Rate
allowed for all arrhythmia related NURSE R2 203 per beneficiary per year (on all) including minor
Arwyp Medical Centre Life Rosepark Hospital
conditions) procedures and consumables
Life Bedford Gardens Hospital
Netcare Universitas For consultations with an out-of-area: Limited to 3 per
Sunninghill nursing home (Cardiac beneficiary per year
Netcare Bougainville Private Hospital
electrophysiology centre of ENDOSCOPIES • Colonoscopy Single endoscopy: Co-payment R5 000
Private Hospital excellence – admissions allowed for Horizon Eye Care Centre • Gastroscopy Multiple endoscopy: Co-payment R6 250
• Colonoscopy + Gastroscopy Limited to Overall Annual Limit
Life Brenthurst Clinic all arrhythmia related conditions)
W WESTERN CAPE
• Sigmoidoscopy
Life Carstenhof Clinic
Zuid-Afrikaans (Cardiac CONSULTATION AND Out-of-hospital (rooms or home) If referred by GP: 80% of the lower of cost or Scheme Rate M
VISITS WITH SPECIALISTS (including minor procedures and consumables) R2 147 per
Dr S K Matseke Memorial Hospital electrophysiology centre of
Mediclinic Cape Town beneficiary per year
Clinix Naledi-Nkanyezi excellence – admissions allowed for If not referred by GP: 60% of the lower of cost or Scheme Rate
all arrhythmia related conditions)
Life Vincent Pallotti Hospital R2 147 per beneficiary per year
Private Hospital
Melomed Mitchells Plain DENTISTRY Dental practitioners 80% of the lower of cost or Scheme Rate M
L LIMPOPO
Netcare Clinton Clinic For basic dentistry; Oral Hygienist and Dental Therapists M = R3 519
Mediclinic Panorama M + 1 = R5 806
Life Genesis Clinic M + 2 = R6 830
Mediclinic Stellenbosch
M + 3 = R7 835
Mediclinic Emfuleni Mediclinic Limpopo
Mediclinic Vergelegen Advanced dentistry No benefit –
Netcare Femina Hospital
M MPUMALANGA
Life Peninsula Hospital MEDICINE AND Chronic medicines* (other than antiretrovirals) as per 100% of SEP including dispensing fee subject to use of SABMAS M
Life Fourways Hospital INJECTION MATERIAL Chronic Disease List (26 conditions covered) Pharmacy Network Provider
Melomed Gatesville 20% co-payment for non-Network Provider
Mediclinic Legae Private Hospital Reference pricing/MMAP applies
Life Cosmos Hospital
Mediclinic Winelands Orthopaedic
Lenmed Ahmed Kathrada Prescribed acute medicines. Acute Medicine Limit: M
Hospital
E EASTERN CAPE
M = R3 398
Private Hospital M + 1 = R5 574
Netcare Kuilsriver Hospital
M + 2 = R6 307
14 Life Groenkloof Hospital M + 3 = R6 922 15
Life Mercantile Hospital
Louis Pasteur Hospital Exception hospitals TTO after hospital event Subject to the Acute Medicine Limit
Midvaal Private Hospital Life St George’s Hospital
Melomed Bellville (Cardiac Pharmacy-advised therapy (PAT)/Over-the-counter No benefit –
electrophysiology centre – medicines (OTC) ##
K KWAZULU NATAL
Mediclinic Morningside Homeopathic medicine Subject to the Acute Medicine Limit
arrhythmia conditions only)
Life Robinson Private Hospital
Life Kingsbury Hospital Immunisation and vaccines Subject to the acute medicine limit M
Life Roseacres Clinic Life Chatsmed Garden Hospital (Ophthalmology and peripheral MENTAL HEALTH Consults and procedures R4 395 per family and dual accumulation of 21 days in M
Life Suikerbosrand Clinic Life Entabeni Hospital vascular surgery only) hospital or 15 out of hospital psychotherapy sessions
NON-SURGICAL Out-of-hospital (performed in doctor’s rooms only) Limited Overall Annual Limit M
Wits Donald Gordon Midlands Medical Centre
Christiaan Barnard Memorial PROCEDURES AND TESTS
Medical Centre Life Westville Hospital hospital (Cardiac electrophysiology OPTICAL Frames and readers including spectacle lenses R1 762 per beneficiary every 2 benefit years M
Life Wilgeheuwel Hospital Ethekwini Hospital centre – arrhythmia conditions only) Contact lenses No benefit –
Botshelong Empilweni Clinic
