Benefit Guide 2024

Malcor Medical Aid Scheme | 2024
BENEFIT GUIDE
A
03
CONTENTS
CONTENTS
A healthy approach to quality and care
04 Who can join the Malcor Medical Aid Scheme
04 Who may join as your dependant
05 General guidelines on the Malcor Medical Aid

Scheme
09 Helping you get the most out of your cover
11 Patient Management Programme and Chronic

Illness Cover
19 Screening Benefits
22 Medicine Benefits
23 Medical Benefit
25 Ex Gratia Benefit
27 Cover for emergencies
28 Advanced technology and convenience
29 Your health plan at your fingertips
31 The Malcor Medical Aid Scheme benefit tables

– Plans A, B and C
41 The Malcor Medical Aid Scheme benefit tables

– Plan D
45 Reporting fraud or malpractice
45 Key information
46 General exclusions
50 Contact us
52 The Council for Medical Schemes

A HEALTHY
APPROACH
TO QUALITY
AND CARE
IN 2024
Malcor Medical Aid Scheme provides excellent healthcare benefits

that would truly make a difference in the lives of you and your
loved ones. You have complete peace of mind that your healthcare
is in good hands at every stage of your health journey.
We have designed this benefit guide to provide you with a summary of information
on how to get the most out of the Scheme’s benefits. To see what we have in store
for you in 2024, you can also access the guide on the homepage of the website
www.malcormedicalaid.co.za.
ABOUT THIS BENEFIT GUIDE

This booklet serves as a guide to the Malcor Medical Aid Scheme. It consists of
information about your membership and benefits. This Benefit Guide is merely a
summary of the benefits and features of the Malcor Medical Aid Scheme plans and is
subject to the Rules of the Malcor Medical Aid Scheme. The Rules of the Scheme will
apply in all circumstances. Members who require further information should contact
their personnel departments or the Scheme at 0860 100 698.
3
This brochure provides you with a summary of the
benefits and features of the Malcor Medical Aid Scheme,
pending approval from the Council for Medical Schemes.
The Malcor Medical Aid Scheme is a closed Scheme, and
is administered by Discovery Health (Pty) Ltd.
This brochure gives you a brief outline of the benefits

Malcor Medical Aid Scheme offers. This does not replace
the Scheme Rules. The registered Scheme Rules are
legally binding and always take precedence.
Detailed benefit documents may be obtained from

www.malcormedicalaid.co.za > Find a document if
you are registered as an online user. Please share
this information with your dependants who are your
beneficiary members of the Malcor Medical Aid Scheme.
WHO CA N J OI N T HE M A L COR
M EDI CAL A I D SCHEME?
The Malcor Medical Aid Scheme is a restricted-access medical
scheme for a number of associated employer groups. An
employer is defined as ‘any company or organisation that
was previously a subsidiary or an associated company of
Malbak Limited at the time of the latter’s dissolution in 1996,
or has subsequently been acquired by such companies or
organisations’. Employers currently making use of the Malcor
Medical Aid Scheme include, but are not limited to, CFAO
Motors South Africa formerly known as Unitrans Automotive,
Defy Appliances (Pty) Ltd, Aspen Holdings (Pty) Ltd and Omnia
Holdings Limited.
Membership is available to all employees of approved

employers subject, in certain cases, to the satisfactory
outcome of a medical examination.
WHO M A Y J OI N AS YOUR
DEPEN DANT ?
Your spouse or partner in a committed and serious
relationship similar to marriage, including mutual
dependency and both partners living in a shared and
common household.
our children can be added as dependants on your health

Y
plan. Your child needs to be financially dependent on you
to qualify for cover as an adult dependant. They may be
students, or are mentally or physically disabled.
You have 30 days in which to register a new spouse.

We count the 30 days from the date of marriage.
You have 60 days in which to register a newborn baby.

We count the 60 days from the date of birth.
4
GENERAL
GUIDELINES
ON THE MALCOR
M E D I CA L A I D SC H EME
embers and their dependants are entitled to benefits from

M It is recommended that members who are about to embark
the date their membership commences as reflected on their on any costly treatment that does not require specific
membership cards. preauthorisation, such as orthodontic treatment, submit
quotations to the Scheme to obtain information about the
There are certain limitations and exclusions applicable to all
extent to which the Scheme will cover the proposed treatment.
members. To avoid incurring personal liability for medical
treatment, members should, if in any doubt, refer to the PLAN D members might be required to preauthorise all
Scheme’s Rules or contact the Scheme for clarification prior benefits BEFORE consulting with service providers.
to agreeing to such treatment. You may confirm benefits by calling Enablemed on
0860 002 402.
he Scheme is, according to the Medical Schemes Act,
T
allowed to apply a Late-Joiner Penalty (LJP) to an applicant or Annual limits are apportioned according to the period of
to the dependant of an applicant who fits the definition of a membership in relation to the benefit year i.e. 1 January
late-joiner. The LJP fee is a percentage increase in a member’s to 31 December. Thus your benefit limits will be prorated if
contribution. It is a lifetime penalty that is not be removed, you join during the benefit year.
even when members move from one registered South African
medical scheme to another.
FO U R I N N O VATIVE CO VER PLA N S

Plan A Plan C
A traditional, fully comprehensive plan designed for those A traditional, fully comprehensive plan designed for those
seeking complete healthcare cover seeking basic healthcare cover
Excellent out-of-hospital limits Limited out-of-hospital cover
All in-hospital costs are covered at 100% of the Scheme Rate All in-hospital costs are covered at 100% of the Scheme Rate
Plan B Plan D
A traditional, fully comprehensive plan designed for those Low-cost, network option administered by Enablemed
seeking decent healthcare cover Choice of own GP and access to private hospitals
Good out-of-hospital limits Chronic medicine is covered as set out in the Prescribed
All in-hospital costs are covered at 100% of the Scheme Rate Minimum Benefit guidelines and includes chronic illnesses
that are on the Chronic Disease List.
5
P R E A U T H OR IS ATIO N F O R PREA UT HORI SA T I ON I S AL SO
HOS P I T A L I S ATIO N REQUI RED FOR T HE FOL L OWI NG
You must call the Malcor Medical Aid Scheme on
T REA T MEN T
0860 100 698 to get preauthorisation for all your hospital Chronic renal dialysis
treatment, except in the case of an emergency.
Oncology and radiotherapy
You will be given an authorisation number if your treatment
is approved. In the case of an emergency where you are Hospice
unable to phone the Malcor Medical Aid Scheme to obtain Sterilisation
authorisation in advance, you or a family member must call
the Scheme within three days from the date of admission. Infertility treatments
Step-down and rehabilitation facilities in the

private sector
Specialised dentistry in hospital
Registered nursing services
Super antibiotics
Biologicals.
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D A Y S U R G ER Y NETW O R K F O R Gynaecological procedures
C ER T A I N P RO CED UR ES O R Colposcopy with large loop excision of the transformation
O P E R A T I ONS Diagnostic Dilatation and Curettage
Endometrial ablation
Certain procedures must be performed at one of the
Scheme’s Day-Surgery Network facilities. You will find details Diagnostic Hysteroscopy
of the Day Surgery facilities near you on the website at Examination under anaesthesia
www.malcormedicalaid.co.za Diagnostic laparoscopy
You must have the listed procedures done at one of these Simple vulval and introitus procedures: simple
accredited Day Surgery Network facilities as they are the hymenotomy, partial hymenectomy, simple vulvectomy,
Designated Service Providers for the Scheme. excision bartholin’s gland cyst
If you do not go to one of the Scheme’s designated facilities, Vaginal, cervix and oviduct procedures: excision vaginal
a R6 300 deductible will apply to the facility account. septum, cyst or tumour, tubal ligation or occlusion,
uterine cervix cerclage, removal cerclage suture
Ear, nose and throat procedures Suction curettage

