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.

Consultations at a network pharmacy wellness clinic with a nurse practitioner
The Scheme pays R260 per visit, subject to a Family Limit of R520 per year.

General Practitioners
Network GP in rooms
You are entitled to six routine consultations or visits for acute conditions, provided you obtain them from a Prime Cure facility, a network general practitioner (GP) or nursing practitioner. Thereafter, any further consultations require authorisation. If you do not get authorisation, you will be responsible to cover the cost of the consultation.

Non-network GP
You will have a 20% co-payment per visit when visiting a non-network GP, subject to authorisation within 72 hours after the consultation. Facility fees are not covered. Non-network GP consultations are limited to a maximum of R1 000 per consultation (including related expenses) per beneficiary, maximum of 1 consultation per beneficiary or 2 per family per year.

Specialists
You need a referral by a Prime Cure facility or network doctor for a specialist visit. Obtain authorisation by phoning 0861 665 665. Specialist consultations are limited to
R3 456 per family, 5 consultations per family and a maximum of 3 consultations per beneficiary per year. Subject to authorisation.

You will have to pay 30% of the consultation if you voluntarily visit a non-Prime Cure specialist and do not get authorisation. Services are paid up to the Prime Cure agreed rate only. Medication prescribed and obtained at a Prime Cure network pharmacy is included in this limit.

Specialist consultations in rooms for PMB and emergencies
PMB conditions: Subject to programme registration and authorisation.
Emergencies: Authorisation must be obtained within 72 hours after the event.
Services are paid up to the Prime Cure agreed rate only.

Allied healthcare services
These include services like audiology, dietetics, occupational therapy, podiatry, physiotherapy, psychology, social services and speech therapy. Authorisation and referral are required. A co-payment of 50% of Prime Cure negotiated/agreed rate applies if you self-refer to any practitioner. Allied healthcare services are limited to R 2 650 per family with a maximum of R1 765 per beneficiary per year.

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