Melomed Tokai (Cardiac Eye examinations Limited to Overall Annual Limit M
and Heart Centre
Hillcrest Private Hospital electrophysiology centre – PATHOLOGY AND Pathology Limited to Overall Annual Limit M
Bougainville Private Hospital MEDICAL TECHNOLOGY
arrhythmia conditions only)
Clinix Private Hospital Sebokeng PHYSIOTHERAPY, Physiotherapy and Biokinetics R1 901 per family per year M
Exception hospitals BIOKINETICS AND
Life Flora Hospital St Augustine’s (Cardiac CHIROPRACTORS
Life Springs Parkland Hospital electrophysiology centre –
RADIOLOGY AND Basic Radiology Limited to Overall Annual Limit M
RADIOGRAPHY Specialised Radiology Limited to Overall Annual Limit Co-payment of R3 040 on
Life Wilgers Hospital arrhythmia conditions only) MRI & CT scans
Nelson Mandela Childrens Hospital
Gateway Private Hospital (Cardiac REMEDIAL AND OTHER Audiology, dietetics, hearing aid acoustics, occupational 80% of the lower of cost or Scheme Rate R2 026
electrophysiology centre – THERAPIES therapy, orthoptics, podiatry and speech therapy per family collectively for all services
Union Hospital
arrhythmia conditions only) Treatment and medicines prescribed or supplied for: Homeopathic medication covered from acute if M
Unitas Hospital Homeopathy, Naturopathy, Osteopathy prescribed by a registered homeopath
Ethekwini (Cardiac
MAJOR MEDICAL BENEFITS (SUBJECT TO OVERALL ANNUAL LIMIT)
Exception hospitals Electrophysiology centre of
Life Faerie Glen Hospital (Foot and excellence - admissions allowed for ALCOHOLISM AND DRUG For applicable services 100% of the lower of cost or Scheme Rate M
DEPENDENCY* 21 days at a SANCA facility or SANCA rates per beneficiary
ankle orthopaedic procedures only) all arrhythmia related conditions)
AMBULANCE SERVICES* Emergency transport only (call 082 911) 100% of the lower of cost or Scheme Rate (Netcare 911) M
N NORTH WEST
Mediclinic Medforum (maternity MEDICAL AND SURGICAL Medical and surgical appliances Medical and Surgical Appliances Limit – R7 346 per family M
related admissions) APPLIANCES per year
Hearing aids Once every three years per ear subject to the Medical and
Mediclinic Midstream (Cardiac
Netcare Ferncrest Hospital Surgical Appliances Limit
electrophysiology centre of Hearing aid repairs (including batteries) Once every two years, Sub-limit or R3 073 per beneficiary M
excellence – admissions allowed for subject to the Medical and Surgical Appliances Limit
all arrhythmia related conditions) Home oxygen, cylinders, concentrators and ventilation Limited Overall Annual Limit and subject to approval if M
expenses, excluding CPAP machines purchased
*
Benefits denoted by an asterisk are subject to authorisation ##
Denotes benefits which are only available on the Comprehensive option
2021 2021
DAY-TO-DAY BENEFITS TREATMENT ESSENTIAL OPTION ESSENTIAL MONETARY LIMIT
ROUTINE Benefits are subject to the following routine benefit limits (R)
and category sub-limits MAJOR MEDICAL BENEFITS (CONTINUED)
M R21 941 M+1 R29 254 M+2 R35 180 M+3 R39 707 Member
liable for a co-payment where applicable BLOOD AND BLOOD Blood, blood equivalents and blood products Limited to Overall Annual Limit M
PRODUCTS
ALTERNATIVE Acupuncture, naturopathy and osteopathy 80% of the lower of cost or Scheme Rate R
HEALTHCARE SERVICES CONSULTATIONS In-hospital (general practitioners, specialists 100% of the lower of cost or Scheme Rate M
AND VISITS and nurse practitioners)
CONSULTATIONS AND Out-of-hospital (general practitioners, specialists and nurse Consultations and visits limit: (including minor procedures R
VISITS practitioners – rooms or home) and consumables) R4 857 per beneficiary per year ENDOSCOPIES • Colonoscopy Single endoscopy: Co-payment R5 000
• Gastroscopy Multiple endoscopy: Co-payment R6 250
