Comprehensive
(High Cover)
Oncology programme at 100% of Scheme tariff.
Subject to pre-authorisation and DSP (ICON).
Biologicals and other high-cost medicine Limited to R384,507 per beneficiary.
Unlimited PMBs. Limited to R426,000 per family for non-PMBs.
Paid at 80% at a DSP and no cover at a non-DSP, once limit is reached. 30% co-payment applies for use of non-DSP.
Sub-limit of R57,680 pb for Brachytherapy and sub-limit of R426,000 for specialised drugs.
Medicine according to preferred provider list. DSP or 20% co-pay.
Oncology Programme covers first R500,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co-payment.
Limited to R624,000 at DSPs. Subject to Core protocol at ICON. 25% co-payment for use of non-DSP.
Unlimited. ICON enhanced protocols apply.
Co-payments apply to voluntary non-network services (10%) and/or deviating from protocol (10%).
R500,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme.
Limit of R718,112 per beneficiary, thereafter PMB only.
Subject to pre-auth and registration on Oncology Programme (Co-payment applies for use of non-DSP)
Comprehensive
(High Cover)
Oncology programme at 100% of Scheme tariff.
Subject to pre-authorisation and DSP (ICON).
Biologicals and other high-cost medicine Limited to R192,126 per beneficiary.
Unlimited PMBs. Limited to R319,500 per family for non-PMBs.
Paid at 80% at a DSP
and no cover at a non-DSP, once limit is reached. 30% co-payment applies for use of non-DSP.
Sub-limit of R150,000 for specialised drugs/biologicals. Sub-limit of R57,680 pb for Brachytherapy.
Medicine according to preferred provider list. DSP or 20% co-pay.
–
–
PMB Unlimited
Non-PMB limit of R476,700 pfpa. Protocols and DSP (ICON) apply.
Co-payments apply to voluntary non-network services (10%) and/or deviating from protocol (15%).
R500,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme.
–
Comprehensive
(Medium to High Cover)
Oncology programme at 100% of Scheme tariff.
Subject to pre-authorisation and DSP (ICON)
Unlimited PMBs. Limited to R266,300 per family for non-PMBs.
Paid at 80% at a DSP and no cover at a non-DSP, once limit is reached. 30% co-payment applies for use of non-DSP.
Sub-limit of R57,680 pb for Brachytherapy. Pre-auth required.
Medicine according to preferred provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
–
PMB Unlimited
Non-PMB limit of R313,900 pfpa.
Protocols and DSP (ICON) apply.
Co-payments
apply to voluntary non-network
services (10%) and/or deviating from protocol (20%).
R400,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme.
Limit of R478,741 per beneficiary, thereafter PMB only.
Subject to pre-auth and registration on Oncology Programme (Co-payment applies for use of non-DSP)
Comprehensive
(Medium to High Cover)
–
Unlimited PMBs. Limited to R266,300 per family for non-PMBs.
Paid at 80% at a DSP and no cover at a non-DSP, once limit is reached. 30% co-payment applies for use of non-DSP.
Sub-limit of R150,000 for specialised drugs/biologicals. Sub-limit of R57,680 pb for Brachytherapy.
Medicine according to preferred provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
Limited to R499,100 at DSPs. Subject to Essential protocol at ICON. 25% co-payment for use of non-DSP.
PMB Unlimited
Non-PMB limit of R313,900 pfpa.
Protocols and DSP (ICON) apply.
Co-payments
apply to voluntary non-network
services (10%) and/or deviating from protocol (20%).
R400,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme.
Limit of R478,741 per beneficiary, thereafter PMB only.
Subject to pre-auth and registration on Oncology Programme (Co-payment applies for use of non-DSP)
Comprehensive
(Medium to High Cover)
–
Unlimited PMBs. Limited to R266,300 per family for non-PMBs.
Paid at 80% at a DSP and no cover at a non-DSP, once limit is reached. 30% co-payment applies for use of non-DSP.
