Consultations and procedures out of hospital

Standard Care Plan members have access to an Overall Out Of Hospital Family Benefit, limited to R5 070 per adult and R2 530 per child per year.

This limit includes consultations, visits, procedures, alternative and allied healthcare services, acute medicine and Pharmacist Advised Therapy (PAT).

How to calculate your Family Limit

R1 000
x 2 = R2 000
x 1 = R200
Family Limit
R2 200

Use the combined available limit for one or more family member or treatment

This benefit has two categories and sublimits:

Sublimit 1: Alternative and Allied Healthcare Services
R 3 275 per adult, R685 per child per year – subject to the Overall Out Of Hospital Family Limit.

This sublimit applies to:

  • Acupuncture, audiology, chiropody, chiropractic services (including x-rays), dietetics, homeopathy, naturopathy, occupational therapy, orthoptics, physiotherapy, podiatry, psychology, registered nurse services, social services, speech therapy.
  • Orthotists and prosthetists
    Use our Designated Service Provider, the Discovery Health network of orthotists and prosthetists.
    If you use a non-DSP provider, you are responsible for the difference in cost.
  • Private nursing instead of hospitalisation.

Sublimit 2: GP and specialist consultations and procedures and medicines (acute and PAT)
R 4 760 per adult, R2 380 per child per year – subject to the Overall Out Of Hospital Family Limit.

This sublimit applies to:

  • GPs and specialist in rooms (non-PMB): Consultations, visits, procedures and treatments in rooms, acute medicine and injection material out of hospital.
  • PAT medicine (Pharmacist Advised Therapy): R105 per purchase, 5 purchases per family every 3 months.

These two sublimits do not add up to the Overall Out of Hospital Family Limit, but act as a security net within this benefit. Members can choose which service they need most. The sublimits ensure that the member still has at least a minimum amount available for the other category.

Specialist and GP consultations for chronic PMB conditions do not fall under above limits, but are subject to Scheme protocols and registration of the chronic condition.

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