Major medical cover

Benefits guide - English
Benefits guide - Afrikaans

Select plan

  • Admissions to private hospitals for accidents/trauma

    Admissions for medical emergencies, accidents or trauma will be covered in a Transmed private hospital network hospital

    Paid at the Transmed rate

    Note: Refer to the definition of an emergency below, as per the Medical Schemes Act

    Pre-authorisation required
    Please call 0800 225 151

    Definition
    An emergency is defined in terms of the Medical Scheme's Act and the rules as the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part or would place a person's life in serious jeopardy.

    100%

    at Transmed rate

  • Admissions to private hospitals for maternity

    Transmed private hospital network is the DSP

    Paid at the Transmed rate

    Members with confirmed pregnancies must call 0800 225 151 to access the benefit

    Pre-authorisation required
    Please call 0800 225 151
            Online antenatal course: www.bellybabies.co.za
    Refer to the benefit guide page 26 for more information

    100%

    at Transmed rate

  • PMB-related admissions to private hospitals for children

    PMB -related admissions for children who are under 12 years old will be covered in a Transmed private hospital network hospital

    Paid at the Transmed rate

    A 30% co-payment applies for the voluntary use of a non-network hospital and is payable on the hospital claim

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • Admissions to private hospitals for in-hospital dentistry

    Transmed private hospital network is the DSP

    Admission protocols apply

    Removal of impacted teeth

    Extensive conservative treatment for children under 6

    Certain surgical procedures (fistula closure)

    Dental/Surgical procedures are subject to the availability of funds in the specialised dentistry limit

    The fee for the hospitalisation and anaesthetist are paid from major medical benefit if procedure is approved

    A 30% co-payment applies for the voluntary use of a non-network hospital and is payable on the hospital claim

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • Admissions to private hospitals related to non-PMB procedures

    The following non-PMB related procedures will be covered in a Transmed private hospital network hospital:

    • functional endoscopic sinus surgery
    • tonsillectomy and adenoidectomy
    • grommets
    • sterilisations
    • vasectomies
    • strabismus (squint eye) repair

    Paid at the Transmed rate

    A 30% co-payment applies for the voluntary use of a non-network hospital and is payable on the hospital claim

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • Admissions to psychiatric/mental institutions (including treatment for alcohol and substance abuse)

    PMB conditions are covered

    Limited to 21 days per beneficiary per year

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • Admissions related to cancer treatment

    Transmed private hospital network is the DSP

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • Cataract surgery

    The OMG network and State hospitals are DSPs

    A 20% co-payment on the total hospital and associated provider costs applies for using a provider other than an OMG network 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

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • Private hospital admissions not listed above

    Only PMB conditions for major medical events are covered

    State hospitals are the DSPs

    If a State hospital is not accessible in terms of the set criteria, authorisation will be considered for admission to a hospital on the Transmed private hospital network as the secondary DSP

    Paid 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 State hospital(DSP)

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • State hospital admissions

    State hospitals are the DSPs

    100% cover according to the UPFS rate at a State hospital for PMB and non-PMB admissions

    Please call 0800 225 151

    100%

    UPFS rate

  • Emergency treatment including consultations and procedures in an emergency room or casualty facility for children under the age of 12

    Authorisation required within 1 working day of the emergency treatment

    If no authorisation is obtained, services will be paid from the day-to-day benefit, subject to the availability of funds

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at the Transmed rate

  • Emergency visits in hospital casualties

    Paid at the Transmed rate if life-threatening

    Authorisation required within 1 working day of the emergency treatment

    If no authorisation is obtained, services will be paid from the day-to-day benefit, subject to the availability of funds

    Please call 0800 225 151

    100%

    at Transmed rate

  • In-hospital radiology

    Only PMB conditions

    Basic radiology (X-rays)
    Subject to case management and clinical protocols

    Advanced radiology (MRI and CT scans)
    In and out of hospital

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • Prostheses - combined annual sub-limit prostheses - reimbursed for PMB conditions

    Only PMB conditions

    Subject to case management, clinical protocols and individual prostheses limits

    R74 200 per beneficiary per year

    Pre-authorisation required
    Please call 0800 225 151

    Pacemaker and leads Limited to R40 000
    Pacemaker - double chamber Limited to R45 000
    Cervical and lumbar disc replacement Limited to R16 000
    Partial hip replacement Limited to R19 000
    Hip revision Limited to R43 000
    Total hip replacement Limited to R54 000
    Total knee replacement Limited to R46 500
    Total shoulder replacement Limited to R49 000
    Total knee revision Limited to R45 000
    Spinal fusion Limited to R 46 000
    Cardiac stents (per stent) to a maximum of three Limited to R21 200
    Grafts (per graft) Limited to R22 500
    Cardiac valves (per valve) Limited to R30 000
    Hernia mesh (umbilical repair) Limited to R11 000
    Hernia mesh (other) Limited to R5 500
    Non-specified items Limited to R21 000

    Below internal prostheses does not form part of the combined limit

    Endovascular aneurysm repair (EVAR), Anaconda and equivalents R280 00 Per beneficiary per year
    Pacemaker plus defibrillator R100 000 Per beneficiary per year
    Brain stimulator R150 000 Per beneficiary per year
    Transcatheter aortic valve implantation (TAVI) R240 000 per beneficiary per year

    100%

    at cost

  • Orthopaedic, surgical and medical appliances

    Subject to case management, clinical protocols and individual appliances limits
    Pre-authorisation required
    Please call 0800 225 151

    Wheelchairs (subject to clinical criteria)

    Non-motorised wheelchair
    OR
    Motorised wheelchair
    R8 000 (once every five years)
    Hand prothesis R10 000 (once every two years)
    Arm prosthesis R26 000 (once every two years)
    Above knee prosthesis R75 000 (once every two years)
    Below knee prosthesis R68 000 (once every two years)
    Silicone sleeve replacements for artificial limbs R9 500 (once every year)
    Back brace following surgical procedures R7 700
    Walking aids R2 000

    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 an international donor search and harvesting willl 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

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • Dialysis

    100% at a State hospital or Transmed private hospital network hospital or approved dialysis centre

    Paid 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 DSP (State hospital)

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • Oncology (cancer) treatment

    Paid at the Transmed rate at a State hospital or through the Independent Clinical Oncology Network (ICON)

    Unlimited benefit for treatment falling within 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

    Reference pricing is applicable to oncology (cancer) medication

    Subject to evidence-based clinical protocols

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0800 225 151

    100%

    at Transmed rate

  • Terminal care benefit

    Subject to pre-authorisation (home assessment if indicated)

    Once-off limit of R15 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

    Applicable for treatment provided in an accredited facility (hospice/sub-acute/homecare by registered nurse)

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0800 225 151



    100%

    at 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 per enrolment

    Members may be liable for a co-payment if a pharmacy outside of the Transmed pharmacy network is used

    Reference pricing applies

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0860 109 793

    100%

    at Transmed rate

  • Ambulance services

    Transfer protocols apply

    Paid at the Transmed rate

    Pre-authorisation required
    Please call 0800 115 750

    100%

    at Transmed rate