Uterine evacuation and curettage
Tonsillectomy and/or adenoidectomy
Repair nasal turbinates, nasal septum Eye procedure
Simple procedures for nose bleed (extensive cautery)
Cataract surgery
Scopes, nasal endoscopy (laryngoscopy)
Treatment of glaucoma
Middle ear procedures (mastoidectomy, myringoplasty,
Other eye procedures: (removal of foreign body,
myringotomy and/ grommets)
conjunctival surgery (repair laceration, pterygium),
Sinus lavage glaucoma surgery, probing and repair of tear ducts,
vitrectomy, retinal surgery, eyelid surgery, strabismus
Orthopaedic procedures repair)
Tendon and/or ligament repair, muscle debridement, Corneal transplant
fascia procedures (tenotomy, tenodesis. tenolysis,
repair/reconstruction, capsulotomy, capsulectomy, Ganglionectomy
synovectomy, excision tendon sheath lesion, fasciotomy,
fasciectomy) Simple superficial lymphadenectomy
Repair of bunion toe deformity Approved breast procedures
Arthroscopy, arthrotomy (shoulder, elbow, knee, ankle, Mastectomy for gynecomastia
hand, wrist, foot, temporomandibular joint), arthrodesis
Lumpectomy (fibroadenoma)
(hand, wrist, foot)
Treatment of simple closed fractures and or dislocations, Skin procedures
removal of pins, and plates, subject to individual case
Debridement
review
Simple repair of superficial wounds
Minor joint arthroplasty (intercarpal, carpometacarpal
and metacarpophalangeal, interphalangeal joint Remove of lesions (dependent on site and diameter)
arthroplasty)
Biopsies
Gastrointestinal procedures Skin, soft tissue, muscle bone, lymph, eye, mouth, throat,
Gastrointestinal scopes (oesophagoscopy, gastroscopy, breast, cervix, valva, prostate, penis, testes, subcutaneous
colonoscopy, sigmoidoscopy, proctoscopy, anoscopy) tissue
Anorectal procedures (treatment of haemorrhoids,

Removal of foreign body
fissure, fistula)
Subcutaneous tissue, muscle, external auditory, canal
Urological procedures under general anaesthesia
Cystoscopy
Simple hernia procedures
Male genital procedures (circumcision, repair of penis,
exploration of testes and scrotum, orchiectomy, Umbilical hernia repair
epididymectomy, excision hydrocoele, excision varicocele Inguinal hernia repair
vasectomy)
Nerve procedures
Neuroplasty median nerve, ulnar nerve, digital, nerve
of hand or foot
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8
HELPING
YOU
GET THE MOST OUT
OF YOUR COVER
M AK E THE F ULL CO VE R CHOI CE
We offer members the choice to be covered in full for hospitalisation, specialists

(in-hospital), chronic medicine and GP consultations. Look out for the Full Cover
Choice stamp in this benefit guide. It shows you when to use our range of online
tools that guide you to full cover.
Remember that your claims are still subject to the overall annual limit. We have
payment arrangements with certain GPs. These GPs agree to join the Discovery
Health GP Network to which you have access.
We will refer to the networks and payment arrangements throughout the

Benefit Guide.
M E M B E R S O N THE MALCO R MEDI CA L AI D

SCHE M E M AY HAVE A CO –PAYMEN T FOR
IN -A N D O U T-O F -HO S PITAL S PECI AL I ST COVER
If you are treated by a specialist out-of-hospital, the Malcor Medical Aid Scheme
will cover up to 120% of the Scheme Rate for Plan A and 100% of the Scheme
Rate for Plan B and C. Please log in to the Malcor Medical Aid Scheme website
at www.malcormedicalaid.co.za > Doctor visits > Find a healthcare professional
to find your nearest in-hospital network specialist at a DSP hospital for full cover.
The Malcor Medical Aid Scheme has selected the following hospitals as the
Scheme’s in-hospital Designated Service Provider (DSP) or ‘network’:

National
All MediClinic hospitals

Kwazulu-Natal
Busamed Gateway
Busamed Hillcrest

East London
Life East-London
Gqeberha

Life St George’s
The Scheme will cover up to 100% of the Scheme Rate if you are treated
in a hospital outside of the network.
9
WHEN YO U N EED GP N ET WORK
TO G O TO T HE DOCT ORS ARE
D O CTO R PA I D DI RECT L Y
I N FUL L
Our Medical and Provider Search Advisor (MaPS) When you see a GP in the GP Network, their
tool helps you find a healthcare professional with consultation cost will be paid in full. If you
whom we have an agreement. These healthcare choose to usea GP that is not in the network,
professionals have agreed to only charge you the the Scheme will reimburse your consultation at
Scheme Rate and we pay them in full. the Scheme Rate.
Log in to www.malcormedicalaid.co.za and click Please log in to the Malcor Medical Aid Scheme
on Doctor visits > Find a healthcare professional. website at www.malcormedicalaid.co.za >
You will be able to search for providers by Doctor visits > Find a healthcare professional
geographical location or speciality. Each provider to find your nearest participating GP.
shown on the MaPS tool is shown with a tag to
indicate whether or not they are a network doctor.
CO MPR EHENS IVE MAT ERN I T Y AND POST - BI RT H BENEFI T S

Members on Plan A and Plan B will have access to comprehensive maternity and post-birth risk benefits.
Members will be further supported through access to 24/7 support, advice and guidance. These benefits do
not affect members’ day-to-day benefits and are funded from the risk benefit at the Scheme Rate. The benefit
must be activated by the member by dialing 0860 100 698.
Benefits during Pregnancy Post-birth Benefits

ntenatal Consultations: 12 visits to a GP,
A Post natal classes or consultation with a nurse:
gynaecologist or midwife 5 pre-or post natal classes or consultations
with a registered nurse

Ultrasound Scans & Prenatal Screening: Up to
2 ultrasound scans, 1 nuchal translucency or
GP & Specialist Consultations: Up to 2 visits
Non-Invasive Prenatal Test (NIPT) or down with a GP, paediatrician or ENT for baby
syndrome screening test covered

Six Week Consultation: 1 six week post-birth

Blood Tests: Defined list of tests per pregnancy consultation with a GP or gynaecologist

Pre- or postnatal Classes or Consultation with
Nutrition Assessment: 1 nutrition assessment
a nurse: Up to 5 pre-or post natal classes or with a dietician
consultations with a registered nurse

Mental Health: 2 mental health consultations

Private Ward Cover: up to Scheme rate p/day with a GP, gynaecologist or psychologist
(Plan A only)

Lactation Consultation: 1 lactation consultation

Essential registered devices: up to R4,160 with a registered nurse or lactation specialist.
(Plan A) R2,060 (Plan B) e.g. breast pumps
and smart thermometers.
CO VER F O R G O ING T O CA SUAL T Y

If you are admitted to hospital from casualty, we will cover the costs of the casualty visit from your Hospital
Benefit, as long as we preauthorise your hospital admission. If an admission occures after hours, you must
apply for authorisation on the next available working day. If you go to a casualty or emergency room and
you are not admitted to hospital, the Scheme will pay the claims from your out-of-hospital benefits. Some
casualties charge a facility fee, which we do not cover.
10
PATIENT
MANAGEMENT
PROGRAMMES
A N D CH R ONI C I L L N ESS COVER
The Scheme will fund approved medicine on the medicine list or medicine with the same active ingredient as the approved
medicine list up to the Maximum Medical Aid Price (MMAP). Medicine not on the medicine list will not be approved from the
Chronic Illness Benefit (CIB) and will be funded from the Acute Medicine limit or by yourself. There are further Additional
Disease List conditions that are covered for members on Malcor Plan A.
A D V A N CE D ILLNES S B ENEF IT Chronic Disease List (CDL) conditions (all plans)

All members qualify for chronic medication for the following
Members with cancer have access to a comprehensive
27 conditions on the Chronic Disease List (CDL) that the
quality care programme. This programme offers unlimited
Medical Schemes Act (No 131 of 1998) defines as Prescribed
cover for approved care at home.
Minimum Benefits:
C O V E R F OR CHR O NIC MED ICINES Addison’s Disease Dysrythmia

Asthma Epilepsy
The following guidelines apply to chronic medication
covered by the Scheme Bipolar Mood Disorder Glaucoma
Bronchiectasis Haemophilia
The Chronic Illness Benefit covers approved medicine for
Cardiac Failure HIV/AIDS
the 27 Prescribed Minimum Benefit (PMB) Chronic Disease
List (CDL) conditions, including HIV and AIDS. The Scheme Cardiomyopathy Hyperlipidaemia
will fund approved medicine on the medicine list or Chronic Obstructive Hypertension
medicine with the same active ingredient as the approved Pulmonary Disease
Hypothyroidism
medicine up to the Maximum Medical Aid Price (MMAP). Chronic Renal Disease
Multiple Sclerosis
Medicine not on the medicine list will not be approved from
Coronary Artery Disease
the Chronic Illness Benefit (CIB) and will be funded from Parkinson’s Disease
Crohn’s Disease
the Acute Medicine limit or by yourself. Rheumatoid Arthritis
Diabetes Insipidus
Schizophrenia
If your condition is approved by the Chronic Illness Benefit,
Diabetes Mellitus Type 1
it will cover certain procedures, tests and consultations Systemic Lupus
Diabetes Mellitus Type 2 Erythematosus
for the diagnosis and ongoing management of the 27
Prescribed Minimum Benefits (PMBs) Chronic Disease Ulcerative Colitis.
List CDL conditions (including HIV and AIDS) in line with
Prescribed Minimum Benefits.
11
ADDITIONAL DISEASE LIST (ADL) AVAILABLE TO PLAN A MEMBERS ONLY