ENDOSCOPIES • Colonoscopy Single endoscopy: Co-payment R4 100 • Colonoscopy + Gastroscopy Limited to Overall Annual Limit
• Gastroscopy Multiple endoscopy: Co-payment R5 150 • Sigmoidoscopy
• Colonoscopy + Gastroscopy Subject to the day-to-day-limit
• Sigmoidoscopy DENTISTRY* Osseo-integrated implants and Orthognatic surgery Upfront deductible for Basic dentistry In Hospital 12 years and –
Orthodontic treatment younger – R2 650 In Hospital / R1 200 in Day Clinic. 13 years
DENTISTRY Dental practitioners Upfront deductible for Basic dentistry In Hospital depending R and older – 6 800 In Hospital / R4 350 in Day Clinic
For basic dentistry; Oral Hygienist and Dental Therapists on age and place of service: 12 years and younger - R2 650 In
Hospital / R1200 in Day Clinic. 13 years and older -R 6 800 In Oral Surgery and Maxillo-Facial Surgery 100% of the lower of cost or Scheme Rate M
Hospital / R4 350 Day
HOSPITALISATION* In patient (accommodation in general ward, high care ward Admissions outside this network will result in a R7 650 M
Advanced dentistry Advanced Dental limit: M and intensive care unit, theatre fees, medicines, materials, deductible. 100% of the lower of cost or Scheme Rate in an
M: R10 970 hospital equipment and transportation of blood) Acute Hospital Network facility
M + 1 or more: R14 352
Outpatient (services and materials, excluding TTOs) 100% of the lower of cost or Scheme Rate M
MEDICINES AND Chronic medicines* (other than antiretrovirals) as per 100% of SEP including dispensing fee, subject to use of
INJECTION MATERIAL Chronic Disease List (26 conditions covered) SABMAS Pharmacy Network Provider. 20% co-payment for Alternatives to hospitalisation (step-down facility, private Limited to Overall Annual Limit M
non-Network Provider. Reference pricing/MMAP applies nursing and rehabilitation centres)
Prescribed acute medicine Subject to the day-to-day limit M IMMUNE DEFICIENCY Antiretroviral and related medicines 100% as determined by Aid for AIDS (DSP) M
Oral contraceptives Subject to the day-to-day limit, and further limited to R RELATED TO HIV/AIDS* All other services Subject to registration on the Aid for AIDS Programme
R2 302 per female beneficiary
MATERNITY* Normal delivery: Hospitalisation (accommodation in 100% of the lower of cost or Scheme Rate M
TTO after hospital event Subject to the day-to-day limit a private or provincial hospital, theatre fees, labour ward Register with the Maternity Management Programme
fees, drugs, dressings, medicines and materials)
Pharmacy assisted therapy Subject to Positive MSA MSA
Caesarean section: Hospitalisation (accommodation 100% of the lower of cost or Scheme Rate M
Immunisation and vaccines Subject to the day-to-day limit R in a private or provincial hospital, theatre fees, labour ward Limited to R23 460 per confinement (limit may be exceeded
fees, drugs, dressings, medicines and materials) for emergency/clinical reasons)
Homeopathic medicine Subject to the day-to-day limit
Register with the Maternity Management Programme
MENTAL HEALTH Consults and procedures R13 207 per family and dual accumulation of 21 days in M
hospital or 15 out-of-hospital psychotherapy sessions. Medical services and midwifery (antenatal consultations, 100% of the lower of cost or Scheme Rate M
pregnancy scans, tests, delivery services by a midwife)
NON-SURGICAL Out-of-hospital (performed in doctor’s rooms only) Unlimited Overall Annual Limit M
PROCEDURES AND TESTS MENTAL HEALTH* Hospitalisation (accommodation in a general ward) Mental Health limit (in-hospital): R27 756 per beneficiary M
16
17
OPTICAL Frames and readers R1 883 per beneficiary every two benefit years, funded from R In-hospital consultations, visits and procedures R4 395 per family and dual accumulation of 21 days in hospital
day-to-day limit or 15 out of hospital psychotherapy sessions.
