Primary

Traditional PlanFrom R1 412 p/m

If you’re interested in simple, straightforward medical cover that covers your hospital care and the most important incidents, this plan is for you. It’s called Traditional because it doesn’t come with a savings account. Instead, just the value-added benefits you need. Especially if you or your family members don’t suffer from a lot of chronic conditions, this plan is a great option.

Summary

  • Major Medical Benefits
    This benefit includes hospital admissions, oncology treatments and renal dialysis, however, these do require pre-authorisation by Hospital Benefit Management.
  • Chronic Medicine Benefits
    Covers medication for the 26 Prescribed Minimum Benefit chronic conditions that requires medication on an ongoing basis.
  • Out of Hospital Benefits
    Covers day-to-day medical expenses for example: GP consultations, optometry, basic dentistry and day to day benefits.
  • Supplementary Benefits
    Additional benefits, medical expenses incurred in or out of hospital. All the following benefits are paid from the Overall Annual Limit and are subject to benefit limits.

What will it cost?

  • Contributions are calculated for the first three child dependants only.
  • Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations.
  • Subject to pre-authorisation
  • All benefits are per annum, unless otherwise stated
Principal Member R1 412
Adult Dependant R1 105
Child Dependant R450

Major Medical Benefits

This benefit includes hospital admissions, oncology treatments and renal dialysis, however, these do require pre-authorisation by Hospital Benefit Management except in the case of emergencies.

Overall Annual Limit:
Unlimited
Reimbursement Rate:
100% Bonitas Rate
Hospital Network:
N/A
Sub-limits applicable:
1All members enrolled in clinical trials should inform the scheme
GP & Specialist Consultations Unlimited
Pathology Unlimited
General Radiology Unlimited
Paramedical Services (Allied Medical, Professions) Unlimited
Oncology1 R127 000 per family, subject to overall annual limit
Organ Transplants PMB’s, only covered as per state protocols
Chronic Renal Dialysis PMB’s, only covered as per state protocols
Maxillo Facial Surgery Subject to Overall Annual Limit, excluding orthognathic surgery
Medication to take out (TTO) R290 per beneficiary, per admission
Physical Rehabilitation R38 000 per family, subject to overall annual limit
Alternatives to hospitalisation R12 700 per family

Deductions

R1 000 deductible
  1. Colonoscopy
  2. Conservative Back Treatment
  3. Cystoscopy
  4. Facet Joint Injections
  5. Flexible Sigmoidoscopy
  6. Functional Nasal Surgery
  7. Gastroscopy
  8. Hysteroscopy (but not endometrial ablation)
  9. Myringotomy
  10. Tonsillectomy and Adenoidectomy (except PMB’s)
  11. Umbilical Hernia Repair
  12. Varicose Vein Surgery
R2 500 deductible
  1. Arthroscopy
  2. Diagnostic Laparoscopy
  3. Hysterectomy (except cancer and PMB’s)
  4. Percutaneous Radiofrequency Ablations
  5. Percutaneous Rhizotomies
  6. Laparoscopic Appendectomy
  7. Laparoscopic Nephrectomy
R5 000 deductible
  1. Back Surgery including spinal fusion
  2. Joint replacements e.g. Hip & Knee replacements (except PMB’s)
  3. Laparoscopic Pyeloplasty
  4. Laparoscopic Radical Prostatectomy
  5. Nissen Fundoplication (Reflux Surgery)

Chronic Medicine Benefits

Covers medication for the 26 Prescribed Minimum Benefit chronic conditions that requires medication on an ongoing basis.

Limit:
A specified list of 26 conditions are covered
Formulary list:
Restrictive formularies apply
Provider:
Pharmacy Direct 40% co-payment will apply at a non Designated Service Provider.
Chronic Medicine Management
To apply for chronic medicine authorisation, the member, doctor or pharmacist can call the chronic medicine call centre on 0860 100 608 or email cmm@medscheme.co.za and request an application form.

A specified list of 26 conditions is provided.

