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Member contributions 2021

HEALTHPACT PREMIUM HEALTHPACT SILVER HEALTHPACT SELECT

Hospital cover only Hospital cover with Medical Savings Account (MSA)
Hospital cover with day-to-day benefits and Medical Savings Account (MSA)
Principal member R2,408 R2,402 (including R300 savings per month) R6,834 (including R300 savings per month)
Adult beneficiary R2,408 R2,402 (including R300 savings per month) R6,834 (including R300 savings per month)
Minor beneficiary R425 R360 (including R45 savings per month) R1,105 (including R49 savings per month)
Medical Savings Account (MSA)
None Compulsory savings included in contribution Compulsory savings included in contribution


> Hospitalisation

HEALTHPACT PREMIUM HEALTHPACT SILVER HEALTHPACT SELECT

Overall annual limit Benefits must be authorised

Unlimited
Authorised admissions to hospital
Unlimited
Authorised admissions to hospital
Unlimited
Authorised admissions to hospital

Hospital accommodation
Ward fees, operating theatres, unattached theatres and day hospitals

Up to 100% of the CMP tariff or Agreed Tariff in intensive care, specialised intensive care, high care and general wards. Subject to pre-authorisation. Up to 100% of the CMP tariff or Agreed Tariff in intensive care, specialised intensive care, high care and general wards. Subject to pre-authorisation. Up to 100% of the CMP tariff or Agreed Tariff in intensive care, specialised intensive care, high care and general wards. Subject to pre-authorisation.
Emergency room treatment only
Outpatient services
No cover, except for PMBs Payable from MSA - except for PMBs Payable from MSA, thereafter from day-to-day pool - except for PMBs
Hospitalisation/ institutionalisation for treatment of mental illness, alcoholism and drug addiction No cover, except for PMBs. Subject to pre-authorisation. Payable from MSA - except for PMBs. Subject to pre-authorisation.

Payable from MSA, thereafter from day-to-day pool - except for PMBs. Subject to pre-authorisation.

Treatment in lieu of hospitalisation
Registered step-down facilities, hospices, registered nurses and rehabilitation centres when hospitalisation is not clinically appropriate

100% of CMP tariff for hospices and registered nurses, limited to 15 days per beneficiary. Subject to pre-authorisation. 100% of CMP tariff for hospices and registered nurses, limited to 15 days per beneficiary. Subject to pre-authorisation. 100% of CMP tariff for hospices and registered nurses, limited to 15 days per beneficiary. Subject to pre-authorisation.
Emergency services Provided by a registered ambulance service 100% of CMP tariff - except for PMBs. Subject to pre-authorisation. 100% of CMP tariff - except for PMBs. Subject to pre-authorisation. 100% of CMP tariff - except for PMBs. Subject to pre-authorisation.
Blood transfusions
In-hospital
100% of cost to a maximum of 100% of CMP tariff. Subject to pre-authorisation. 100% of cost to a maximum of 100% of CMP tariff. Subject to pre-authorisation. 100% of cost to a maximum of 100% of CMP tariff. Subject to pre-authorisation.
Materials and devices Used in-hospital 100% of cost to a maximum of Single Exit Price/Agreed Tariff/pre-authorised tariff. Subject to pre-authorisation. 100% of cost to a maximum of Single Exit Price/Agreed Tariff/pre-authorised tariff. Subject to pre-authorisation. 100% of cost to a maximum of Single Exit Price/Agreed Tariff/pre-authorised tariff. Subject to pre-authorisation.

Medicines
Dispensed and used in-hospital

100% of cost, up to the Single Exit Price for approved medicines. Subject to pre-authorisation. 100% of cost, up to the Single Exit Price for approved medicines. Subject to pre-authorisation. 100% of cost, up to the Single Exit Price for approved medicines. Subject to pre-authorisation.
Supplementary services eg. physio, occupational, speech therapists and dieticians
100% of CMP tariff. Subject to pre-authorisation. 100% of CMP tariff. Subject to pre-authorisation. 100% of CMP tariff. Subject to pre-authorisation.
Consultations, procedures and operations performed by general practitioners 200% of CMP tariff. Subject to pre-authorisation. 100% of CMP tariff. Subject to pre-authorisation. 200% of CMP tariff. Subject to pre-authorisation.