Acne Motor Neurone Disease
Allergic Rhinitis Myasthenia Gravis
Ankylosing Spondylitis Narcolepsy
Arthritis Obsessive Compulsive Disorder
Attention Deficit and Hyperactivity Disorder (ADHD) Osteoarthritis
Barret’s Oesophagus Osteoporosis
Chronic Hepatitis Paget’s Disease
Cystic Fibrosis Psoriasis
Depression Psoriatic Arthritis.
Gastro-oesophageal Reflux Disease
You must apply for chronic cover by completing a Chronic Illness Benefit application form with your doctor and submit it
for review. The application form is available at www.malcormedicalaid.co.za > Find a document. Alternatively, you can call
0860 100 698 or your healthcare professional can call 0860 44 55 66 for assistance. For a condition to be covered from the
Chronic Illness Benefit, there are certain benefit entry criteria that the member needs to meet. If necessary, you or your
doctor may have to supply additional information or copies of certain documents to finalise your application. If you leave
out any information or do not provide the medical tests or documents needed with the application, cover will only start from
when we receive the outstanding information.
C OV E R F OR D IAB ETES Your doctor will work with you to manage your condition
Your Diabetes Cardiometabolic Care Programme is based

Diabetes Cardiometabolic Care Programme on international and locally accepted clinical and lifestyle
Are you living with diabetes? guidelines.
We will help you to manage your diabetes and the many Through the programme, you and your doctor (who must be
challenges that comes from living with this condition through on our Premier Plus GP network) can:
our Diabetes Cardiometabolic Care (DCC) Programme. We
Agree on key goals
encourage you to join this programme as it brings together
a team of health professionals to ensure you get high-quality Track your progress on a personalised dashboard on
coordinated healthcare and improved outcomes. HealthID (a system for doctors)
You also have access to various tools and extra benefits to Generate your Diabetes Management Score to help identify
monitor and manage your condition, as well as dedicated care which areas to focus on to stabilise your condition and
navigators to help with all your diabetes-related needs. improve your overall health.
If you visit a doctor who is not part of the Premier Plus GP

How to join the Diabetes Cardiometabolic Care
Network, you may have to pay part of the cost.
Programme
If you have any questions
If you are registered on the Chronic Illness Benefit for
diabetes, you automatically have access to the Diabetes Call 0860 100 698 or email
Cardiometabolic Care Programme through your chosen [email protected]
Premier Plus GP.
Remember, if left untreated, diabetes may result in serious
If you are not yet registered, ask your doctor to help you get complications. We are here to help you navigate the journey.
started. Detailed information about this programme will be
shared with you once registered. Continuous Glucose Monitoring (CGM) Benefit
Check if your doctor is on our network If you are registered on the Chronic Illness Benefit (CIB) for
Type I diabetes, you will have access to a list of Continuous
To check if your regular doctor is on our network, you can: Glucose Monitoring (GCM) sensors, if you are enrolled onto
Visit www.malcormedicalaid.co.za the Diabetes Cardiometabolic Care Programme via your
Premier Plus GP. These devices enable you to measure your
Choose Find a healthcare provider on the Discovery app
glucose levels more frequently, helping you to better manage
Call 0860 100 698 your condition and understand causes of variability. Use of
a CGM device will give you insight into the effect your diet,
Email: [email protected]
medication and daily activities have on your glucose levels.
CGM sensors meeting the criteria set out above will fund from
your overall annual limit, up to a monthly limit.
The devices used with the CGM sensors for qualifying

members will fund from your external medical appliances limit
and overall out-of-hospital limit. 12
C O V E R F OR HIV AND AID S
HIVCare Programme HIV Prophylactics
For members living with HIV and AIDS, the HIVCare If you, as a Malcor member, need HIV prophylactics to prevent
Programme provides comprehensive disease management. HIV infection from mother-to-child transmission, occupational
We take the utmost care to protect the right to privacy and and traumatic exposure to HIV or sexual assault, please call
confidentiality of our members. Malcor Medical Aid Scheme immediately on 0860 100 698 as
treatment must start as soon as possible.
Malcor members are encouraged to enrol in the HIVCare
Programme by calling the Malcor Medical Aid Scheme on This treatment is paid for by the Malcor Medical Aid Scheme
0860 100 698. at Scheme Rate.
The case managers will assist you and guide you with your
treatment plan and benefits. Members or dependants who
are HIV positive but have not yet enrolled are encouraged to
do so. Your health and medical treatment are of the utmost
importance.
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Mental Health Care Programme HOME CA RE N URSI NG
Mental health disorders are among the leading causes of ill-
Members have access to quality home-based care delivered
health and disability worldwide. A focus on enhanced support
by Discovery Home Care. This benefit gives members
for mental wellbeing is important in all facets of society
access to certain treatment that can be provided in a home
including individuals, families and workplaces.
environment, making it possible to receive care without being
Mental Health Care Programme (out of hospital) admitted to hospital. Preauthorisation is required.
All members with a history of depression have access to

a Mental Health Care Programme designed to offer those SERVICE WHAT IT INVOLVES
diagnosed with acute or episodic major depression, optimal
care in a coordinated network to ensure the best outcomes. The administration of IV clinical
therapy for stable patients
To enroll you onto the programme, a GP in the Premier Plus IV Infusion where a hospital admission is
GP network or a psychologist in the Mental Health Care not required.
Programme Network will perform a PHQ-9 assessment to
confirm depression severity. Qualifying members will then Wound care for venous ulcer,
gain access to the programme that runs over a 6-month diabetic foot ulcers, pressure
sore and other moderate to
period but can be extended to 12 months by your enrolling Wound care severe wounds if patient’s
provider where clinically appropriate. condition is stable and hospital
admission is not required.
Additional benefits available on the Mental Health Care
Programme for qualifying members:
One extended consultation with your Premier Plus GP This service offers home visits for
healthy mothers, and their babies,
annually
if they choose to be discharged
Two standard consultations with your enrolling Premier a day early from hospital. This
Post-natal care
Plus provider service includes three day visits
by a midwife, within a six-week
Funding for antidepressant medicine on the formulary if postnatal period.
prescribed by your Premier Plus GP
Additional psychotherapy sessions with your psychologist

on the Mental Health Care Programme Network payable
up to a limit of R3,339.
Mental Health Relapse Prevention Programme

A team of care coordinators including psychiatric nurses and
registered counsellors will proactively reach out to members
who are identified with a high probability of a psychiatric
admission.
Members enrolled on the Relapse Prevention Programme,

in addition to the support and education provided by the
care coordinator, will have access to an additional basket of
outpatient care in order ensure that their condition can be
effectively managed in the outpatient setting.
The relapse prevention basket of care includes:
Two psychiatrist visits

Six counselling sessions (psychologist, social worker,
occupational therapist or registered counsellor.
Should the care coordinator identify that the member is

struggling, the treating doctor will also be alerted.
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Cover for Hospital at Home
Hospital at Home Benefit Experience has shown that
hospital-level care can be delivered safely in a home-setting
for a range of clinically appropriate conditions. Members
will have access to funding for select low acuity medical
conditions, as well as a range of clinically appropriate services
and procedures to safely manage any referred medical and
post-operative admission.
To access this benefit, your treating specialist must identify

you as a member with an illness that can be treated at home
and will first consult with you to confirm if you are digitally
engaged and that your home environment is suitable to
receive care at home. It remains your choice to be treated in
hospital even if you qualify for a Hospital at Home admission.
Admissions to Hospital at Home are subject to preauthorisation

in lieu of hospitalisation. The pre-authorisation enables
risk-based funding for approved remote monitoring devices
and healthcare services for patients who meet the clinical and
benefit criteria.
While receiving care at home, members have 24/7 access

to an in person and a virtual care team. This real-time
connection ensures that patients can always reach a clinician
if they have questions or concerns. Family members are
kept up to date on the patient’s progress, either during the
home visits, or through a virtual consultation. Depending on
a patient’s specific needs, consultations with allied healthcare
professionals may be incorporated into their personalised
care plan.
Programme Enrolment
All treating physicians will be made aware of the programme.
Treating providers, in conjunction with Discovery Health’s

in-hospital case managers will identify members and inform
them of the programme based on clear criteria.
Programme Funding
All services offered as part of the Hospital at Home

programme fund from the overall annual limit for in-hospital
expenses where there is a valid preauthorisation in lieu of
hospitalisation.
This unlocks risk-based funding for approved devices and

healthcare services for those who meet the clinical and
benefit criteria.
Patient specific eligibility criteria applies for use of certain

services, as determined by the treating care team.
Devices
Qualifying members will have funding for a defined list of

registered devices funded up to 100% of the Scheme Rate,
with a limit of R4,250 per person per year.
The applicable registered remote monitoring devices will be

delivered directly to qualifying members by the nurse on their
first visit.
15
16
Typical Hospital at Home member journey illustrated below.
CLINICAL ASSESSMENT
ADMISSION TO THE PATIENT’S HOME
AND REFERRAL
STEP 01 STEP 03 STEP 05

