Value Care Plan

Overview

The Value Care Plan provides primary healthcare through a network of Prime Cure facilities and providers only.

Facilities are available in major centres nationwide. Members on this plan may only obtain their healthcare services from a Prime Cure facility or network provider.

Value Care Plan provides the most cost-effective benefits for families' basic healthcare needs. Additional to the treatment of Prescribed Minimum Benefit (PMB) conditions, this plan includes the below benefits.

Find more information on the Value Care Plan here in our Frequently Asked Questions section.

Contributions 2019

Member Adult dependant Child dependant
R895 R895 R220

Value Care Plan limits

In Hospital

Family Hospital Limit R157 500 Including:

+

Sublimit: Private Prime Cure hospital R68 250

+

Sublimit: Blood transfusions R15 550

+

Sublimit: Pathology R17 850 per family

+

Sublimit: Specialised Radiology R17 850 per family

+

Sublimit: Internal surgical prostheses
R27 300 per family

+

Sublimit: Phychlatric services R7 560
per family, 5 days

+

Sublimit: Allied health care services
R7 560 per family, 5 days

Out of Hospital

Consultations: Nurse practitioner at Prime Cure network
pharmacy R520 per family, maximum R260 per visit

+

Consultations: Prime Cure network GPs unlimited
Authorisation needed after 6th consultation per beneficiary

+

Consultations: Specialist R3 465 per family,
5 consultations per family, limited to 3 per benefitiary

+

Sublimit: Specialised Radiology R17 850 per family

+

Pharmacist Advised Therapy (PAT): R95 per purchase
limited to three purchases up to R285 per beneficiary

+

Consultations out of network: R1 000 per consultation.
One consultation per benefitiary or two per family

Prime Cure facilities and network providers

Find a registered Prime Cure network doctor, pharmacy, dentist, hospital or optometrist.

OR

Send a SMS to iFind: 33900

The SMS must read as follows: "Doctor Watloo" or "Dentist Watloo"
You will receive a SMS back within a minute, listing the doctor's name and telephone number.

Using a provider out of the Prime Cure network will result in a co-payment, which can be the difference between the actual cost and the network rate, or a specified value, as per the Rules.

Your benefits

Ambulance services

Value Care Plan members are entitled to obtain emergency ambulance services from a Prime Cure Designated Service Provider only. Phone 0861 665 665 and press option 1 to obtain authorisation. The member, family member or friend must contact Prime Cure on 0861 665 665 within 48 hours of the incident.

Authorise inter-hospital transfers before the event.

Ambulance services are subject to the Family Hospital Limit, unless PMB.

Cancer

Value Care Plan members are entitled to receive cancer (oncology) treatment, provided a Prime Cure facility or network practitioner refers them to a specialist.

Find out more
Consultations

For all consultations (doctor’s visits), including maternity consultations, members of the Value Care Plan will need to use Prime Cure facilities and the practitioner network.

Find out more
Dentistry

Members of the Value Care Plan are entitled to the following dental benefits:
Preventative treatment, Conservative treatments, Specialised dentistry, Emergency consultations and Dental hospital admission.

Find out more
Diabetes

Members of the Value Care Plan, diagnosed with diabetes, need to register their condition with Prime Cure on 0861 665 665. On registration, members will receive a detailed treatment plan indicating the services and medicine that are allowed, according to the relevant protocols. The relevant doctor will inform the member of the benefits available.

Eye Care

Every Value Care Plan beneficiary is entitled to one eye examination per year and one pair of spectacles (lenses and frames) every 2 years. The benefit does not cover contact lenses or sunglasses.
If you get a prescription for spectacles, you need to obtain your spectacles within one month.

HIV/AIDS

Prime Cure offers HIV-positive members and dependants of the Value Care Plan a confidential management programme, aimed at keeping them well and providing access to increased benefits to help manage their condition more effectively.

Find out more
Hospitalisation

Members on the Value Care Plan must obtain authorisation for hospitalisation and must use Prime Cure private hospitals or public hospital facilities. A Prime Cure doctor referral and authorisation is necessary for all planned hospital admissions as well as for admissions following a casualty visit.