Consultations, procedures and operations performed by registered medical specialists

Written referral required

200% of CMP tariff. Subject to pre-authorisation. 100% of CMP tariff. Subject to pre-authorisation. 200% of CMP tariff. Subject to pre-authorisation.

Laparoscopic and endoscopic procedures performed in-hospital

Written referral required

200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure
(co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation.
100% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure
(co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation.
200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure
(co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation.


> Consultations and out-of-hospital procedures – GPs and specialists

HEALTHPACT PREMIUM HEALTHPACT SILVER HEALTHPACT SELECT

General practitioner consultations and procedures

Any procedure performed by a General Practitioner requires pre-authorisation

One GP visit per beneficiary per year, at 100% of CMP tariff - except for PMBs. Up to two GP visits per beneficiary per year, at 100% of CMP tariff, thereafter payable from MSA - except for PMBs. 200% of CMP tariff, payable from MSA, thereafter from day-to-day pool - except for PMBs.

Registered medical specialist consultations and procedures

Written referral required

No cover, except for PMBs. Subject to pre-authorisation. Payable from MSA - except for PMBs. Subject to pre-authorisation. Payable from MSA, thereafter from day-to-day pool - except for PMBs. Subject to pre-authorisation.

Laparoscopic and endoscopic procedures

Written referral required

200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure (co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation. 100% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure (co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation. 200% of CMP tariff. Laparoscopic procedures as per the endoscopic surgeon’s guidelines with a co-payment per scope, per procedure (co-payments are the same across all three plans – click here to view them in a pop-up window). Subject to pre-authorisation.
Supplementary services eg. physio, occupational, speech therapists and dieticians
No cover, except for PMBs. Subject to pre-authorisation. Payable from MSA - except for PMBs. Subject to pre-authorisation. Payable from MSA, thereafter from day-to-day pool - except for PMBs. Subject to pre-authorisation.

> Consultations and out-of-hospital procedures – Dentistry, orthodontics and oral surgery

HEALTHPACT PREMIUM HEALTHPACT SILVER HEALTHPACT SELECT
General dental practitioner consultations No cover 100% of CMP tariff limited to R553 per beneficiary, thereafter payable from MSA - except for PMBs. Subject to pre-authorisation. Payable from MSA, thereafter from day-to-day pool - except for PMBs. Subject to pre-authorisation.
General dental practitioner procedures In-hospital and according to Dental Protocols 100% of cost, up to 120% of the CMP tariff for procedures and operations which require hospitalisation, except for PMBs. 100% of cost, up to 100% of the CMP tariff for procedures and operations which require hospitalisation, except for PMBs. 100% of cost, up to 120% of the CMP tariff for procedures and operations which require hospitalisation, except for PMBs.
Orthodontic treatment No cover Payable from MSA Payable from MSA, thereafter from
day-to-day pool

Maxillo-facial surgeons
In-hospital procedures

Written referral required 

120% of CMP tariff - except for PMBs. Subject to pre-authorisation. 100% of CMP tariff - except for PMBs. Subject to pre-authorisation. 120% of CMP tariff - except for PMBs. Subject to pre-authorisation.
Maxillo-facial surgeons and orthodontists
Dental implants, general dental treatment, orthodontic treatment, orthognathic procedures, periodontic treatment and prosthodontic treatment and according to Dental Protocols
No cover Payable from MSA Payable from MSA, thereafter from
day-to-day pool

> Consultations and out-of-hospital procedures – Maternity and paediatrics

HEALTHPACT PREMIUM HEALTHPACT SILVER HEALTHPACT SELECT
Maternity confinements
Birth or delivery
200% of CMP tariff; only medically-necessary caesareans are covered - except for PMBs. Subject to pre-authorisation. 100% of CMP tariff; only medically-necessary caesareans are covered - except for PMBs. Subject to pre-authorisation. 200% of CMP tariff; with cover for elective caesareans are covered - except for PMBs. Subject to pre-authorisation.