PATIENT PRESENTS AT TRANSPORT LIVE MONITORING
CASUALTY OR DOCTOR’S
PRACTICE The patient travels home or is The patient’s condition is
transported by ambulance or monitored 24/7 through a secure
A 60-year-old, patient presents at
casualty with an acute cough, pleuritic medical taxi service dashboard by their treating
chest pain and fever healthcare provider, their
Doctor diagnoses patient HomeCare nurse and a team of
with community acquired clinicians in the ER Consulting
pneumonia and discusses clinical command centre
Hospital at Home as an option
for treatment
The patient confirms that

they have a suitable home
environment to receive care
at home, and are digitally
engaged
STEP 02 STEP 04
DOCTOR REFERRAL CARE COORDINATION AND HOME SET-UP
he doctor completes the Hospital at Home

T A HomeCare nurse meets the patient at home, where
application form and emails through to the Scheme they are:
The doctor also shares the patient’s personalised Informed of their treatment plan
treatment plan which indicates that intravenous Set up and instructed on relevant devices and apps
infusion (IV), oral medication and remote monitoring
Provided with medicine
is required with a Biofourmis device
Set up with an IV
Oncology Programme The benefit is targeted at four conditions currently: acute

myocardial infarction/ischaemic heart disease, pneumonia,
If you are diagnosed with cancer, you must register on the heart failure and Chronic Obstructive Pulmonary Disease
Malcor Medical Aid Scheme’s Oncology Programme. The (COPD). Predictive modelling will identify those members
Malcor Medical Aid Scheme’s Oncology Programme follows who are deemed at highest risk of being readmitted for these
the ICON or SAOC protocols and guidelines. Oncology limits conditions and the benefit will be available to them.
will apply for non-PMB treatment.
The benefit has three components:
Please register by calling 0860 100 698.
Weekly coaching sessions via WhatsApp/Email/call over a
Readmission Prevention Benefit period of four weeks
The focus of this benefit is to decrease the readmission rates A GP follow-up consultation funded from risk; and
by ensuring that patients discharged from acute care do not
A medicine reconciliation at the point of discharge
suffer a relapse or deterioration that may require readmission
performed by the treating doctor.
to hospital for unplanned reasons.
These components will occur intensely within the first 10 -14
days of the patient leaving the hospital.
17
DISCHARGE
STEP 07 STEP 08
CLINICAL SERVICES DISCHARGE
Blood samples are taken to track how the patient is he patient is responding well to treatment and is
T
responding to treatment and the patient’s treating doctor discharged from Hospital at Home
receives a notification when the results are shared from
The HomeCare nurse assists with:
the lab.
– Delivery of take-home medicine
– Discharge planning services
STEP 06
HEALTHCARE PROFESSIONAL
CONSULTATIONS
The patient receives daily visits from their treating

HomeCare nurse and conducts daily online
consultations with their physician to track their
progress
As part of their treatment plan, the patient also

receives daily treatment from a physiotherapist
The typical member journey of a member eligible for the the Readmission Prevention Benefit is illustrated below.
Virtual Virtual Virtual

HomeCare HomeCare HomeCare
Days after discharge
0 – 1 – 2 – 3 – 4 – 5 – 7 – 1 0 – 1 2 – 1 5 – 1 7 – 2 0 – 2 5 – 3 0 Prevention of readmisson
M EMBER
JO URNEY Med recon
Home Care Follow-up with Handover of care to GP
Physical Visit treating doctor
Virtual House Calls World Health Organisation (WHO) global

Virtual House Call by GPs is an initiative whereby GPs on the outbreak benefit
Scheme GP or Premier Plus GP Network will proactively reach Baskets of care which includes in-hospital and out-of-
out to their “at risk” members who might be inappropriately hospital management and supportive treatment of global
rationing care. The aim of this benefits is to prevent disease World Health Organisation recognised disease outbreaks,
exacerbations and serious admissions. The Scheme will subject to Prescribed Minimum Benefit guidelines or as
fund one virtual house call per annum for members who are otherwise legislated.
registered for a condition on the Chronic Illness Benefit (CIB)
excluding oncology.
18
SCREENING
BENEFIT
Members on Plan A, Plan B and Plan C will have access to a Screening Benefit. This benefit includes
funding of selected screening tests to better manage your health. By paying these tests from your
Screening Benefit that funds from the Overall annual in-hospital benefit, your existing radiology and
pathology benefits will last longer.
Screening test consisting of Pap smear

Blood glucose One Pap smear per female beneficiary over 18 years
Blood pressure Every three years
Cholesterol
Further Pap smears are funded from the pathology benefit.
Body Mass Index
Limits may apply.
Colorectal cancer/bowel screening Prostate-specific antigen test

One faecal occult or faecal immunochemical test (FOBT/FIT) One prostate-specific antigen test per male beneficiary
per male and female beneficiary
Once per annum
Every two years
Further prostate-specific antigen tests are funded from the
Must be between 45 and 75 years old
pathology benefit. Limits may apply.
Includes the cost of one colonoscopy for at risk members
HIV test
or those with a positive faecal occult test
Unlimited HIV test per male and female beneficiary
Mammogram
Bone density test
One mammogram per female beneficiary 40 years
or older. One bone density test per male and female beneficiary
over the age of 50 years
Every two years
Once per annum
One mammogram for at-risk females under 40 years,
frequency will be determined based on clinical guidelines Further bone density tests are funded from the radiology
benefit. Limits may apply.
Further mammograms are funded from the radiology
benefit. Limits may apply.
19
20
21
MEDICINE
BENEFIT
TYPE OF MEDICINE OBTAINED FROM PRESCRIBED BY PAID FROM
Medicines given to you while

you are in-hospital (you are an In-Hospital Benefit
admitted patient)
Medicines given to you when

you leave the hospital (you are
IN-HOSPITAL
being discharged as a patient).

Hospital Benefit
Medicine is billed by the hospital
directly – you are not handed a
script to collect from the pharmacy
Medicines given to you when you

leave the hospital (you are being
Seven day supply:
discharged as a patient). Medicine
paid from your Acute
is not billed by the hospital directly
Medicine Benefit
– you are handed a script to collect
from the pharmacy
Prescribed acute (schedule 0-6) Acute Medicine Benefit
Approved prescribed chronic

(must be registered on the or Chronic Illness Benefit
OUT-OF-HOSPITAL
Chronic Illness Benefit)
Acute Medicine Benefit

Pharmacy prescribed or self- (up to the over-the-
or
prescribed (schedule 0, 1 or 2) counter medicine
sub-limit)
Acute Medicine Benefit

Approved vitamins
or or Managed Care
(HIV, Oncology, Pre-natal only)
Programme risk
Prescribed vitamins
Iron, single and multivitamins
with a NAPPI code, only when
prescribed by a physician. Limited Acute Medicine Benefit
to R75 and/or 500ml/60 tablets per
script. Tonics, mineral supplements
and baby food is not covered.
Hospital Pharmacy Doctor Self
22
MEDICAL
BENEFIT
GEN E R A L G UID ELINES : THE Medication preferred provider
SC HE M E A P PLIES THE F O LLO WI N G Dis-Chem have been appointed as the Scheme’s Designated
GU I D E L I N E S IN R ES PECT O F Service Provider (DSP) for all medication requirements.
Dis-Chem have offered the Scheme a beneficial dispensing
ME D I CI N E B ENEF ITS O N PLAN S fee structure. Should a member choose to obtain their
A , B A N D C: medication from a provider who is unable to match this
dispensing fee arrangement, they will be personally liable
Generic medication for any resultant excess.
Generic medicines are produced once patents of original

