Consultations

Overall Out of Hospital family Limit

Standard Care Plan members have access to an Overall Out of Hospital Family Benefit, limited to R6 795 per adult and R3 385 per child per year. This limit includes consultations, visits, procedures, alternative and allied healthcare services, acute medicine and Pharmacist Advised Therapy (PAT).

This benefit has two categories and sub limits:

Sub limit 1: Alternative and Allied Healthcare Services

R4 390 per adult, R920 per child per year - subject to the Overall Out of Hospital Family Limit.

This sub limit 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.
Private nursing instead of hospitalisation.

Sub limit 2: GP and specialist consultations and procedures and medicines (acute and PAT)

R6 380 per adult, R3 190 per child - subject to the Overall Out of Hospital Family Limit.

This sub limit applies to:

GPs and specialist in rooms (non-PMB), consultations, virtual consultations, visits, procedures and treatments in rooms, acute medicine and injection material out of hospital
Specialist consultations and procedures will be funded up to the agreed rate when visiting a Premier Network Specialists
For consultations with non-network specialists, claims will be reimbursed at 100 % of the Scheme Reimbursement Rate (SRR)
Medicine: NAPPI coded acute medicine and injection material prescribed or dispensed by a registered homeopath
PAT medicine: R735 per purchase, per family every 3 months.

These two sub limits do not add up to the Overall Out of Hospital Family Limit, but act as a security net within this combined benefit. Members can choose which service they need most. The sub limits 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.

How to calculate your Family Limit

Adult
R1 000

Child
R200

x 2 = R2 000

x 1 = R200

Family Limit
R2 200

Psychiatric conditions - PMB:

15 consults at a network psychologist.

When enrolled by a Premier Plus GP, you have access to antidepressant medication

Psychiatric conditions - Non-PMB:

3 GP or psychologist consults up to R3 325 per beneficiary with your enrolling Premier Plus GP.

Antidepressant medication funded form the Non-PMB Chronic Medication Benefit if the chronic condition has been registered.

When enrolled by a Premier Plus GP, you have access to antidepressant medication.