Spectacle lenses Subject to the day-to-day limit R NON-SURGICAL In-hospital 100% of the lower of cost or Scheme Rate M
One pair per person per year PROCEDURES Limited Overall Annual Limit
Sub-limit for lens hardening – R286 per lens for hardening AND TESTS*
and tinting up to 35%
ONCOLOGY* Consultations, visits, treatment, medicines and material 100% of the lower of cost or Scheme Rate up to R200 000 M
Contact lenses Subject to the day-to-day limit R used in radiotherapy/chemotherapy per beneficiary per rolling 12 months, after which 80% of the
One pair per person per year lower of cost or Scheme Rate
Sub-limit of R1 883 per beneficiary once every benefit year
OPTICAL Refractive surgery ## No benefit –
Eye examinations Subject to the day-to-day limit R
ORGAN TRANSPLANTS *
Consultations, visits, harvesting and transplantation Organ Transplant Limit: R62 958 per family M
PATHOLOGY AND Pathology Subject to the day-to-day limit R
MEDICAL TECHNOLOGY Anti-rejection medicines 100% of cost M
PHYSIOTHERAPY, Out-of-hospital Subject to the day-to-day limit R Subject to organ transplant limit
BIOKINETICS AND PATHOLOGY AND MEDICAL In-hospital 100% of the lower of cost or Scheme Rate M
CHIROPRACTORS TECHNOLOGY
RADIOLOGY AND Basic Radiology Subject to the day-to-day limit R
PHYSIOTHERAPY, In-hospital R1 901 per family per year M
RADIOGRAPHY
Specialised radiology Unlimited Overall Annual Limit BIOKINETICS AND No benefit for chiropractors
CHIROPRACTORS
REMEDIAL AND OTHER Audiology, dietetics, hearing aid acoustics, occupational Subject to the day-to-day limit
THERAPIES therapy, orthoptics, podiatry and speech therapy PROSTHESES* Internal and external 100% of cost M
R64 489 per family per year
Alternative Healthcare Services Subject to the day-to-day limit R
Treatment and medicines prescribed or supplied for: RADIOLOGY AND Basic radiology Limited to Overall Annual Limit M
Homeopathy, Naturopathy, Osteopathy RADIOGRAPHY*
Specialised radiology* Limited to Overall Annual Limit M
MAJOR MEDICAL BENEFITS
RENAL DIALYSIS *
Acute and Chronic Renal Dialysis including specialists 100% of the lower of cost or Scheme Rate M
ALCOHOLISM AND DRUG For applicable services 100% of the cost for all services M
R56 404 per family
DEPENDENCY* 21 days at a SANCA facility or SANCA rates per beneficiary
AMBULANCE SERVICES* Emergency transport only (call 082 911) 100% of the lower of cost or Scheme Rate (Netcare 911) M SURGICAL PROCEDURES* In-and-out-of-hospital 100% of the lower of cost or Scheme Rate M
No benefit for elective knee and hip replacement surgery
APPLIANCES *
Medical and surgical appliances R17 579 per family per year M For PMB approved hip and knee prostheses, the Internal and
External Prostheses limit will apply if a non-preferred supplier
Hearing aids Once every three years per ear subject to the Medical and is used
Surgical Appliances Limit
COMPASSIONATE CARE Holistic hospice/home-based end-of-life care 100% of the lower of cost or Scheme Rate
Hearing aid repairs (including batteries) Once every two years Sub-limit or R3 073 per beneficiary M
BENEFIT Subject to your Overall Annual Limit with a sub-limit of R44 553
subject to the Medical and Surgical Appliances Limit
per beneficiary per lifetime
Home oxygen, cylinders, concentrators and ventilation Unlimited Overall Annual Limit, subject to approval if M
expenses, excluding CPAP machines purchased *
Benefits denoted by an asterisk are subject to authorisation ##
Denotes benefits which are only available on the Comprehensive option
*
Benefits denoted by an asterisk are subject to authorisation NO TE
NO TE This benefit summary is for information purposes only and does not supersede the Scheme Rules. In the
event of any discrepancy between the summary and the Scheme Rules, the Rules will prevail.