drugs have expired. They have the same active ingredients DESI GNAT ED SERVI CE PROVI DER
as the original medicines. They may, however, be in a different ( DSP) PHARM A CY N ET WORK FOR
form from the original drug and will not be in the same
packaging.
ONCOL OGY A N D ONCOL OGY-
REL AT ED MEDI CI N E
By using generics, members can use less of their Acute
Medicine Benefit each time they claim. However, members The DSP Pharmacy Network must be used to obtain your
are still assured of quality because all generic medicines oncology medicines. A 20% co-payment applies when using a
sold in South Africa must be approved by the Medicines pharmacy outside of the oncology DSP Pharmacy Network.
Control Council.
There are primarily two service settings catered for within the
DSP arrangement: those providing medication administered
Maximum medical aid price (MMAP®)
in-rooms; and for medication scripted and dispensed through
The Scheme covers the cost of medication up to the a retail pharmacy.
recommended MMAP®. This price represents the lowest
average price available in the marketplace for a particular For medicines administered in-rooms:
classification of drug. This price is in most cases the lowest
Treatment administered in the doctor’s rooms, such as
average generic price as well.
injectable and infusional chemotherapy, should be obtained
Members are fully responsible for the difference between the from a courier pharmacy that is contracted as a DSP.
actual price charged for medication and the related MMAP®
The In-room treatment services are provided through
level. For this reason members are urged to ask their doctors
a network of courier pharmacies. Usually, the treating
to prescribe generic medication wherever possible.
oncologist will have an arrangement in place with a courier
If there is no generic alternative on the MMAP list, the full
pharmacy to dispense and deliver treatment to their practice
cost of the original drug will be paid by the Scheme.
(treatment facility). The following courier pharmacies
(providing oncology specific services) are included in the DSP
Medicine price structure
network offering:
Current legislation regulates the pricing of all medication and
Dis-Chem’s Oncology Courier Pharmacy
the Scheme will cover medication up to a maximum of this
Medipost Pharmacy
Single Exit Price, subject to MMAP®. Legislation also allows
for a dispensing fee to be charged and this is covered by Qestmed
the Scheme up to the amount charged by the Scheme’s DSP, Olsens Pharmacy
being Dis-Chem.
Southern Rx
Certain providers dispensing, bill the Scheme directly for

treatment done in rooms and these practices would be
However, administrative costs, including those for exempt from the DSP arrangement. It would also not apply
faxes, telephone calls, transaction and delivery to chemotherapy administered in-hospital.
fees and any other sundry fees charged by the
medication supplier, are not covered by the Scheme.
23
For medicines scripted and dispensed at Over-the-counter medicines (OTC)
a retail pharmacy Pharmacists can prescribe and dispense schedule 0, 1
Oncology and oncology-related medicine (like supportive and 2 medicines for the treatment of minor ailments
medicine, oral chemotherapy and hormonal therapy) is such as dysmenorrhoea, headaches, sinusitis, abdominal
usually scripted by the treating doctor for the member to colic, stomach cramps, dyspepsia, heartburn, constipation,
obtain from their local retail or courier pharmacy. The DSP diarrhoea, muscular pain, coughs and colds, flu, sprains,
arrangement for scripted and dispensed medication will be insect bites, rashes, itchy skin, hayfever, nausea and vomiting,
covered in full at the following pharmacies: migraines, worms, vaginitis, anti-fungal and anti-viral conditions.
These costs will be paid by the Scheme and deducted off the
MedXpress Network Pharmacy
relevant plan-specific acute medicine OTC sub-limit.
Dis-Chem’s Oncology Courier Pharmacy
Medipost Pharmacy
Qestmed
Olsen’s Pharmacy VI SI T
Southern Rx www.malcormedicalaid.co.za > Medicine for
more information.
24
EX
GRATIA
BENEFIT
W H A T I S E X G R ATIA?
Ex-Gratia is defined by the Council for Medical Schemes
(CMS) as ‘a discretionary benefit which a medical aid scheme
may consider to fund in addition to the benefits as per the
registered Rules of a medical scheme. Schemes are not
obliged to make provision there for in the rules and
members have no statutory rights thereto’.
The Board of Trustees may in its absolute discretion increase

the amount payable in terms of the Rules of the Scheme as
an Ex-Gratia award. As Ex-Gratia awards are
not registered benefits, but are awarded at the discretion
of the Board of Trustees.
Ex-Gratia requests are considered on an individual basis

and any decision made will in no way set a precedent or
determine future policy. Decisions taken by the Board is final
and are not subject to appeal or dispute.
A discretionary benefit which a medical aid scheme

may consider to fund in addition to the benefits as
per the registered Rules of a medical scheme. Schemes
are not obliged to make provision there for in the rules
and members have no statutory rights thereto.
25
PRESCRIBED MINIMUM
BENEFITS (PMBs) AND
DESIGNATED SERVICE
PROVIDERS (DSPs)
W HAT I S A PMB? WHAT WE COVER
Prescribed Minimum Benefits are
AS A PRESCRI BED
prescribed by law as a minimum M I N I MUM BENEF I T
benefit package to which each
The Prescribed Minimum Benefits
medical scheme member is entitled.
make provision for the cover of the
The Regulations to the Medical
diagnosis, treatment and ongoing
Schemes Act of 1998 require that
care of:
medical schemes need to provide
cover for certain conditions even • 271 diagnoses and their associated
when scheme exclusions or waiting treatment
periods apply, or when the member • 27 chronic conditions
has reached the limit for a benefit.
• Emergency treatment.
HO W PM B CL A I MS REMEMBER
AR E PA I D
Your hospital admission is subject
Your cover depends on whether you to approval and preauthorisation.
choose to use the Malcor Medical Aid If you need to be admitted for
Scheme’s Designated Service Providers emergency medical treatment, please
(DSPs) or not. arrange for authorisation 72 hours
after your admission or have a family
The Malcor Medical Aid Scheme has
member contact us to arrange this.
selected MediClinic facilities Busamed
Gateway, Busamed Hillcrest (in KZN), Out-of-hospital PMB cover is
Life East London (East London) and subject to approval and pre-
Life St George’s (Gqeberha) as the authorisation. The application
Scheme’s in-hospital Designated Service form can be downloaded from
Provider (DSP) or ‘network’. The latest www.malcormedicalaid.co.za >
list of hospitals and other service Find a document or by calling
providers is available at the Scheme on 0860 100 698.
www.malcormedicalaid.co.za >
Doctor visits > Find a healthcare
professional
B ENEFI T T I P
If you choose to use the Malcor Medical Aid Scheme’s DSPs, the Scheme
will pay your medical expenses in full, from your Hospital Benefit. If you
choose not to use a DSP, the Scheme will pay for medical expenses incurred
while you are admitted to hospital at up to the Scheme Rate. You will be
responsible for the balance as a co-payment.
26
COVER
F O R E MER GENC I ES
Y O U R HE A LTH B ENEF ITS ALS O I NCL UDE

C O V E R F OR MED ICAL EMER G EN CI ES I N
SO U T H A F R ICA.
Emergencies in South Africa Motor vehicle accidents
In an emergency, call Discovery The member must inform the Scheme
911 on 0860 999 911 – this number is about the accident as soon as ossible.
displayed on your membership card Discovery Health will assist with the
for easy reference. Road Accident Fund claim in the
following ways:
Cover while travelling
Discovery Health will refer the
overseas member to a Discovery Health
approved attorney who will assist
If you require emergency medical
the member with their claim
services while overseas, that would
against the Road Accident Fund (the
normally be covered by the Malcor
member may however make use
Medical Aid Scheme, you can claim
of their own attorney).
the reimbursement of the cost of
these services back from the Malcor
If the member uses one of
Medical Aid Scheme on your return. Discovery Health’s approved
The Malcor Medical Aid Scheme will attorneys, those attorneys will
refund you at the Malcor Rate that analyse the member’s accident
would have been paid if emergency (at no cost to the member) to
medical services had been obtained in determine whether the member
South Africa. has a valid claim.
Please download the international

If the member chooses to use
claim form from the website and send their own attorney, the member
it to us with the detailed claim so that should ask their attorney to contact
we can review the claims for payment. the Scheme in order to assist
the member’s attorneys with the
Malcor medical aid scheme accident-related accounts and
emergency service any fee-related queries which the
attorneys may have.
Cover is provided for emergency medical
evacuations. The Discovery Medicopters, The Scheme will pay for accident-
supported by ground staff, provide related healthcare expenses in
medical support and air evacuation in accordance with the rules of the
extreme critical cases. The emergency Scheme and the member’s plan type.
helicopters operate from Johannesburg, If the Road Accident Fund pays for
Cape Town and Durban medical expenses which were also
paid by the Scheme, the Scheme
must be reimbursed in accordance
with the amount paid by the Road
Accident Fund.
In an emergency, please call the Discovery 911 emergency services number

which you will find on your membership card and the car sticker that has
been provided (Plan A, B and C only).
27
ADVANCED
TECHNOLOGY
AND CONVENIENCE
WHEN YO U’R E AT T HE M A N A GI NG DI A BET ES
D O CTO R – HEALT H I D DI GI T AL L Y
HealthID, Discovery Health’s application for The Malcor Medical Aid Scheme will fund
healthcare professionals, is the first of its kind in a telemetric glucometer for all members
South Africa. Many doctors in the network will registered for diabetes. These devices provide an
be able to access your health records with your efficient and simple user interface for capturing
consent. Remember that member confidentiality blood glucose readings and insulin levels, and
will be protected at all times and your information for logging exercise and meals – all in real time.
can only be accessed with your consent.
The data captured through this device integrates
seamlessly with HealthID (an application that
doctors can download) to access members’
information remotely and identify risks in a
Online bookings: timely manner.
You can conveniently use the Discovery app These benefits allow doctors to spend less time
to make real time online bookings. You can downloading data and more time focusing
download the Discovery app by going to the on the health of patients, making diabetes
Apple AppStore or Google Play. management easier for members of the
Malcor Medical Aid Scheme. These benefits are
provided through Dis-Chem pharmacies and
will be funded subject to your external medical
appliances limit and overall out-of-hospital limit.
28
YOUR HEALTH
PL A N A T Y O UR F I NG ERTIPS
Managing your health plan online and on the Discovery app puts you fully in
touch with your health plan no matter where you are. If your mobile device
is with you, so is your plan (available for Plans A, B and C).
A PP
Electronic membership card Find a healthcare provider