Ante-natal consultations and foetal scans
In- or out-of-hospital

Provided by a registered gynaecological or radiology practice

200% of the CMP tariff, limited to R2,396 per family per year - except for PMBs 100% of the CMP tariff, limited to R2,396 per family per year, thereafter payable from MSA - except for PMBs 200% of the CMP tariff, limited to R2,996 per family per year, thereafter payable from MSA and then from day-to-day pool - except for PMBs
Paediatrician consultations
200% of CMP tariff, limited to R2,029 per child per year - except for PMBs 100% of the CMP tariff, limited to R956 per child per year, thereafter payable from MSA - except for PMBs 200% of the CMP tariff, payable from MSA, thereafter from day-to-day pool - except for PMBs
Paediatrician procedures and operations 200% of CMP tariff. Subject to pre-authorisation. 100% of CMP tariff. Subject to pre-authorisation. 200% of CMP tariff. Subject to pre-authorisation.

> Consultations and out-of-hospital procedures – Diagnostics – x-rays, radiology and pathology

HEALTHPACT PREMIUM HEALTHPACT SILVER HEALTHPACT SELECT

Radiologist procedures, Angiograms, CT scans, duplex doppler scans, interventional radiology, MRI scans, and nuclear medical investigations

Written referral required

100% of CMP tariff, limited to R12,524 per beneficiary per year, with a co-payment of R1,500 per event on all procedures - except for PMBs. Subject to pre-authorisation. 100% of CMP tariff, limited to R12,524 per beneficiary per year, with a co-payment of R1,500 per event on all procedures, thereafter payable from MSA - except for PMBs. Subject to pre-authorisation. 100% of CMP tariff, limited to R12,524 per beneficiary per year, with a co-payment of R1,500 per event on all procedures, thereafter payable from MSA and then from day-to-day pool - except for PMBs. Subject to pre-authorisation.

Black and white x-rays

 In-hospital

100% of CMP tariff. Subject to pre-authorisation. 100% of CMP tariff. Subject to pre-authorisation. 100% of CMP tariff. Subject to pre-authorisation.
Black and white x-rays Out-of-hospital No cover, except for PMBs Payable from MSA - except for PMBs Payable from MSA, thereafter from day-to-day pool - except for PMBs

Mammogram benefit

Provided by a registered radiology practice

100% of the CMP tariff, with co-payment of R300 per female beneficiary over the age of 49 years, once every 2 years, limited to R1,613 – except for PMBs. Subject to pre-authorisation. 100% of the CMP tariff, with co-payment of R300 per female beneficiary over the age of 49 years, once every 2 years, limited to R1,613 with co-payment of R300 . Thereafter, payable from MSA – except for PMBs. Subject to pre-authorisation. 100% of the CMP tariff, with co-payment of R300 per female beneficiary over the age of 49 years, once every 2 years, limited to R1,613 with co-payment of R300 . Thereafter, payable from MSA, and then from day-to-day pool – except for PMBs. Subject to pre-authorisation.

Bone density benefit

Provided by a registered radiology practice

100% of the CMP tariff, per beneficiary, over the age of 50, once every 5 years - except for PMBs 100% of the CMP tariff, per beneficiary, over the age of 50, once every 5 years. Thereafter payable from MSA - except for PMBs 100% of the CMP tariff, per beneficiary, over the age of 50, once every 5 years. Thereafter payable from MSA, and then from day-to-day pool - except for PMBs

Pathology services
in-and-out of hospital

With Pathcare and Lancet Laboratories who are SANAS-accredited

Written referral required

In-and-out pathology is covered in full as long as you use Pathcare or Lancet Laboratories, who are SANAS-accredited

In-hospital pathology services performed by a service provider other than Pathcare or Lancet Laboratories, will only be covered from your insured benefits during the first 24 hours (of an emergency admission), and only when approved by CMP and performed by a SANAS-accredited pathologist

Any out-of-hospital pathology will be for your own account, if you don’t use a Preferred Provider (Pathcare or Lancet)
In-and-out pathology is covered in full as long as you use Pathcare or Lancet Laboratories, who are SANAS-accredited

In-hospital pathology services performed by a service provider other than Pathcare or Lancet Laboratories, will only be covered from your insured benefits during the first 24 hours (of an emergency admission), and only when approved by CMP and performed by a SANAS-accredited pathologist

Any out-of-hospital pathology will be paid from available funds in your Medical Savings Account (MSA), if you don’t use a Preferred Provider (Pathcare or Lancet)
In-and-out pathology is covered in full as long as you use Pathcare or Lancet Laboratories, who are SANAS-accredited

