The Networx Option

The NetworX option is an affordable health care plan with exceptional value for students and low-income employees in the corporate sector, and offer sessential cover with in the universal Health care Provider Network.

Contributions & Beneļ¬ts

Networx Principal Adult Child
 R0 - R500 R285 R285 R166
 R501 - R4 000 R575 R546 R201
 R4 001 - R5 000 R593 R564 R208
 R5 001 - R6 000 R710 R674 R249
 R6 001 - R8 000 R743 R707 R260
 R8 001 - R9 000 R845 R804 R297
 R9 001 - R10 000 R897 R853 R314
 R10 000+ R1 650 R1 485 R578

 

Annual Flexi Benefit (AFB)
 R2 664 p/b  R3 972 p/f

Day To Day Savings & Limits

A child Dependant is a Dependant who is under the age of 21 years. An adult Dependant is a Dependant who is 21 years or older and not a full-time student. The above rates are only applicable to the member and a   maximum of three of his/her child  Dependants.

 Benefit Unlimited Limited Description
 Overall annual limit PMBs Non-PMBs 100% of the agreed tariff. Non-PMBs limited to R1050.000 P/F
 Privatehospitalandnursing homes  *  * 100% of the agreed tariff, subject to OAL. Pre-authorisation required. Co-payment for non-authorisation.
 Ward fees: general, high care, intensive care  * 100% of the agreed tariff, subject to OAL and pre-authorisation
 Theatre fee  * 100% of the agreed tariff, subject to OAL and pre-authorisation
 Medicationwhile inhospital  * Subject to OAL
 Take-out medication  * Subject to OAL, limited to 7 day supply andR285perdischarge.RPandformulary applicable
 Cost while in hospital  * 100% of the agreed tariff, subject to OAL
 Specialist costs while in hospital  * 100% of the agreed tariff, subject to OAL (exclude dental treatment)
 Surgical prostheses and electronics nuclear devices  * 100% of the agreed tariff, PMBs only
 Basic radiology  * 100% of the agreed tariff, subject to OAL and protocols
 Basic radiology  * 100% of the agreed tariff, subject to OAL and protocols
 Specialised radiology, including MRVCT and ET scans  * 100% of the agreed tariff, subject to OAL and pre-authorisation, high resolution CT scans/PET scans subject to special medical motivation, PMBs
 Confinements  * 100% of the agreed tariff, subject to OAL and pre-authorisation required, normal birth limited to two days and caesarean section limited to three days in hospital. See specialist benefit for ante-natal visits benefit
 Physiotherapy  * 100% of the agreed tariff, subject to OAL and protocols
 Mental health: psychiatric hospitalisation  * Limited to 21 days p/f, subject to OAL, protocols and PMBs. DSP only
 Alcoholism, drug dependence and narcotism  * PMBs only; subject to pre-authorisation and protocols
 Organ transplants, plasmapheresis renal analysis  * PMBs only, subject to pre-authorisation and protocols. DSP only, includes the transportation of the organ, surgically related procedures, professional fees and immunosuppressant drugs.
 Biological agents  * PMBs only, pre-authorisation and protocols apply
 Professional sports injuries  * Subject to OAL
 Oncology  * Subject to OAL pre-authorisation and protocols apply.

 

Alternatives To Hospitilization

Benefit Unlimited Limited Description
 Step-down nursing facilities, Hospice and rehabilitation


 * 100%ofthe agreedtariff,subjecttoOAL. Pre-authorisation,PMBsandprotocols
 Surgical procedures out-of-hospital  
 * 100%ofthe agreedtariff,subjecttoOAL. Pre-authorisation,PMBsandprotocols
 Wound Care in lieu of hospitalisation  
 * Unlimited, authorisation required

Student Medical Aid for only R285pm

In-hospital benefits prescribed minimum benefit: overall annual limit(OAL)for non-PMBandelective admissions
  • Unlimited,subject to scheme protocols.
  • R1050 000 per family per year.

Services covered in hospital 100% of the agreed tariff (AT) subject to OAL. Pre-authorisation and network DSP hospital. All treatment in hospital is

subjecttocase managementandscheme protocols

  • GPs and specialist
  • Wardfees-general, ICU and highcare
  • Theatre fees Alcoholism, drug dependence and narcotism
  • Medication whilst in hospital
  • Blood transfusion
  • Oncology
  • Surgical prosthesis (PMBs only)
  • Clinical technogists limited to R10615p/f
  • Radiology–MRI,CT and PET scan
  • Pathology
  • Confinement limited to two days for normal birth and three days to caesarean section
  • Psychiatric treatment is limited to 21 day sin hospital
  • Organ and bone marrow transplant, plasmapheresis and renal dialysis (PMBonly)
  • Cover for professional sports
  • Emergency medical treatments for injuries resulting from accidents or trauma
  • Physiotherapy
Cover for chronic conditions 27 chronic conditions covered Chronic medicationis subject to the core formulary list of medicines and formulary reference price (FRP).Membersarerequiredtoregisterall chronicconditions
  • Chronic medication is unlimited, subject to medicine formulary and if prescribes by a universal network provider and dispensed within a universal pharmacy or dispensing universal network GP. Any voluntary use of chronic medicine prescribed by an out-of-network provider and any  non-formulary
  • medicines areforthe member’sownaccount,unless pre-authorisationbythemedicaladvisor.PMB
  • Subjecttoformularyreferencepricing

Unlimited  day-to- day service

Notsubjectto annualflexibenefit(AFB) Subject to the use of the universal providernetwork

  • GPvisits-unlimitedattheselecteduniversal networkSubjecttoclinicalnecessity
  • Two out of area visits p/b per annum (20% co-payment at point of service limited to maximum of R955per event, including medicine, pathology and radiology, excluding facility fees)
  • Acute medication- unlimited if prescribe by a universal network GP or by the specialist provided member referred by a universal Subject formulary. No cover for non-formulary medicine unless otherwise pre-authorised. No cover in case of voluntary use of non-universal providers or voluntary use of specialist without referral by a universalnetworkGP
  • Basic radiology-unlimited subject to specific codes, referral by auniversal network GP required
  • Basic pathology-unlimited,subject to codes referral by auniversal network GP required.

Day-to-day services paid from the annualflexi benefitat100% ofagreed tariffAFB- R2664p/b

R3972 p/f

  • Specialist consultations-limited to 2p/b, max3 p/f subject to referral by auniversal network GP, pre-authorisation required. Referrals limited to specialists in DSP network hospital only. Ante-natal visits pre pregnancy
  • Basic dentistry-limited to 1 consultation p/b including preventativ ecare, infection control, filling sextractions and dentalx-raysatthe universal network dentist
  • Optometry- limited to 1 test p/b every 24 months, includinglenses- clear plastic lenses for single vision and frames limited R737. Bi-focal and frames limited to R1180 at a universal network optometrist. Contact lenses paid from AFB
  • Hospitalemergencyroom/casualtyemergencyvisits

 

 

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