Sub-limit of R150,000 for specialised drugs/biologicals. Sub-limit of R57,680 pb for Brachytherapy.
Medicine according to preferred provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
Limited to R499,100 at DSPs. Subject to Essential protocol at ICON. 25% co-payment for use of non-DSP.
PMB Unlimited
Non-PMB limit of R313,700 pfpa Protocols and DSP (ICON) apply.
Co- payments apply to voluntary non-network services (10%) and/or deviating from protocol (20%).
R400,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme.
Limit of R478,741 per beneficiary, thereafter PMB only.
Subject to pre-auth and registration on Oncology Programme (Co-payment applies for use of non-DSP)
Hospital & Savings
(Low to Medium Cover)
Oncology programme at 100% of Scheme tariff.
Subject to pre-authorisation and DSP (ICON)
Unlimited PMBs. Limited to R213,000 per family for non-PMBs.
Paid at 80% at a DSP
and no cover at a non-DSP, once limit is reached. 30% co-payment applies for use of non-DSP.
Sub-limit of R57,680 pb for Brachytherapy. Pre-auth required.
Medicine according to preferred provider list. DSP or 20% co-pay
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
Limited to R311,900 at DSPs. Subject to Essential protocol at ICON. 25% co-payment for use of non-DSP.
PMB Unlimited
Non-PMB limit of R275,100 pfpa. Protocols and DSP (ICON) apply.
Co- payments apply to voluntary non-network services (10%) and/or deviating from protocol (20%).
R400,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme.
–
Hospital & Savings
(Low to Medium Cover)
Oncology programme at 100% of Scheme tariff.
Subject to pre-authorisation and DSP (ICON)
Unlimited PMBs. Limited to R213,000 per family for non-PMBs.
Paid at 80% at a DSP and no cover at a non-DSP, once limit is reached. 30% co-payment applies for use of non-DSP.
Sub-limit of R57,680 pb for
Brachytherapy. Pre-auth required.
Medicine according to preferred provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
Limited to R311,900 at DSPs. Subject to Essential protocol at ICON. 25% co-payment for use of non-DSP.
PMB Unlimited
Non-PMB limit of R242,500 pfpa Protocols and DSP (ICON) apply.
Co- payments apply to voluntary non-network services (10%) and/or deviating from protocol (20%).
R400,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme.
Limit of R239,371 per beneficiary, thereafter PMB only.
Subject to pre-auth and registration on Oncology Programme (Co-payment applies for use of non-DSP)
Hospital & Savings
(Low to Medium Cover)
Oncology programme at 100% of Scheme tariff.
Subject to pre-authorisation and DSP (ICON)
Unlimited PMBs. Limited to R213,000 per family for non-PMBs.
Paid at 80% at a DSP and no cover at a non-DSP, once limit is reached. 30% co-payment applies for use of non-DSP.
Sub-limit of R57,680 pb for Brachytherapy. Pre-auth required.
Medicine according to preferred provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
Limited to R311,900 at DSPs. Subject to Essential protocol at ICON. 25% co-payment for use of non-DSP.
PMB Unlimited
Non-PMB limit of R275,100 pfpa. Protocols and DSP (ICON) apply.
Co- payments apply to voluntary non-network services (10%) and/or deviating from protocol (20%).
R400,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme.
Limit of R239,371 per beneficiary, thereafter PMB only.
Subject to pre-auth and registration on Oncology Programme (Co-payment applies for use of non-DSP)
Hospital & Savings
(Low to Medium Cover)
–
Unlimited PMBs. Limited to R213,000 per family for non-PMBs.
Paid at 80% at a DSP and no cover at a non-DSP, once limit is reached. 30% co-payment applies for use of non-DSP.
Sub-limit of R57,680 pb for Brachytherapy. Pre-auth required.