View your electronic membership card Find your closest healthcare provider
with your membership number. who we have a payment arrangement
with such as pharmacies and hospitals,
specialists or GPs and be covered in full.
Submit and track your claims Request a document

Submit claims by taking a photo of your Need a copy of your membership
claim using your smartphone camera certificate, latest tax certificate or other
and submit. You can also view a detailed important medical scheme documents?
claims history. Request it on our app and it will be
emailed directly to you.
Access the procedure library

Track your day-to-day medical spend
View information on hospital procedures
and benefits
in our comprehensive series of medical
Access important benefit information procedure guides. You can also view a
about your specific plan. You can also list of your approved planned hospital
keep track of your available benefits. admissions.
Access your health records Update your emergency details

View a full medical record of all doctor Update your blood type, allergies and
visits, health metrics, past medicine, emergency contact information.
hospital visits and dates of X-rays Give consent to your doctor accessing
or blood tests. It is all stored in an your medical records
organised timeline that is easy
and convenient to use. Give consent to your doctor to get
access to your medical records on
HealthID. This information will help your
doctor understand your medical history
and assist you during a consultation.
DESKT OP
A website that responds Keeping track of your claims
to your device We have securely stored information
Our website has been designed to work about your claims. You can submit
on a variety of different digital devices your claim online, view your claims
– your computer, your tablet and your statement, do a claims search if you
cellphone. No matter what size the are looking for a specific claim, see a
screen, the information will always be summary of your hospital claims and
customised to your particular device even view your claims transaction
making it easy to read. history.
Keeping track of your benefits Accessing important documents

You can keep track of your available We have securely stored documents so
benefits online. You can access all that they are available when you need
important benefit information about them most. Whether you are looking
your plan. for your tax certificate, membership
certificate or simply looking for an
application form, we have them all
Ordering medicine stored on our website.
You can order medicine from MedXpress
to be delivered to your preferred address.
You can do this by taking a photo of your Finding a healthcare professional
new script and submitting it. You can also
re-order an existing repeat script. You can use our Medical and Provider
Search tool to find a healthcare
Download now: professional. You can also find one who
we cover in full so that you don’t have
a co-payment on your consultation.
You can even filter your search by
speciality and area and the results will
be tailored to your requirements.
29
S UB MIT YO U R CL AI M S ON YOUR SMART PHON E A P P I N
3 EAS Y S TEPS:
Download the Discovery app from the Take a photo of the claim and
App Store or Google Play and log in immediately upload it or use your
phone to scan the QR code*
Select Submit a claim from * If

the claim has a QR code, simply scan the QR
the menu code from within the Discovery app.
30
THE MALCOR
MEDICAL AID SCHEME
B E N E F I T T A B L ES
H OS P I T A L B ENEF ITS : PLANS A, B A N D C
Benefit limits are prorated if a member joins the Malcor Medical Aid Scheme during the year unless
otherwise stated. Preauthorisation is required before admission, except in the case of an emergency.
Plan A Plan B Plan C
HEALTHCARE ANNUAL ANNUAL ANNUAL

BASIS OF COVER
SERVICE LIMITS LIMITS LIMITS
Statutory Prescribed Services rendered by public hospitals/DSP at 100% Unlimited Unlimited Unlimited
Minimum Benefits of cost or agreed rate or 100% of the Scheme
Rate in a private hospital where the beneficiary
voluntarily elects another service provider
Where PMB performed in a private hospital
involuntarily such procedure will be paid
at 100% of cost
All Prescribed Minimum Benefits are paid
according to the regulations.
Overall annual limit for 100% of the Scheme Rate funded from overall Unlimited Unlimited R1 000 000 per
in-hospital expenses annual in-hospital benefit family per annum
Preauthorisation required
Day Surgery Network for 100% of the Scheme Rate funded from overall Unlimited for listed Unlimited for listed Overall annual in-
certain procedures or annual in-hospital benefit procedures procedures hospital limit
operations Day-Surgery Network applies as DSP A R6,300 deductible A R6,300 A R6,300 deductible
(refer to “Day Surgery Preauthorisation required will apply for deductible will will apply for
Network for certain Subject to protocols and clinical entry criteria voluntary use of apply for voluntary voluntary use of
procedures or operations” a non-DSP Day use of a non- a non-DSP Day
elsewhere in this Benefit Surgery Network DSP Day Surgery Surgery Network
Guide for the list of Network
procedures)
Health at Home 100% of the Scheme Rate funded from overall Basket of care as Basket of care as Basket of care as
Home-based healthcare annual in-hospital benefit set by the Scheme set by the Scheme set by the Scheme
for clinically appropriate Preferred Provider Network applies (where
chronic and acute treatment applicable)
and conditions that can be Preauhorisation required
treated at home Subject to the treatment meeting the treatment
guidelines and clinical and benefit entry criteria
Home Care Nursing for 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual in-
IV Infusion, wound care annual in-hospital benefit No benefit out of No benefit out of hospital limit
and post-natal care Discovery Home Care is the DSP DSP DSP No benefit out of
Preauthorisation required DSP
Subject to protocols and clinical entry criteria
Home-monitoring devices 100% of the Scheme Rate funded from overall R4 250 per R4 250 per R4 250 per
A defined list of registered annual in-hospital benefit beneficiary per year beneficiary per beneficiary per year
devices clinically Preauhorisation required for the device year
appropriate for chronic Subject to clinical protocols and benefit entry
and/or acute conditions criteria
Accommodation, materials, 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
theatre fees annual in-hospital benefit in-hospital limit
Preauthorisationrequired
Blood transfusions 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
annual in-hospital benefit in-hospital limit
Ambulance (local 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
emergency evacuation) annual in-hospital benefit in-hospital limit
DSP applies
31