This benefit summary is for information purposes only and does not supersede the Scheme Rules. In the
event of any discrepancy between the summary and the Scheme Rules, the Rules will prevail.2021 Contributions for 2021
TREATMENT COMPREHENSIVE OPTION COMPREHENSIVE MONETARY LIMIT
COMPREHENSIVE OPTION
BASIC MONTHLY ESSENTIAL OPTION
TOTAL MONTHLY CONTRIBUTION
MAJOR MEDICAL BENEFITS (CONTINUED) INCOME (R) TOTAL MONTHLY CONTRIBUTION
(INCLUDES 10% SAVINGS)
BLOOD AND BLOOD Blood, blood equivalents and blood products Unlimited Overall Annual Limit M
PRODUCTS MAIN MEMBER ADULT CHILD MAIN MEMBER ADULT CHILD
CONSULTATIONS In-hospital (general practitioners, specialists Consultations and visits limit: R4 857 per beneficiary per year M
0 – 5 700 1 229 1 229 367 2 927 2 927 879
AND VISITS and nurse practitioners) including minor procedures and consumables
ENDOSCOPIES • Colonoscopy Single endoscopy: Co-payment R4 100
• Gastroscopy Multiple endoscopy: Co-payment R5 150 5 701 – 8 700 1 444 1 444 431 3 135 3 135 943
• Colonoscopy + Gastroscopy
• Sigmoidoscopy
8 701 – 11 500 1 485 1 485 443 3 201 3 201 961
DENTISTRY* Osseo-integrated implants and orthognatic surgery Advanced Dental limit: M
(including the cost of hospitalisation, dental practitioners, M: R10 970
11 501 – 14 400 1 535 1 535 462 3 264 3 624 978
anaesthetist fees and implants) M + 1 or more: R14 352
Oral Surgery and Maxillo-Facial Surgery Unlimited Overall Annual Limit M
14 401 – 17 200 1 582 1 582 473 3 331 3 331 1 005
HOSPITALISATION* In patient (accommodation in general ward, high care 100% of the lower of cost or Scheme Rate M
ward and intensive care unit, theatre fees, medicines,
materials, hospital equipment and transportation of 17 201 – 20 100 1 633 1 633 491 3 407 3 407 1 019
blood)
Outpatient (services and materials, excluding TTOs) 100% of the lower of cost or Scheme Rate M 20 101 – 23 100 1 698 1 698 508 3 473 3 473 1 043
Alternatives to hospitalisation (step-down facility and private Step-down facilities and private nursing: Unlimited M
nursing)
23 101 – 28 800 1 760 1 760 529 3 545 3 545 1 062
Rehabilitation centres Unlimited M
Private hospital rehabilitation services R87 817 per family per year 28 801 – 34 400 1 822 1 822 551 3 608 3 608 1 079
IMMUNE DEFICIENCY Antiretroviral and related medicines 100% as determined by Aid for AIDS (DSP) M
RELATED TO HIV/AIDS* All other services Subject to registration on the Aid for AIDS Programme
34 401 – 39 600 1 888 1 888 567 3 676 3 676 1 100
MATERNITY* Normal delivery: Hospitalisation (accommodation in a 100% of the lower of cost or Scheme Rate M
private or provincial hospital, theatre fees, labour ward fees, Register with the Maternity Management Programme
drugs, dressings, medicines and materials) 39 601 – 44 900 1 945 1 945 584 3 750 3 750 1 121
Caesarean section: Hospitalisation (accommodation in a 100% of the lower of cost or Scheme Rate M
private or provincial hospital, theatre fees, labour ward Register with the Maternity Management Programme 44 901+ 2 003 2 003 602 3 826 3 826 1 144
fees, drugs, dressings, medicines and materials)
Medical services and midwifery (antenatal consultations, 100% of the lower of cost or Scheme Rate M
pregnancy scans, tests, delivery services by a midwife)
MENTAL HEALTH* Hospitalisation (accommodation in a general ward, 100% of the lower of cost or Scheme Rate M
18 electro convulsive therapy (ECT), medicines, materials R40 863 per beneficiary
19
and hospital equipment)
In-hospital consultations, visits and procedures 100% of the lower of cost or Scheme Rate M
NON-SURGICAL In-hospital Unlimited Overall Annual Limit M
PROCEDURES
AND TESTS*
ONCOLOGY* Consultations, visits, treatment, medicines and material 100% of the lower of cost or Scheme Rate up to R400 000 M
used in radiotherapy/chemotherapy per beneficiary per rolling 12 months, after which 80% of the
lower of cost or Scheme Rate
OPTICAL Refractive surgery## 100% of the lower of cost or Scheme Rate M
R9 748 per beneficiary per life-time subject to clinical protocols
ORGAN TRANSPLANTS* Consultations, visits, harvesting and transplantation Unlimited Overall Annual Limit M
Anti-rejection medicines Unlimited Overall Annual Limit M
PATHOLOGY AND MEDICAL In-hospital Subject to the day-to-day limit M
TECHNOLOGY
PHYSIOTHERAPY, In-hospital Subject to the day-to-day limit M
BIOKINETICS AND
CHIROPRACTORS
PROSTHESES* Internal and external 100% of cost M
R73 488 per family per year.