  1. Addison’s Disease
  2. Asthma
  3. Bipolar Mood Disorder
  4. Bronchiectasis
  5. Cardiac Failure
  6. Cardiomyopathy
  7. Chronic Renal Disease
  8. Chronic Obstructive Pulmonary Disease
  9. Coronary Artery Disease
  10. Crohn’s Disease
  11. Diabetes Insipidus
  12. Diabetes Mellitus Type 1
  13. Diabetes Mellitus Type 2
  14. Dysrhythmias
  15. Epilepsy
  16. Glaucoma
  17. Haemophilia
  18. Hyperlipidaemia
  19. Hypertension
  20. Hypothyroidism
  21. Multiple Sclerosis
  22. Parkinson’s Disease
  23. Rheumatoid Arthritis
  24. Schizophrenia
  25. Systemic Lupus Erythematosus
  26. Ulcerative Colitis

Out of Hospital Benefits

Covers day-to-day medical expenses for example:

  • GP consultations
  • Optometry
  • Basic dentistry
  • Day to Day benefits

The Bonitas GP Network is the scheme’s Designated Service Provider for the provision of Prescribed Minimum Benefits. PMB’s are covered at 100% of scheme rate, at the Network GP, once benefit limits are exhausted. 40% co-payment will apply to PMB’s at a non-network provider once benefit limits are exhausted.

GP Benefit
GP Benefit In Network Non Network
Benefit included in the Network benefit
Member R 1 500 R 500
Member + 1 R 2 850 R 950
Member + 2 R 3 300 R 1 100
Member + 3 R 3 600 R 1 200
Member + 4 + R 4 000 R 1 350
Day to day Benefit
This benefit covers specialist consultations, acute medication, pharmacy advised therapy ,out of hospital radiology and pathology, paramedical services( dietetics, occupational therapy, speech therapy, social workers, audiology, physiotherapy and others). Specialist consultations will be payable on referral by your GP.
Day to Day In Network
Member R 1 600
Member + 1 R 2 900
Member + 2 R 3 400
Member + 3 R 3 700
Member + 4 + R 4 000
Sub-limit of R380 per beneficiary and R1100 per family for Pharmacy Advised Therapy. (PAT).
Specialist Consultations
Gynaecologist Female beneficiaries, 1 visit per annum without referral.
Paediatricians No referral required for beneficiaries under age 2.
Oncologist & Ophthalmologists No referral required
In addition to the day to day benefit the following is also provided:
Conservative Dentistry Subject to clinical protocols and Bonitas Dental Tariff (BDT)
Specialised Dentistry No Benefit
Optometry 2-year benefit from anniversary of claiming, per beneficiary
Optometric examination 100% of cost at Network Provider, or R 295 at a non-network provider.
Frames & prescription lenses/add-ons R300 per beneficiary at a Network Provider. No benefit at a non-network provider
Clear Single Vision R 150 per lens or
Clear Aquity Flat-Top Bifocal R 325 per lens or
Clear Aquity Multifocal (Up to bifocal limit) R 600 per lens or
Contact lenses R 750 per beneficiary

Supplementary Benefits

Additional benefits, medical expenses incurred in or out of hospital. All the following benefits are paid from the Overall Annual Limit and are subject to benefit limits. These include:

  • Maternity Care
  • Immune deficiency related to HIV infection
  • Specialised radiology (joint limit in & out of hospital)
  • Mental Health
  • Childhood Illness benefit
  • Infant Paediatric benefit
Supplementary Benefits
Maternity Care* per event (ante- and postnatal) Unlimited hospitalisation, subject to pre-authorisation and overall annual limit, 6 ante-natal consultations, 2 x 2D scans and 4 post-natal consultations with midwife.
Immune deficiency related to HIV infection* R19 000 per beneficiary, subject to Aid for AIDS (AfA) registration. Clinical protocols applies. Subject to overall annual limit
Mental Health Benefits* R12 200 per family, subject to pre- authorisation, includes a sub-limit of R7 400 for consultations in & out of hospital
Specialised Radiology* (joint limit in & out of hospital) R9 500 per family, subject to pre-authorisation and overall annual limit
Emergency Medical Transportation Subject to ER24 authorisation.
Endoscopies in practitioners room Subject to Overall Annual limit and pre-authorisation
Prostheses Internal and External* PMB’s only
HIV test and Flu vaccine 1 each per beneficiary per annum
Infant Paediatric Benefit (out of hospital paid from risk) 1 consultation before the age of 1 year. 1 consultation between the ages of 1 and 2 years
Childhood illness benefit. Consultations paid from risk 1 GP consultation p.b.p.a between the ages of 2 and 12 years
Appliances
General appliances R5 550 per family, subject to overall annual limit
Wheelchairs & large orthopaedic appliances Included in the general appliance limit
Stoma Products & CPAP machines May exceed general appliance limit by R5 000
Hearing aids R7 400 per family, biennial benefit (Jan 2012 - Dec 2013)
Oxygen: Home ventilation* Subject to overall annual limit and pre-authorisation by Hospital Management