Find out more
Maternity

Value Care Plan members have access to antenatal and postnatal care through Prime Cure facilities and network doctors.

Antenatal care: Consultations, GP and specialists
You are entitled to GP consultations, 2 specialist consultations and 2 ultrasound (2D) scans per pregnancy.

Confinement in hospital
We treat the delivery in hospital as a normal hospital admission and the annual Family Hospital Limit applies. Please ensure your Prime Cure healthcare provider registers you on the maternity management programme by phoning 0861 665 665.

Medicine

Acute medicine, inclusive of dental medication
Formulary medicine only, to be obtained at network GP, dentist or pharmacy.

Pharmacy Advised Therapy (PAT)
R285 per family per year (R95 per purchase up to a maximum of 3 purchases per beneficiary).
Formulary medicine only, to be obtained at network GP, dentist or pharmacy.

Find out more
Preventative care

Flu Vaccine
For members of the Value Care Plan, the Scheme pays the cost of one flu vaccine per year, per beneficiary.

Health check
The Scheme pays one Health check per beneficiary per year. The Health check must be done at Wellness partners. It includes the measurement of your cholesterol, blood glucose, BMI and blood pressure.

Other benefits

Read more about other benefits of the Value Care Plan, such as treatment for Alcohol and Drug treatment, Kidney Disease, and Pathology and Radiology services.

Find out more

Disclaimer: All benefits paid at 100% of Scheme Reimbursement Rate (SRR), negotiated rate or at cost if PMB. Tariffs available from the Call Centre.

Familiarise yourself with the most important Scheme exclusions and Rule reminders.

Benefit information on this website is a summary of the registered Scheme Rules. In case of discrepancies the Rules shall prevail.

Authorisation

Authorisation is required for certain procedures, treatments, hospitalisation and medical or surgical appliances.

In some instances, you will not be covered if you did not authorise your treatment.
Please phone Prime Cure on 0861 665 665 to receive authorisation for:

  • Ambulance services
  • Specialised conditions (for example cancer, renal disease, diabetes, HIV/AIDS)
  • Hospitalisation
  • Medicines for PMB chronic conditions
  • Maternity programme
  • Rehabilitation and sub-acute care
  • Oxygen therapy

How to claim

Value Care Plan members belong to a network plan and may only use Prime Cure facilities or Prime Cure network healthcare providers, or both. Prime Cure pays these healthcare providers to provide you with healthcare services. You do not have to pay any accounts unless you have not complied with the Rules or use a healthcare provider outside the network in an emergency. If you receive healthcare services outside the network for an emergency, submit your claim and proof of payment to the address below:

Email: anglo@primecure.co.za
Post: Prime Cure Health Claims, Private Bag X13, Rivonia, 2128

What you may not claim for

General Scheme and Value Care Plan exclusions

The following are some of the Scheme exclusions (for a full list please refer to the Rules). These you would need to pay:

  • Frail care
  • PET scans
  • Deep brain stimulator devices for Parkinson's disease or epilepsy
  • Implant devices for chronic pain management
  • Polysomnogram and CPAP titrations
  • Facility fees
  • No cover for medicine not found on the medicine list
  • Injury or illness that occur beyond the borders of the Republic of South Africa
  • Dental extractions for non-medical purposes
  • All costs related to radial keratotomy and refractive surgery
  • Contact lenses, sunglasses and accessories

The following medicines are specifically excluded unless authorised:

  • Erythropoietin (unless the beneficiary is eligible for renal transplantation)
  • Interferons
  • Biologicals and bio technological substances
  • Immunoglobulins

Third-party claims

Anglo Medical Scheme Rules state that claims for costs that are recoverable from a third party (for example, the Road Accident Fund, or any other insurance fund) are not payable by the Scheme or Prime Cure. Emergency treatments will be paid but will need to be refunded. However, Anglo Medical Scheme is aware that the time taken for these claims to be finalised can vary from a couple of months to years after the accident or incident.

As a result, Prime Cure will agree to settle these accounts after requesting a letter of undertaking from you. Prime Cure will manage the case with the relevant attorneys and service providers.

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