Major medical cover Guardian plan
Guardian plan
- State hospital admissions
The DSP is State hospitals
Paid at Transmed rate
100% cover at a State hospital, subject to the UPFS for PMB and non-PMB admissions
100 %
UPFS rate
- Private hospital admissions
Only PMB conditions for major medical events and selected knee and hip replacements through ICPS
No benefit for non-PMB conditions
If a State hospital is not accessible in terms of the set criteria for PMB treatment, authorisation will be considered for admission to a hospital on the Transmed private hospital network as the secondary DSP and payable at the Transmed rate
The co-payment for the voluntary use of a non-DSP will be the amount equal to the difference between the total cost incurred in respect of the hospital services, including all related medical services, and the cost that would have been payable to the State hospital (DSP) or secondary DSP - whichever is applicable
Pre-authorisation required
Please call 0800 225 151Paid according to Pre-authorisation
- In-hospital dentistry
Provided through DENIS
Subject to protocols and limitations
Only PMB conditions and certain surgical procedures (fistula closure)
Paid at the Transmed rate
The fee for the hospitalisation and anaesthetist are paid from the major medical benefit
Dental treatment /procedures are subject to the availability of funds in the specialised dentistry limit of
R5 090 per family per yearPre-authorisation required
Please call 0800 225 151Paid according to Pre-authorisation
- In-hospital services
info Including GP and specialist services, pathology and radiology
100% cover for PMB and non-PMB admissions at a State hospital
Subject to the UPFS
Paid at Transmed rateAdvance radiology (MRI and CT scans)
Subject to case management and clinical protocolsPre-authorisation required
Please call 0800 225 151100 %
UPFS rate
- Internal Prostheses - combined annual-sub-limit prostheses - reimbursed for PMB conditions
Only PMB conditions and selected knee and hip replacements
Subject to individual prosthesis limits
Medical motivation may be required
R77 000 per beneficiary per year
Pre-authorisation required
Please call 0800 225 151Pacemaker and leads Limited to R44 000 Cervical and lumbar disc replacement Limited to R30 000 Partial hip replacement Limited to R36 000 Hip revision Limited to R50 000 Total hip replacement Limited to R67 760 Total knee replacement Limited to R61 300 Partial knee replacement Limited to R30 000 Total shoulder replacement Limited to R57 200 Total knee revision Limited to R45 000 Spinal fusion Limited to R55 660 Cardiac stents (per stent) to a maximum of 3 Limited to R25 650 Grafts (per graft) Limited to R28 500 Cardiac valves (per valve) Limited to R37 500 Hernia Mesh Limited to R11 000 Non-specified items Limited to R25 000 Below internal prostheses does not form part of the combined limit
Endovascular aneurysm repair (EVAR), Anaconda and equivalents R280 000 Per beneficiary per year Pacemaker (double chamber) R120 000 per beneficiary per year Pacemaker plus defibrillator R280 000 Per beneficiary per year Brain stimulator R200 000 Per beneficiary per year Transcatheter Aortic Valve Implantation (TAVI) R280 000 Per beneficiary per year 100 %
at cost
- Orthopaedic, surgical and medical appliances
Subject to individual appliance limits
Medical motivation may be required
Pre-authorisation required
Please call 0800 225 151Wheelchairs (subject to clinical criteria)
Non-motorised wheelchair
OR
Motorised wheelchairR9 900
(per beneficiary once every five years)Hand prothesis R10 000 per beneficiary once every two years) Arm prosthesis - Below elbow R26 000 (per beneficiary once every two years) Arm prosthesis - Above elbow R120 000 (per beneficiary once every two years) Above knee prosthesis R150 000 (per beneficiary once every two years) Below knee prosthesis R120 000 (per beneficiary once every two years) Silicone sleeve replacements for artificial limbs R20 000 (per beneficiary once every year) Back brace following surgical procedures R25 000 (per beneficiary per year) Walking aids R2 660 (per beneficiary per year) Hearing aids Per beneficiary once every three years Per ear R9 284 Hearing aid repairs Part of the hearing aid limit 100 %
at cost
- Organ transplants
Subject to case management and clinical protocols
Harvesting cost of organs (both live and cadavers) is subject to PMB legislation
International donors
The cost of international donor search and harvesting shall be limited to R225 000 (irrespective of the rand/dollar/euro exchange rate)In all cases, special approval is required from the Principal Officer or his delegate before an international donor search can be funded and a confirmation of the non-availability of a suitable local donor is required
The recipient must be a Transmed member
Pre-authorisation required
Please call 0800 225 151100 %
at the Transmed rate
- Ambulance services
Transfer protocols apply
Paid at Transmed rate
Pre-authorisation required
Please call 0800 115 750100 %
at the Transmed rate
- Emergency visits in hospital casualties
Paid at Transmed rate if life-threatening
Authorisation is required within 1 working day of the emergency treatment
If no authorisation is obtained, services will be paid from general day-to-day benefits, subject to the availability of funds
Please call 0800 225 151
100 %
at the Transmed rate
- Dialysis
The DSP is State hospitals
100% cover at a State hospital, subject to the UPFSPaid at the Transmed rate
If a State hospital is not accessible in terms of the set criteria, authorisation can be obtained for admission to a hospital on the Transmed private hospital network as secondary DSP or approved dialysis centres
Pre-authorisation required
Please call 0800 225 151100 %
at the Transmed rate
- Oncology (cancer) treatment
The Independent Clinical Oncology Network (ICON) of private oncologists and State hospitals are DSPs
Paid at the Transmed rate
Benefits are restricted to tier 1 of the South African Oncology Consortium (SAOC) guidelines
Limited to 1 PET scan per beneficiary per year
A 20% co-payment applies for using a provider other than an ICON service provider or the State
Oncology (cancer) medication to be obtained through the Transmed oncology network and is subject to evidence-based clinical protocols.
Reference pricing applies to oncology (cancer) medication
Pre-authorisation required
Please call 0800 225 151100 %
at the Transmed rate
- HIV and AIDS benefit
Members are encouraged to register on the HIV YourLife programme
Obtain medicine from a Transmed pharmacy network or courier pharmacy, as selected during enrolmentMembers may be liable for a co-payment if a pharmacy outside of the Transmed pharmacy network is used
Reference pricing applies
Pre-authorisation required
Please call 0860 109 793 (all calls are handled confidentially)100 %
at the Transmed rate
- Cataract surgery
The Ophthalmology Management Group (OMG) network and State hospitals are DSPs
Paid at the Transmed rate
A 20% co-payment on the total hospital and associated provider costs applies for using a provider other than an OMG provider or the State
In addition to cataract surgery, the following services will be covered, subject to pre-authorisation:
- the consultation during which the diagnosis is made and confirmed
- the relevant tests performed to make the diagnosis as per the applicable algorithm
- medication administered as part of the prosedure, as per the applicable algorithm
- any other medical services, as per the applicable algorithm
Pre-authorisation required
Please call 0800 225 151100 %
at the Transmed rate
- Terminal care benefit
Subject to pre-authorisation (home assessment if indicated)
Once-off limit of R25 000 per beneficiary (this is an additional benefit and the financial limit is not applicable to any services rendered which qualify for payment in terms of the PMB legislation)
Only applicable for treatment provided in an accredited facility (hospice/sub-acute/homecare by registered nurse)
Pre-authorisation required
Please call 0800 225 151100 %
at the Transmed rate