BASIS OF COVER
Specialists 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
Specialist Network applies as DSP
GP 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
GP Network applies as DSP
Virtual House Call For all registered Chronic Illness Benefit (CIB) One Virtual House One Virtual House One Virtual House
Virtual GP House Call conditions (excluding oncology) Call per annum per Call per annum per Call per annum per
Consultation (initiated by a 100% of the Scheme Rate funded from overall beneficiary beneficiary beneficiary
network GP) via telephone, annual in-hospital benefit DSP for GPs: GP
DrConnect or another virtual Network or Premier Plus GP Network
platform (to be claimed with
code VDHC by provider)
Comprehensive Maternity 100% of the Scheme Rate funded from overall Antenatal Antenatal Refer to Maternity
benefits annual in-hospital benefit consultations are consultations are Out-of-hospital
Antenatal consultations, limited to 12 visits. limited to 12 visits. benefits
Antenatal classes, Pre or post natal Pre or post natal
Ultrasound scans and classes are limited to classes are limited
prenatal screening, Blood 5 consultations with to 5 consultations
tests, Private ward, Essential a registered nurse. A with a registered
registered devices limit of 2 Ultrasound nurse. A limit of 2
scans and one Ultrasound scans
nuchal translucency and one nuchal
or NIPT or down translucency or
syndrome screening NIPT or down
test are covered. syndrome
Blood tests are screening test are
limited to a defined covered. Blood
basket. Private tests are limited to
ward cover up to a defined basket.
Scheme rate per day. No benefit for
Cover on essential private ward cover.
registered devices is Cover on essential
limited to R4,160 registered devices
is limited to R2,060
Post-birth benefits 100% of the Scheme Rate funded from overall Consultations with Consultations with Refer to Maternity
GP and specialist visits, annual in-hospital benefit a GP, paediatrician a GP, paediatrician Out-of-hospital
Post natal consultations, or an ENT is limited or an ENT is limited benefits
Six week post-birth to 2 visits for to 2 visits for
consultation, Nutrition your baby. Pre or your baby. Pre or
assessment, Mental health post natal classes post natal classes
consultation, Lactation are limited to 5 are limited to 5
consultation consultations with consultations with
a registered nurse. a registered nurse.
A limit of one six- A limit of one six-
week post-birth week post-birth
consultation with consultation with
a GP, midwife or a GP, midwife or
gynaecologist is gynaecologist is
covered. A limit covered. A limit
of one nutrition of one nutrition
assessment with a assessment with a
dietician is covered. dietician is covered.
Mental health Mental health
consultations with consultations a GP,
a GP, gynaecologist gynaecologist or
or psychologist psychologist
is limited to 2 is limited to 2
visits. A limit of visits. A limit of
one lactation one lactation
consultation with a consultation with a
nurse or lactation nurse or lactation
specialist is covered specialist is covered
Organ transplants 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
annual in-hospital benefit. PMB at cost in-hospital limit
32
BASIS OF COVER
Internal prosthesis 100% of the Scheme Rate funded from overall R131,150 per R90,054 per R48,200 per
(hip, knee, shoulder annual in-hospital benefit beneficiary per beneficiary per beneficiary per
joints,artificial eyes, Preauthorisation required annum annum annum
intraocular lenses,
defibrillators, pacemakers, Sub-limits:
stents, spinal items, etc.) Hip R65,575 R45,016 No sub-limits.
Knee R65,575 R45,016 Subject to overall
Pacemakers R65,575 R45,016 internal prothesis
Stents R29,170 R25,730 limit.
Cardiac stents 100% of the Scheme Rate funded from overall 3 stents per 3 stents per 3 stents per
(limited to the internal annual in-hospital benefit beneficiary beneficiary beneficiary
prosthesis sub-limit for Preauthorisation required per annum per annum per annum
stents for Plan A and Plan B.
For Plan C it is subject to the
internal prosthesis sub-limit)
Bone-anchored 100% of the Scheme Rate funded from overall Subject to internal Subject to internal Subject to internal
hearing aid annual in-hospital benefit prosthesis limit prosthesis limit prosthesis limit
Spinal prosthesis 100% of the Scheme Rate funded from overall Subject to internal Subject to internal Subject to internal
annual in-hospital benefit prosthesis limit prosthesis limit prosthesis limit
External medical items 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
(HALO traction, embolytic annual in-hospital benefit in-hospital limit
stockings, certain back Preauthorisation required
braces)
Pathology 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
Radiology 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
Endoscopies 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
Specialised radiology 100% of the Scheme Rate Unlimited Unlimited Out-of-hospital:
(MRI, CT scans, PET scans, Preauthorisation required Overall annual Overall annual Overall annual out-
nuclear medicine studies, in-hospital limit in-hospital limit of-hospital limit
angiograms, arthrograms) regardless of regardless of
setting (out of setting (out of In-hospital: Overall
hospital or in hospital or in annual in-hospital
hospital) hospital) limit
Dentistry 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
(maxilla-facial procedures) annual in-hospital benefit in-hospital limit
Conservative dentistry and specialised dentistry
not covered in-hospital unless preauthorised
In theatre dentistry - 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
Children under the age annual in-hospital benefit in-hospital limit
of 12 years Preauthorisation required
Ophthalmologic procedures 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
(corneal crosslinking annual in-hospital benefit in-hospital limit
included) Preauthorisation required
Mental health 100% of the Scheme Rate funded from overall 21 days per 21 days per 21 days per
annual in-hospital benefit beneficiary beneficiary beneficiary
Preauthorisation required per annum per annum per annum
Drug and alcohol 100% of the Scheme Rate funded from overall 21 days per 21 days per 21 days per
rehabilitation annual in-hospital benefit beneficiary beneficiary beneficiary
DSP applies per annum per annum per annum
Detoxification for 100% of the Scheme Rate funded from overall Three days per Three days per Three days per
substance dependency annual in-hospital benefit beneficiary per beneficiary per beneficiary per
DSP applies approved event, approved event, approved event,
subject to subject to subject to
Preauthorisation required rehabilitation days rehabilitation days rehabilitation days
being available. being available. being available.
33

BASIS OF COVER
Allied professionals 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
(acousticians, biokineticists, annual in-hospital benefit in-hospital limit
chiropractors, dietitians, Preauthorisation required
nursing providers,
occupational therapists,
physiotherapists,
podiatrists, psychologists,
psychometrics, social
workers, speech and hearing
therapists)
Private nursing, step 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
down, sub-acute physical annual in-hospital benefit in-hospital limit
rehabilitation Preauthorisation required
Renal dialysis 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
DSP applies
Medication supplied 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
in-hospital annual in-hospital benefit in-hospital limit
To-take-out (TTO) 100% of the Scheme Rate funded from overall Limited to seven Limited to seven Limited to seven
medication annual in-hospital benefit days if billed on the days if billed on the days if billed on the
Preauthorisation required hospital account hospital account hospital account
International travel 100% of claim funded from the overall annual R500,000 per R500,000 per R500,000 per
in-hospital benefit beneficiary per beneficiary per beneficiary per
Preauthorisationrequired journey, 90 days journey, 90 days journey, 90 days
from departure from departure from departure
date date date
Home oxygen 100% of the Scheme Rate funded from overall Unlimited Unlimited Overall annual
DSP applies
HIV and AIDS-related 100% of the Scheme Rate funded from Unlimited Unlimited Overall annual out-
treatment overall-annual in-hospital benefit of-hospital limit.
PMB criteria apply Approved PMB’s
will fund through
the limit
Post-exposure HIV 100% of scheme rate Unlimited Unlimited Overall annual out-
prophylaxis following PMB criteria apply of-hospital limit.
occupational exposure, Approved PMB’s
traumatic exposure will fund through
or sexual assault the limit
HIV prophylaxis to 100% of scheme rate Unlimited Unlimited Overall annual out-
prevent mother-to-child PMB criteria apply of-hospital limit.
transmission Approved PMB’s
will fund through
the limit
Prescribed antiretroviral 100% of scheme rate Unlimited Unlimited Overall annual out-
medication for HIV/AIDS PMB criteria apply of-hospital limit.
and medication to treat Approved PMB’s
opportunistic infections will fund through
such as tuberculosis the limit
and pneumonia
Oncology treatment and 100% of the Scheme Rate funded from the R500,000 per family R300,000 per family R200,000 per family
medication oncology limit. per annum per annum per annum
Subject to ICON and SAOC guidelines and
Preauthorisation by Scheme
Oncology Pharmacy DSP applies – 20%
co-payment out-of-network.
Wigs are covered from the overall out-of-hospital
benefits, subject to the external medical items limit.
34
BASIS OF COVER
Pre-Advanced Illness 100% of the Scheme Rate funded from overall 1 x Social worker 1 x Social worker 1 x Social worker
Benefit: member support annual in-hospital benefit visit (as per visit (as per visit (as per
programme Counselling Counselling Counselling
(Pre-Advanced Illness network) network) network)
Benefit Care team enrolls 1 x GP visit 1 x GP visit 1 x GP visit
member on AIB) (palliative trained (palliative trained (palliative trained
GP) GP) GP)
Advanced Illness Benefit 100% of the Scheme Rate funded from the overall Unlimited Unlimited Unlimited
(end-of-life care at home) annual in-hospital benefit
DSP applies
Stem cell transplants 100% of the Scheme Rate funded from R500,000 per R300,000 per R200,000 per
overall annual in-hospital benefit family per annum family per annum family per annum
(part of the (part of the (part of the
Oncology Benefit) Oncology Benefit) Oncology Benefit)
O U T - O F -HO S PITAL B ENEF ITS : PL A N S A, B A N D C


BASIS OF COVER
Overall annual limit for 100% of the Scheme Rate funded from overall R132, 420 per R79,000 per family Annual limit per
out-of-hospital expenses annual out-of-hospital benefit family per annum family based
per annum on number of
dependants:
M– R9,765
M1 – R17,560
M2 – R21,460
M3 – R25,430
M4+ – R29,250
GPs and homeopaths 100% of the Scheme Rate funded from overall Overall annual Annual limit per Overall annual
annual out-of-hospital benefit out-of-hospital family based out-of-hospital
DSP for GPs: GP Network benefit limit on number of benefit limit
dependants:
M– 6 visits
M1 – 12 visits
M2 – 16 visits
M3 – 20 visits
M4+ – 24 visits
When the limit is
reached, claims are
funded at 50% of
the Scheme Rate
from the overall
out-of-hospital
benefit.
Specialists (cardiologist, Plan A: 120% of the Scheme Rate funded from Annual limit per Annual limit per Overall annual
paediatrician, gynaecologist, overall annual out-of-hospital benefit (excluding family based family based out-of-hospital
specialist physician, dental specialists and anesthetist funded at 100% on number of on number of benefit limit
oncologist, etc.) of the Scheme Rate). dependants: dependants:
Plans B and C: 100% of the Scheme Rate funded M– 7 visits M– 4 visits
from overall annual out-of-hospital benefit
M1 – 12 visits M1 – 8 visits
M4+ – 26 visits M4+ – 17 visits
Maternity consultations 100% of the Scheme Rate funded from overall Refer to the Refer to the Overall annual
(gynaecologist and GPs) annual out-of-hospital benefit Comprehensive Comprehensive out-of-hospital
Maternity and Post Maternity and Post benefit limit
birth benefit birth benefit
Endoscopies 100% of the Scheme Rate funded from Overall annual out- Overall annual out- Overall annual
overall annual out-of-hospital benefit if not of-hospital benefit of-hospital benefit out-of-hospital
preauthorised limit limit benefit limit
35

