All benefits are subject to pre-authorisation and include:

– Unlimited primary health care from your chosen general practitioner

– Medication as per formulary – acute and chronic

– Hospitalisation including step down care as appropriate – subject to pre-authorisation and PMB’s

– Specialist services – subject to pre-authorisation (items excluded Items Excluded);

– Pathology and Radiology services are available provided they are pre-authorised subject to standard treatment protocols

– Ambulance services for medical emergencies Lifemed ambulance 0861 086 911

– Statutory Prescribed Minimum Benefits as authorised, in respect of the relevant health services as described in terms of Section 67(1)(g) of the Act. The purpose in specifying Prescribed Minimum Benefits is to avoid incidents where individuals lose their medical scheme cover in the event of serious illness

The following benefits are provided by accredited providers, subject to limits:

– Optometry

– Dentistry

– Other services

Optometry

Spectacles must be obtained from an accredited optometrist, as authorised via the call centre 0860 00 24 00, necessary for correcting significant visual impairment problems.

Limitations:

Lenses: One set of lenses per beneficiary every 24 months
Frames: One set of frames per beneficiary every 24 months

The cost of single lenses is fully covered subject to the following conditions:

– The refraction error must be equal to, or more than 0.5 dioptre

– The total cost including testing and spectacle is limited to R1580.00 per beneficiary per 24 months

The scheme is not liable for the following

• Replacement of lost spectacles is not covered

Dentistry

All dentistry must be provided by an accredited dentist or dental therapist, after the dentist has obtained authorisation via: Dental Information Systems (Pty) Ltd, call no. at 0860 033 647

The following conservative dentistry is fully covered within managed care protocols:

– Consultations

– Fillings: pre-authorisation applies

– Extractions: pre-authorisation applies

– Prevention: pre-authorisation applies

– Dentures are limited to one set of plastic dentures every four years

Specialised dentistry is subject to an annual limit of R2 125 per family (includes root canal and all periodontal treatment).

Specialist Services

All specialist services must be pre-authorised via the Enablemed National Call line 0860 00 24 00.

Other Services

– Clinical Psychology Limited to 8 consultations per family per year and subject to pre-authorisation.

– Hearing Aids Limited to R2 016 per beneficiary every 4 years and subject to pre-authorisation.

– External Prosthesis A maximum of R1 962 per member per annum for external orthopaedic prosthesis and subject to pre-authorisation.

– Occupational Therapy A maximum of 20 treatments per family per annum and subject to preauthorisation.

– Physiotherapy A maximum of 20 treatments per family per annum and subject to preauthorisation.

– Ambulance services Ambulance services for medical emergencies are available 24 hours a day and subject to pre-authorization by Lifemed, the preferred provider for Makoti Medical Scheme on 0861086911.