The CompCare Wellness NetworX Option

* Disclaimer: Please note that the 2017 CompCare Options are subject to CMS approval.

Prescribed Minimum Benefits:
  • Unlimited subject to scheme protocols.
Overall Annual Limit (OAL):For non-PMB and elective admissions.
  • R1 160 000 per family per year.
100% of the Agreed Tariff (AT), subject to the OAL, pre-authorisation and network of private hospitals. All treatment in hospital is subject to case management and scheme protocols.
  • GPs and specialists.
  • Ward fees general;ICU and High Care.
  • Theatre fees.
  • Medication whilst in hospital.
  • Blood transfusion.
  • Oncology.
  • Surgical prosthesis (PMB only).
  • Clinical technologists limited to R10 110 p/f.
  • Radiology MRI, CT and PET scans.
  • Pathology.
  • Confinements limited to 3 days for normal birth days and 4 days for Caesarean section.
  • Psychiatric treatment is limited to 21 days in hospital.
  • Organ and bone marrow transplants, plasmapheresis and renal dialysis (PMB only).
  • Cover for  professional sports.
  • Emergency medical treatment for injuries resulting from accidents or trauma.
  • Physiotherapy.
  • Alcoholism, drug dependance and narcotism.
27 chronic conditions covered
Chronic medication is subject to the Core Formulary list of medicines and a Formulary Reference Price (FRP). Members are required to register for all chronic conditions.
  • Chronic medication is unlimited, subject to the medicine formulary and if prescribed by a Universal Network Provider and dispensed within a Universal Network pharmacy or dispensing Universal network GP. Any voluntary use of chronic medicine prescribed by out-of-network providers and any non-formulary medicines are for the member?s own account, unless pre-authorised by the medical advisor. PMB rules apply.
  • Subject to Formulary reference pricing.
Services Subject to the use of the Universal Provider Network.
  • GP visits - unlimited at a selected Universal Network GP, subject to clinical necessity.
  • Two out-of-area visits p/b per annum (20% co-payment at point of service limited to a maximum of R1000 per event, (including medicine, pathology and radiology) excluding facility fees.
  • Acute medication - unlimited if prescribed by a Universal; Network GP, or by specialist provided member reffered by a Universal Network GP.Subject to medicine formulary to Formulary.No cover for a non-formulary medicines unless otherwise pre-authorised.No cover in case of voluntary use of non-Universal Providers, or voluntary use of specialist without refferal by a Universal Network GP.
  • Basic radiology - unlimited, subject to specific codes - Referral by the Universal Network GP required.
  • Basic pathology - unlimited, subject to specific codes - Referral by the Universal Network GP required.
AFB R2 940 p/b
            R4 380 p/f
  • Specialist consultations - limited to 2 p/b, max 3 p/f, subject to referral by a Universal Network GP (Pre-authorisation required). Referrals limited to specialists in DSP Network Hospitals only. 2 ante-natal visits per pregnancy.
  • Basic dentistry - limited to 1 consultation p/b including preventative care, infection control, fillings, extractions and dental x-rays at a Universal Network Dentist.
  • Optometry - limited to 1 test p/b every 24 months, including lenses clear plastic lenses for single vision and frames limited to R695. Bi-focals and frames limited to R1 113 at a Universal Network Optometrist. Contact lenses paid from AFB.
  • Hospital emergency room/casualty emergency visits.
Paid from risk.
  • Blood pressure, blood sugar, cholesterol, BMI and waist circumference - limited to R155 p/b over the age of 18.
  • Flu vaccinations - 1 dose p/b per annum - limited to R80.
  • HIV tests - 1 per annum per beneficiary.
  • Emotional wellness benefit.
To obtain the registered scheme rules approved by the Council of Medical Schemes, please email your request through to correspondence@universal.co.za.
 

 
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