PROSTHESIS BENEFIT

Internal Medical/Surgical Prostheses and Appliances

Internal Medical and Surgical Accessories – (including all components such as pins, rods, screws, plates, nails, fixation material or similar items forming an integral and necessary part of the device so implanted and shall be charged, where applicable, as a single unit) which are implanted during an operation into the body as an internal supporting mechanism and/or which for functional medical reasons are implanted as a prosthesis to replace parts of the body – Subject to pre-authorisation and Scheme negotiated price (Paid from Major Medical Benefits).

 

Comprehensive

Executive

Family

Savings

Active Saver

Essential

Network

Limited

Cardiac/Vascular Prostheses and Appliances

 

Stents (Cardiac Peripheral and Aortic)

 

100% of Cost up to R63 168 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

 

100% of Cost up to R63 168 per beneficiary per year
unless
obtained at
a Scheme
DSP or in
accordance
with PMB
Protocol

 

100% of Cost up to R63 168 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

 

100% of Cost up to R56 952 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

 

100% of Cost up to R56 952 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

 

100% of Cost up to R56 952 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

 

 

 

 

PMB Only

 

 

 

Refer to Benefit Summary

 

Valves

Pace Makers

Implantable Defibrillators

Joint Prostheses (Subject to failed conservative treatment and Risk Management)

Hip, Knee, Shoulder or Elbow only (maximum of one per beneficiary per year)

Up to
R53 700 per
beneficiary per
year

Up to
R53 700 per
beneficiary
per year

Up to
R53 700 per
beneficiary
per year

Up to
R50 100 per
beneficiary
per year

 

PMB Only

Up to
R50 100 per
beneficiary
per year.

 

PMB Only

 

Refer to Benefit Summary

Orthopaedic Prostheses and Appliances (Subject to failed conservative treatment and Risk Management)

Spinal fixation devices (max 2 levels unless motivated)

100% of Cost up to R63 168 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

100% of Cost up to R63 168 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

100% of Cost up to R63 168 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

100% of Cost up to R56 952 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

100% of Cost up to R56 952 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

100% of Cost up to R56 952 per beneficiary per year unless obtained at a Scheme DSP or in accordance with PMB Protocol

 

 

 

 

 

PMB Only

 

 

 

 

Refer to Benefit Summary

 

Fixation devices – non spinal

 

 

Bone Lengthening devices

 

Implantable devices, disc
prosthesis, Kyphoplasty

Combined with above limit

Combined with above limit

Combined with above limit

Combined with above limit

 

PMB Only

Combined with above limit

 

Neuro Stimulators and Deep Brain Stimulators

Up to
R37 920 per
beneficiary
per year

Up to
R37 920 per
beneficiary
per year

Up to
R37 920 per
beneficiary
per year

Up to
R35 460 per
beneficiary
per year

 

PMB Only

Up to
R35 460 per
beneficiary
per year

 

PMB Only

 

Refer to Benefit Summary

 

Internal Sphincters and
stimulators

Up to
R60 720 per
beneficiary per
year

Up to
R60 720 per
beneficiary
per year

Up to
R60 720 per
beneficiary
per year

Up to
R56 916 per
beneficiary
per year

 

PMB Only

Up to
R56 916 per
beneficiary
per year

 

PMB Only

 

Refer to Benefit Summary

 

Unspecified/Unlisted above

Up to
R16 200 per
procedure per
year

Up to
R16 200 per
procedure
per year

Up to
R16 200 per
procedure
per year

Up to
R16 200 per
procedure
per year

Up to
R16 200 per
procedure
per year

Up to
R16 200 per
procedure
per year

 

PMB Only

 

Refer to Benefit Summary