Medicine according to preferred provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
Limited to R311,900 at DSPs. Subject to Essential protocol at ICON. 25% co-payment for use of non-DSP.
PMB Unlimited
Non-PMB limit of R275,100 pfpa. Protocols and DSP (ICON) apply.
Co- payments apply to voluntary non-network services (10%) and/or deviating from protocol (20%).
R400,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme.
Limit of R239,371 per beneficiary, thereafter PMB only.
Subject to pre-auth and registration on Oncology Programme (Co-payment applies for use of non-DSP)
Capitation
(Low Cover)
–
Subject to PMB and Network Provider, or a 30% co-payment applies. Pre-auth required.
Medicine according to preferred provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
–
–
R200,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from Evolve Network of Oncologists.
–
Capitation
(Low Cover)
–
Subject to PMB and Network Provider, or a 30% co-payment applies. Pre-auth required.
Medicine according to preferred provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
–
Subject to Prescribed Minimum Benefits. Listed essential cases – clinical guidelines and pre-authorisation apply.
R200,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from Evolve Network of Oncologists.
–
Hospital Plan
(Hospitalization Cover)
–
Unlimited PMBs. Limited to R159,800 per family for non-PMBs.
Paid at 80% at a DSP
and no cover at a non-DSP, once limit is reached. 30% co-payment applies for use of non-DSP.
Sub-limit of R57,680 pb for Brachytherapy. Pre-auth required.
Medicine according to preferred provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
–
–
–
–
Hospital Plan
(Hospitalization Cover)
Oncology programme at 100% of Scheme tariff.
Subject to pre-authorisation and DSP (ICON)
Subject to PMB and Network Provider, or a 30% co-payment applies.
Sub-limit of R57,680 pb for Brachytherapy. Pre-auth
required.
Medicine according to preferred
provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
Covered up to PMB level of care at DSPs. Subject to Essential protocol at ICON. 25% co-payment for use of non-DSP.
PMB Unlimited
Non-PMB limit of R254,100 pfpa. Protocols and DSP (ICON) apply.
Co-payments apply to voluntary non-network services (10%) and/or deviating from protocol (20%).
R300,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme.
–
Hospital Plan
(Hospitalization Cover)
Oncology programme at 100% of Scheme tariff.
Subject to pre-authorisation and DSP (ICON)
Subject to PMB and Network Provider, or a 30% co-payment applies.
Sub-limit of R57,680 pb for Brachytherapy. Pre-auth required.
Medicine according to preferred
provider list. DSP or 20% co-pay.
Oncology Programme covers first R250,000 of approved cancer treatment over 12 month period. Unlimited thereafter, with a 20% co- payment.
Covered up to PMB level of care at DSPs. Subject to Essential protocol at ICON. 25% co-payment for use of non-DSP
PMB Unlimited
Non-PMB limit of R254,100 pfpa. Protocols and DSP (ICON) apply.
Co- payments apply to voluntary non-network services (10%) and/or deviating from protocol (20%).
R300,000 per beneficiary per year, thereafter a 20% co-payment applies.
Treatment must be obtained from an oncologist authorised by the Scheme
Limit of R239,371 per beneficiary, thereafter PMB only.
Subject to pre-auth and registration on Oncology Programme (Co-payment applies for use of non-DSP)
Primary Care
(Network & Income Based)
Approved PMBs at DSPs
Subject to PMB and Network Provider, or a 30% co-payment applies. Pre-auth required.
Medicine according to preferred provider list. DSP or 20% co-pay.
Subject to PMB, use of Network cancer specialist and registration on Oncology Programme.
Covered up to PMB level of care at DSPs. Subject to Essential protocol at ICON.
PMB Unlimited
Non-PMB limit of R242,500 pfpa. Protocols and DSP (ICON) apply.
Co- payments apply to voluntary non-network services (10%) and/or deviating from protocol (20%).
Limited to Prescribed Minimum Benefits at State facilities
–