Hip, knee and spinal prostheses will pay at the agreed rate and
will not accumulate to this limit if a preferred supplier is used.
RADIOLOGY AND Basic radiology: In-hospital diagnostic radiology tests and Subject to the day-to-day limit M
RADIOGRAPHY* scans
Specialised radiology*: In-and-out-of-hospital (including Unlimited Overall Annual Limit. Co-payment of R3 040 on MRI M
magnetic resonance imaging (MRI), CT scans, angiography, bone and CT scans
densitometry and mammograms)
RENAL DIALYSIS* Acute and chronic (consultations, visits, associated services Unlimited Overall Annual Limit M
and materials)
SURGICAL PROCEDURES* In-and-out-of-hospital Unlimited Overall Annual Limit M
COMPASSIONATE CARE Holistic hospice/home-based end-of-life care 100% of the lower of cost or Scheme Rate
BENEFIT Subject to a limit of R62 782 per beneficiary per lifetime
*
Benefits denoted by an asterisk are subject to authorisation ##
Denotes benefits which are only available on the Comprehensive option
Glossary
Visit www.sabmas.co.za and select Doctor
DSP: Designated Service Provider R: Routine benefit
Visits and then Find a Healthcare Provider to
M: Major Medical Benefit SCHEME RATE: Negotiated Rate
MMAP: Maximum Medical Aid Pricing SEP: Single Exit Price
find a network pharmacy nearest to you.
MSA: Medical Savings Account TTO: To take home medication
OAL: Overall Annual Limit7. T he Wellne ss Benef it WHAT
PROGRAMMES
WHAT DO THE WHICH AGES ARE HOW OFTEN ARE HOW MUCH DO WE
PROGRAMMES COVER? COVERED? BENEFITS ALLOWED? COVER?
ARE COVERED?
This benefit is available to all members and their registered beneficiaries. The Wellness Benefit empowers you with
EARLY DEXA bone density scan 50+ years old Once every 3 years 100% of the lower of cost or
better awareness of your health status through the Early Detection Programmes. DETECTION (for osteoporosis and bone Scheme Rate
PROGRAMMES fragmentation)
The Early Detection and Immunisation Programmes not only assist to avoid expensive medical costs in the future, but encourage Cholesterol test All adults Once a year 100% of the lower of cost or
you to keep healthy and improve your quality of life. For your convenience there is no need to register for this benefit; your (Pathologist) Scheme Rate
membership qualifies you automatically.
Blood sugar/glucose test All adults Once a year 100% of the lower of cost or
(Pathologist) Scheme Rate
(for diabetes)
HIV test All beneficiaries Once a year 100% of the lower of cost or
Know your health status – we cover 100% of the Scheme Rate for a variety of health checks.
Scheme Rate
HbA1C test High risk members Once a year R250
Lipogram
What we cover as part of the Wellness Benefit Pap smear Females Once a year 100% of the lower of cost or
Scheme Rate
Pathology test Females Once a year 100% of the lower of cost or
Scheme Rate
WHAT
WHAT DO THE WHICH AGES ARE HOW OFTEN ARE HOW MUCH DO WE Consultation Females Once a year 100% of the lower of cost or
PROGRAMMES
PROGRAMMES COVER? COVERED? BENEFITS ALLOWED? COVER? (for cervical cancer Scheme Rate
ARE COVERED? prevention)
IMMUNISATION Baby immunisations In line with Department 100% of the lower of cost or
Glaucoma test 40-49 years old Once every two years 100% of the lower of cost or
PROGRAMMES of Health protocols Scheme Rate
(for blindness) Scheme Rate
Tetanus diphtheria booster As needed As needed 100% of the lower of cost
50+ years old Once a year 100% of the lower of cost or
or Scheme Rate
Scheme Rate
Influenza vaccination All Every year 100% of the lower of cost
Maternity – subject to Direct Antiglobulin test One test per female
or Scheme Rate
registration on the Maternity (Coombs) beneficiary per pregnancy
Pneumococcal vaccination 60+ years old and high-risk Every year 100% of the lower of cost Management Programme.
