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Major medical cover
Link plan
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Admissions to private hospitals for accidents/trauma
Emergency admissions related to accidents or trauma (motor vehicle, bike or pedestrian) will be covered in a Universal Healthcare private hospital network hospital, subject to authorisation within 48 hours of the accident
Note: Refer to the definition of an emergency below, as per the Medical Schemes Act
Paid at the Transmed rate
Pre-authorisation required
Please call 0861 686 278Definition
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
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Admissions to private hospitals for maternity
100% cover at a State hospital
Benefit provided through Universal Healthcare network
Paid at the Transmed rate
Pre-authorisation required
Please call 0861 686 278
Online antenatal course: www.bellybabies.co.za
Refer to the benefit guide page 26 for more information
100%
at Transmed rate
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PMB-related admissions to private hospitals for children
PMB-related admissions for children between 1 and 12 years old will be covered in a Universal Healthcare private hospital network hospital
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 State hospital(DSP)
Pre-authorisation required
Please call 0861 686 278
100%
at Transmed rate
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Admissions to private hospitals for in-hospital dentistry
No benefit
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Admissions to private hospitals related to non-PMB procedures
The following non-PMB related procedures will be covered in a Universal Healthcare private hospital network hospital:
- functional endoscopic sinus surgery
- tonsillectomy and adenoidectomy
- sterilisations
- vasectomies
- strabismus repair (squint eye) repair
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 State hospital(DSP)
Pre-authorisation required
Please call 0861 686 278
100%
at Transmed rate
- functional endoscopic sinus surgery
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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 0861 686 278100%
at Transmed rate
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Admissions related to cancer treatment
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 Universal Healthcare 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 the State hospital (DSP)
Pre-authorisation required
Please call 0861 686 278
100%
at Transmed rate
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Cataract surgery
The OMG network and State hospitals are DSPs
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)
Paid at the Transmed rate
Pre-authorisation required
Please call 0861 686 278
100%
at Transmed rate
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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 Universal Healthcare 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 the State hospital (DSP)
Pre-authorisation required
Please call 0861 686 278
100%
at Transmed rate
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State hospital admissions
State hospitals are the DSPs
100% cover according to the UPFS rate at a State hospital for PMB admissions onlyNote
Members using a State hospital for any non-PMB condition must be admitted as private patients and members will be personally liable for the payment of the accountPlease call 0861 686 278
100%
UPFS rate
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Emergency treatment including consultation and procedure in an emergency room or casualty facility for children under the age of 12
Refer to benefit: Emergency treatment including consultation and procedure in hospital casualties
100%
at Transmed rate
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Emergency treatment including consultation and procedure 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, the GP consultation and medicine will be paid as per the out-of-network benefit, the facility fee will not be covered
Please call 0861 686 278
100%
at Transmed rate
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In-hospital radiology
Only PMB conditions
Basic radiology (X-rays)
Subject to case management and clinical protocolsUniversal formulary applicable
Limited to R9 620 per family per year in hospital
Advanced radiology (MRI, CT and PET scans)
Limited to R28 070 per family per year in and out of hospitalPaid at the Transmed rate
Pre-authorisation required
Please call 0861 686 278
100%
at Transmed rate
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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 0861 686 278Pacemaker and leads Limited to R40 000 Pacemaker - double chamber Limited to R85 000 Cervical and lumbar disc replacement Limited to R30 000 Partial hip replacement Limited to R30 000 Hip revision Limited to R43 000 Total hip replacement Limited to R61 600 Total knee replacement Limited to R46 500 Partial knee replacement Limited to R30 000 Total shoulder replacement Limited to R52 000 Knee revision Limited to R45 000 Spinal fusion Limited to R50 600 Cardiac stents (per stent) to a maximum of three Limited to R23 320 Grafts (per graft) Limited to R28 500 Cardiac valves (per valve) Limited to R30 000 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 plus defibrillator R280 000 Per beneficiary per year Brain stimulator R180 000 Per beneficiary per year Transcatheter aortic valve implantation (TAVI) R280 000 Per beneficiary per year 100%
at cost
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Orthopaedic, surgical and medical appliances
Subject to case management, clinical protocols and individual appliances limits
Pre-authorisation required
Please call 0861 686 278Wheelchairs (subject to clinical criteria)
Non-motorised wheelchair
OR
Motorised wheelchairR9 900 (once every five years) Hand prothesis R10 000 (once every two years) Arm prosthesis - Below elbow R26 000 (once every two years) Arm prosthesis - Above elbow R50 000 (once every two years) Above knee prosthesis R150 000 (once every two years) Below knee prosthesis R90 000 (once every two years) Silicone sleeve replacements for artificial limbs R20 000 (once every year) Back brace following surgical procedures R25 000 Walking aids R2 420 100%
at cost
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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 will 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 0861 686 278100%
at Transmed rate
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Dialysis
Unlimited at a State hospital
If a State hospital is not accessible in terms of the set criteria, authorisation can be obtained for involuntary admission to a hospital on the Universal Healthcare private hospital network or approved dialysis centres
Paid at the Transmed rate
The co-payment for using a non-DSP voluntarily 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 a DSP (State hospital)
Pre-authorisation required
Please call 0861 686 278100%
at Transmed rate
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Oncology (cancer) treatment
Paid at the agreed 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 and subject to the overall radiology limit
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 Universal oncology medicine network
A 20% co-payment applies for obtaining oncology (cancer) medication from a non-oncology medicine network service provider
Subject to evidence-based clinical protocols
Paid at the Transmed rate
Pre-authorisation required
Please call 0861 686 278100%
at Transmed rate
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Terminal care benefit
PMB level of care
Paid at the Transmed rate
Pre-authorisation required
Please call 0861 686 278100%
at Transmed rate
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HIV and AIDS benefit
Paid at 100% of cost if obtained from a DSP
Members will be liable for a 20% co-payment if a pharmacy outside the Universal Healthcare network is used
Treatment is subject to compliance with clinical protocols
Paid at the Transmed rate
Pre-authorisation required
Please call 0861 686 278100%
at Transmed rate
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Ambulance services
Only PMB conditions
Transfer protocols apply
Paid at the Transmed rate
Pre-authorisation required
Please call 0800 115 750100%
at Transmed rate