Important rule adjustments and improvements for 2025

After the publication of our Benefit Guide, the Board approved further Rule changes for 2025. Please note these changes as they might differ from what you see in the Benefit Guide. These changes are subject to approval from the Registrar of Medical Schemes.

Value Care Plan:

• Oncology innovation medicine benefit: Members already registered for the Oncology Management Programme do not need to register separately for this benefit.
• Intraocular lens replacement: Subject to preauthorisation, clinical protocols, and the internal prostheses limit, beneficiaries are entitled to this procedure if performed in an accredited ophthalmologist's room or registered day clinic on the Scheme's defined list of network facilities.

Managed Care Plan

• Oncology innovation medicine: A sublimit of R750 000 was introduced where specified innovative or high-cost medicines are funded up to the Single Exit Price (SEP). After reaching this sublimit, payment will be limited to 80% of SEP and the member will be responsible for the balance.
• Intraocular lens replacement: Subject to preauthorisation, clinical protocols, and the internal prostheses limit, beneficiaries are entitled to this procedure if performed in an accredited ophthalmologist's room or registered day clinic on the Scheme's defined list of network facilities.

Value Care Plan:

• Preventive dental treatment for children: Authorisation is only required for children under the age of 12 for preventative treatment.
• Hospital benefit: Within the annual hospital limit, there is a private hospital sublimit for specialist services in hospital of R86 415 per family per annum.
• Pharmacist Advised Therapy (PAT): The limit was amended to R360 per annum.
• Oncology benefit: Beneficiaries registered on the Prime Cure Oncology Programme may obtain treatment at a state facility or contracted network service provider for oncology services, subject to referral by a Prime Cure practitioner or contracted network service provider. Beneficiaries are entitled to the Prime Cure tariff subject to the annual family limit for hospitalisation.

To view the full Scheme Rules, visit www.angloms.co.za and navigate to My Scheme > Scheme Rules.

Published January 2025