Full blood count One test per female
individuals or Scheme Rate
20 beneficiary per pregnancy
21
EARLY Screening benefit (health
REGISTRATION ON THE Platelet count One test per female
DETECTION assessment) at Clicks or
PROGRAMMES Dis-Chem. MATERNITY MANAGEMENT beneficiary per pregnancy
PROGRAMME IS COMPULSORY
Body Mass Index (BMI) All adults Once a year 100% of the lower of cost Grouping: Rh blood group One test per female
or Scheme Rate antigen beneficiary per pregnancy
Blood sugar test (finger All adults Once a year 100% of the lower of cost HIV antibody/ELISA Two tests per female
prick) or Scheme Rate beneficiary per pregnancy
Blood pressure test All adults Once a year 100% of the lower of cost Rubella-IgM: Specific antibody One test per female
or Scheme Rate titer: ELISE/EMIT per Ag beneficiary per pregnancy
Cholesterol test (finger prick) All adults Once a year 100% of the lower of cost Quantitative Khan VDLR or One test per female
or Scheme Rate other flocculation beneficiary per pregnancy
HIV test (finger prick) 16+ years old Once a year 100% of the lower of cost Beta-HCG qualitative blood One test per female
or Scheme Rate test beneficiary per pregnancy
General physical examination 30-59 years old One medical examination 100% of the lower of cost Hepatitis B surface antigen Two tests per female
(at a GP) every three years or Scheme Rate beneficiary per pregnancy
60-69 years old One medical examination 100% of the lower of cost Dentistry General full mouth Once a year per beneficiary 100%
every two years or Scheme Rate examination by a general
dentist or oral hygienist
70+ years old One medical examination 100% of the lower of cost (including sterile tray and
every year or Scheme Rate gloves), plus polishing and
scaling
Mammogram Females 40+ years old Once every two years 100% of the lower of cost or
Scheme Rate
Prostate-specific antigen test Males 40-49 years old Once every five years 100% of the lower of cost
(Pathologist) or Scheme Rate
(for prostate cancer) PLEASE NOTE
Males 50-59 years old Once every three years 100% of the lower of cost
or Scheme Rate As a member, either on the Comprehensive or Essential Option, you automatically qualify for this
Males 60-69 years old One every two years 100% of the lower of cost Wellness Benefit. You do not need to register.
or Scheme Rate
Males 70+ years old Once a year 100% of the lower of cost
or Scheme Rate8 . O ther A reas we help with Aid for AIDS Programme Treatment Baskets for the Prescribed
Minimum Benefit (PMB) Chronic
Aid for AIDS, our HIV management programme, Disease (CDL) conditions
Maternity Management Programme Oncology Management Programme offers members and dependants:
Medicine to treat HIV* and vitamins to boost The Prescribed Minimum Benefit Chronic Disease List is a list
We care about your little ones, even before they’re born. Members registered on the Oncology Management the immune system of conditions which all medical schemes need to cover on all
This is why our Maternity Management Programme is there Programme have access to an oncology ancillary basket. Regular monitoring of the condition the Options they offer to their members. This cover includes
to assist you during pregnancy. Benefit from pre-natal This basket includes items that are not necessarily part funding for the diagnosis, treatment and ongoing care of the
Monitoring of the patient’s response to therapy
healthcare, including advice tailored to the stage in your of your direct treatment, but that will assist with your care listed conditions.
pregnancy. Access quality care in the form of two scans, during treatment, for example, anti-nausea medications Monitoring tests to detect side effects
We will only pay Prescribed Minimum Benefit claims
12 antenatal consultations, antenatal classes, a pregnancy following chemotherapy. Ongoing patient support via dedicated counsellors
if cover for your condition has been approved on the
birth book and pre-natal supplements. You will be entitled
The basket also consists of a list of all the consultations,
Assistance in finding a registered counsellor Chronic Medicine Benefit. Only claims for procedures and
to various pathology tests as set out on page 21.
