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Major medical cover
Prime plan
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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 151Definition
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
Transmed private hospital network is the DSP
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
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 information100%
at Transmed rate
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PMB-related admissions to private hospitals for children
PMB-related admissions for major medical events are covered
Transmed private hospital network is the DSP
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
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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 payable by the member
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
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Admissions to private hospitals related to non-PMB procedures
No benefit for non-PMB conditions in private hospitals
Members admitted for any non-PMB condition must be admitted as private patients and members will be personally liable for the payment of the account
0%
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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 0800 225 151
100%
at Transmed rate
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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
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Cataract surgery
The OMG network is the DSP
A 20% co-payment on the total hospital and associated provider costs applies for using a provider other than an OMG network provider
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
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Private hospital admissions not listed above
Only PMB conditions for major medical events are covered
Transmed private hospital network is the DSP
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
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State hospital admissions
100% cover according to the UPFS rate at a State hospital for PMB admissions only
Note
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 0800 225 151
100%
UPFS rate
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Emergency treatment including consultations and procedures 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, services will be paid for by the member
Please call 0800 225 151
100%
at Transmed rate
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In-hospital radiology
Only PMB conditions
Basic radiology (X-rays)
Subject to case management and clinical protocolsAdvanced radiology (MRI and CT scans)
In and out of hospitalPaid at the Transmed rate
Pre-authorisation required
Please call 0800 225 151
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 0800 225 151Pacemaker 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 R46 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 0800 225 151Wheelchairs (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 0800 225 151100%
at Transmed rate
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Dialysis
Transmed private hospital network or approved dialysis centre
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 151100%
at Transmed rate
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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
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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
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
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Transmed