In-hospital pathology services performed by a service provider other than Pathcare or Lancet Laboratories, will only be covered from your insured benefits during the first 24 hours (of an emergency admission), and only when approved by CMP and performed by a SANAS-accredited pathologist

Any out-of-hospital pathology will be paid from available funds in your Medical Savings Account (MSA) or your day-to-day benefits, if you don’t use a Preferred Provider (Pathcare or Lancet)

> Consultations and out-of-hospital procedures – Prostheses, dialysis, organ transplants and oncology

HEALTHPACT PREMIUM HEALTHPACT SILVER HEALTHPACT SELECT

Prostheses and implants, excluding hearing devices and dental implants

Refer to Prostheses and Implants price list

If introduced internally as an integral part of an operation, 100% of cost, subject to CMP’s prosthetic price list. Limited to R45,912 per beneficiary per year. Subject to pre-authorisation. If introduced internally as an integral part of an operation, 100% of cost, subject to CMP’s prosthetic price list. Limited to R45,912 per beneficiary per year. Subject to pre-authorisation. If introduced internally as an integral part of an operation, 100% of cost, subject to CMP’s prosthetic price list. Limited to R45,912 per beneficiary per year. Subject to pre-authorisation.
External prostheses and surgical appliances (e.g. wheelchairs, crutches, etc.) No cover, except for PMBs. Subject to pre-authorisation. 100% of cost, payable from MSA - except for PMBs. Subject to pre-authorisation. Payable from MSA, thereafter from day-to-day pool - except for PMBs. Subject to pre-authorisation.
Chronic renal dialysis Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation. Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation. Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation.
Organ transplants Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation. Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation. Provided that PMB level of care criteria are met and treatment is provided by a Preferred Provider, covered at 100% of CMP tariff. Subject to pre-authorisation.
Oncology treatment Provided the formularies and treatment protocols of CMP and the SA Oncology Consortium (SAOC) tier guidelines are applied in accordance with an agreed treatment plan, covered at 100% of the CMP tariff, as per the SA Oncology Consortium’s Primary Level of Care treatment guidelines. Treatment plan subject to approval and pre-authorisation. Provided the formularies and treatment protocols of CMP and the SA Oncology Consortium (SAOC) tier guidelines are applied in accordance with an agreed treatment plan, covered at 100% of the CMP tariff, as per the SA Oncology Consortium’s Primary Level of Care treatment guidelines. Treatment plan subject to approval and pre-authorisation. Provided the formularies and treatment protocols of CMP and the SA Oncology Consortium (SAOC) tier guidelines are applied in accordance with an agreed treatment plan, covered at 100% of the CMP tariff, as per the SA Oncology Consortium’s Primary Level of care and Standard Level of Care curative treatment guidelines. Treatment plan subject to approval and pre-authorisation.
Anti-emetics, vitamins, cosmetic and prosthetic appliances forming part of oncology treatment No cover, except for PMBs. Subject to pre-authorisation. Payable from MSA - except for PMBs Payable from MSA, thereafter from day-to-day pool - except for PMBs


> Consultations and out-of-hospital procedures – Prescribed medication

HEALTHPACT PREMIUM HEALTHPACT SILVER HEALTHPACT SELECT

Chronic medication Subject to authorisation

100% of cost to a maximum of Single Exit Price plus the Preferred Provider dispensing fee. Subject to chronic programme protocols. 100% of cost to a maximum of Single Exit Price plus the Preferred Provider dispensing fee. Subject to chronic programme protocols. 100% of cost to a maximum of Single Exit Price plus the Preferred Provider dispensing fee. Subject to chronic programme protocols.
Acute medication No cover, except for PMBs 100% of cost to a maximum of Single Exit Price, plus the agreed Preferred Provider dispensing fee. Limited to R708 per family; thereafter payable from MSA - except for PMBs 100% of cost to a maximum of Single Exit Price, plus the agreed Preferred Provider dispensing fee. Payable from MSA, thereafter from day-to-day pool - except for PMBs
Take-home medication No cover, except for PMBs Payable from MSA - except for PMBs Payable from MSA, thereafter from day-to-day pool - except for PMBs

> Consultations and out-of-hospital procedures – Spectacles, contact lenses and supplementary services
> Preventative benefits
> Conditions covered on the chronic medicine benefit
> What doesn't CMP cover
> Additional notes and terminologies

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