radiology and pathology available to you. for emotional support. consultations listed in the Prescribed Minimum Benefit (PMB)
treatment Baskets will be paid from the Chronic Disease
All of the items within the ancillary basket will be paid from * This includes medicine to prevent mother-to-child
IMPORTANT Basket of Care. The benefits are calculated based
your Oncology Benefit, as long as the correct ICD-10 code is transmission and infection after sexual assault
used. These baskets are allocated based on defined protocols. or needle-stick injury. We will pay for tests and procedures for your condition
You need to register on the Maternity
Management Programme as soon as your If a test confirms that you are HIV positive, you must register according to the treatment baskets We pay for certain tests
If you need any treatment that does not form part of the
pregnancy has been confirmed. Twelve- with Aid for AIDS as soon as possible. Aid for AIDS will keep like blood tests and X-rays according to the PMB treatment
oncology PMB ancillary basket or if you have used up certain
week-scan time? Contact us on 0860 002 133. your status confidential. Contact them on 0860 100 646 and Baskets. This cover includes tests and procedures for both
items within the basket, your Healthcare Provider must
Please keep in mind that if you don’t join request an application form, or ask your Healthcare Provider the diagnosis and ongoing management for each of the PMB
contact us to motivate for extended cover.
this programme, you’ll have to pay for the to call them on your behalf. Chronic Disease List conditions. We pay for listed blood tests,
The Scheme will cover the costs of your oncology treatment scans and X-rays up to a maximum of the Scheme Rate.
gynaecologist consultations and your two
at 100% of the Scheme Rate, up to a threshold. Once this
scans out of your Day-to-day Benefits – this We will not pay claims from the Chronic Disease Basket of
threshold has been reached, the Scheme will continue cover
will make it run out quicker. Wouldn’t you If you are exposed to HIV through sexual assault or from Care in the following instances
at 80% of the Scheme Rate.
rather save that money for a new pram or a a needle or injection, please ask your doctor to call Aid
for AIDS urgently. We can authorise special antiretroviral The claims are submitted without the relevant ICD-10 codes
car seat? To register on the Oncology Programme, please ask your
Healthcare Provider to send through the histology report medicine and we can help you to prevent possible HIV You are not yet registered on the Chronic Disease
confirming the cancer to oncology@sabmas.co.za or fax it infection. Programme for the specific PMB condition
22
through to 011 539 5417. Alternatively, you can contact us You have exceeded the frequency limit on consultations 23
Out-Of-Hospital DTP PMB on 0860 002 133. or tests in the registered Chronic Disease Basket of Care.
To register, please visit www.aidforaids.co.za or send
(Diagnosed Treatment Pair Prescribed To find a doctor who is a Network Provider, please use the
a confidential text message to 083 410 9078. You can
Minimum Benefit) Compassionate Care also fax your membership number to 0800 600 773.
Find a HealthCare Professional tool on www.sabmas.co.za.
The Compassionate Care Benefit gives you access to holistic
The Scheme pays for specific healthcare services related
home-based end-of-life care per person in their lifetime. DID YOU KNOW?
to each of your approved conditions. These services include
treatment, acute medicine, consultations, blood tests and Netcare 911 on 082 911 Netcare 911 has over 200 emergency vehicles
other investigative tests. We cover kidney, heart or liver Advanced Illness Benefit as well as a fleet of fixed-wing and helicopter
treatment relating to transplants as a Prescribed Minimum air ambulances.
If the unthinkable happens and you’re faced with a medical
Benefit (PMB). Members with cancer have access to a comprehensive emergency like a car accident or a heart attack, there’s only
If you want to apply for cover under Prescribed Minimum palliative care programme. This programme offers unlimited one number you must remember: 082 911. (Don’t wait. Put it
9. B enef it
Benefits for treatment of a condition without hospital cover for approved care at home. into your cellphone and your loved ones’ cellphones now!).
admission, you must complete a Prescribed Minimum
Not only is Netcare 911 South Africa’s favourite provider of
E xclusions
Benefit form.
emergency medical services, it has several benefits:
They ensure great response times
They ensure the correct emergency staff is sent to a Like most medical schemes, we don’t cover costs related to
medical emergency to provide the correct level of care treating obesity, self-inflicted injuries, injuries resulting from
professional sport and holidays for healing purposes.
Invoices are sent directly to Netcare 911, so you don’t have
to worry about receiving and submitting them. While we cover dental procedures, we don’t cover dental
treatment under general anaesthetic or conscious sedation,
Another important benefit of Netcare 911 is that you have
once the patient is older than eight years.
access to free telephonic advice from registered nurses and
telephonic trauma assistance by qualified trauma counsellors. We also don’t cover cosmetic procedures like certain plastic,
We encourage you to use this benefit. It’s available 24/7. reconstructive surgeries or dental implants. Look at the
Scheme Rules at www.sabmas.co.za, or check with the
Remember, in an emergency call 082 911.
Customer Care Centre for a list of exclusions.
Please remember to negotiate the best
rates with your doctor.You can also read