BASIS OF COVER
External medical items 100% of cost funded from overall annual R4,632 per family R2,966 per family Overall annual
(walking sticks, commodes, out-of-hospital benefit per annum per annum out-of-hospital
bed pans, toilet seat raisers, benefit limit
crutches, glucometers, foot
orthotics, shoe innersoles,
wigs for specific conditions
etc)
Continuous Glucose 100% of the Scheme Rate funded from overall Limited to 1 Limited to 1 Limited to 1
Monitoring devices annual out-of-hospital benefit per annum per annum per annum
(transmitters and readers): Only for beneficiaries approved and registered per qualifying per qualifying per qualifying
Freestyle Libre (Abbot), on the Chronic Illness Benefit (CIB) for Type beneficiary beneficiary beneficiary
MediLink and Enlite I Diabetes and, enrolled onto the Diabetes Subject to available Subject to available Subject to available
(Medtronic) and Dexcom Cardiometabolic Care (DCC) Programme via your External Medical External Medical External Medical
G6 (Ethitec) devices (or as Premier Plus GP Items limit Items limit Items limit
amended from time to time) Subject to protocols and clinical entry criteria
Continuous Glucose 100% of the Scheme Rate funded from overall Monthly limit: Monthly limit: Monthly limit:
Monitoring sensors for annual in-hospital benefit Adults: Adults: Adults:
use with Freestyle Libre Only for beneficiaries approved and registered R1,560 R780 R780
(Abbot), MediLink and Enlite on the Chronic Illness Benefit (CIB) for Type Children under 18: Children under 18: Children under 18:
(Medtronic) and Dexcom I Diabetes and, enrolled onto the Diabetes R1,560 R1,560 R1,560
G6 (Ethitec) devices (or as Cardiometabolic Care (DCC) Programme via your
amended from time to time) Premier Plus GP
If obtained from a non-network provider, funding
will be from the available acute medication
benefit and limit
Walkers 100% of cost funded from overall annual R761 per family R497 per family Overall annual
out-of-hospital benefit per annum per annum out-of-hospital
benefit limit
Wheelchairs (including 100% of cost funded from overall annual R4,541 per family R2,920 per family Overall annual
buggies and carts) out-of-hospital benefit per annum per annum out-of-hospital
benefit limit
Hearing aids 100% of cost funded from overall annual R23,163 per family R16,212 per family Overall annual
out-of-hospital benefit per annum per annum out-of-hospital
benefit limit
Pathology 100% of the Scheme Rate funded from overall Annual limit per Annual limit per Overall annual
annual out-of-hospital benefit. When the limit family based family based out-of-hospital
is reached, claims are funded at 80% of the on number of on number of benefit limit
Scheme Rate from the overall annual out-of- dependants: dependants:
hospital benefit for Plan A and at 65% for Plan B M– R4,181 M– R1,813
Point of care pathology testing is subject to M1 – R6,762 M1 – R3,173
meeting the Scheme’s Treatment guidelines and M2 – R4,070
Managed Health Care criteria. M2 – R8,710
M3 – R11,148 M3 – R4,983
M4+ – R12,566 M4+ – R5,885
Radiology 100% of the Scheme Rate funded from overall Annual limit per Annual limit per Overall annual
annual out-of-hospital benefit. When the limit family based family based out-of-hospital
is reached, claims are funded at 80% of the on number of on number of benefit limit
Scheme Rate from the overall annual out-of- dependants: dependants:
hospital benefit for Plan A and 65% for Plan B M– R4,181 M– R1,813
M1 – R6,762 M1 – R3,173
M2 – R8,710 M2 – R4,070
M3 – R11,148 M3 – R4,983
M4+ – R12,566 M4+ – R5,885
Pregnancy scans 100% of the Scheme Rate funded from overall Refer to the Refer to the Overall annual
annual out-of-hospital benefit. When the limit Comprehensive Comprehensive out-of-hospital
is reached, claims are funded at 80% of the Scheme Maternity and Post Maternity and Post benefit limit
Rate for Plan A and 65% for Plan B from the overall birth benefit birth benefit
annual out-of-hospital benefit
Claims accumulate to the out-of-hospital radiology limit
Dentistry (conservative 100% of the Scheme Rate funded from overall Annual limit per Annual limit per Overall annual
dentistry and specialised annual out-of-hospital benefit family based family based out-of-hospital
dentistry, inclusive of on number of on number of benefit limit
osseo-integrated implants dependants: dependants:
as well as related sinus lift M– R12,312 M– R5,491
and bone graph procedures)
M1 – R20,510 M1 – R9,151
M2 – R26,665 M2 – R11,883
M3 – R32,730 M3 – R14,626
M4+ – R38,982 M4+ – R15,538
36
BASIS OF COVER
Dental therapy 100% of the Scheme Rate funded from overall R1,565 per family R1,045 per family Overall annual
annual out-of-hospital benefit per annum per annum out-of-hospital
benefit limit
Radial Keratotomy and 100% of the Scheme Rate funded from overall R20 658 per No benefit No benefit
Excimer laser treatment annual out-of-hospital benefit beneficiary per
(performed in hospital annum
or out-of-hospital setting)
Optical benefits (spectacles, 100% of the Scheme Rate funded from overall Annual limit per Annual limit per Overall annual
contact lenses, frames and annual out-of-hospital benefit family based on family based on out-of-hospital
all add-ons) Optometry Network applies: members will dependants: dependants: benefit limit
receive discounts as negotiated (discount M– R5,905 M– R2,817
applies to frames, eyeglass lenses and add-on M1+ – R11,813 M1+ – R6,343
components but excludes contact lenses and
professional services)
Eye tests 100% of the Scheme Rate funded from overall One test per One test per One test per
annual out-of-hospital benefit beneficiary beneficiary beneficiary
per annum per annum per annum
Allied professionals 100% of the Scheme Rate funded from overall R19,928 per family R12,890 per family Overall annual
(acousticians, biokineticists, annual out-of-hospital benefit, subject to the per annum per annum out-of-hospital
chiropractors, dietitians, Allied Professionals limit benefit limit
nursing providers,
occupational therapists,
physiotherapists,
podiatrists, psychologists,
psychometrics, social
workers, speech and
hearing therapists)
Mental health 100% of the Scheme Rate funded from overall Refer to the Allied Refer to the Allied Refer to the Allied
(psychologists and annual out-of-hospital benefit, subject to the professionals out- professionals out- professionals out-
counsellor) Allied Professionals limit and PMBs of-hospital benefit of-hospital benefit of-hospital benefit
limit. limit. limit.
PMBs: 15 PMBs: 15 PMBs: 15
consultations per consultations per consultations per
beneficiaries per beneficiaries per beneficiaries per
annum annum annum
Mental Health Care 100% of the Scheme Rate funded from the One extended One extended One extended
Programme: enhanced out- outpatient Mental Health Care Programme consultation per consultation per consultation per
patient care (for qualifying benefit. Programme duration is between 6 and annum annum annum
members with Major 12-months. Two standard Two standard Two standard
Depression or Episodic DSP: Premier Plus GP Network or a psychologist consultations per consultations per consultations per
Depression within the last in the Mental Health Care Programme Network annum annum annum
12 months who are enrolled
onto the programme) Funding of Funding of Funding of
antidepressant antidepressant antidepressant
medicine medicine medicine
Additional Additional Additional
psychotherapy psychotherapy psychotherapy
clinically approved clinically approved clinically approved
Mental Health Care: 100% of the Scheme Rate funded from the 2 psychiatric visits 2 psychiatric visits 2 psychiatric visits
Relapse Prevention outpatient Mental Health Care Programme 6 counselling 6 counselling 6 counselling
Programme (In addition benefit. sessions sessions sessions
to existing mental health
benefits and PMBs) Care coordination Care coordination Care coordination
services services services
Drug and alcohol No benefit No benefit No benefit No benefit
rehabilitation, detoxand
substance abuse
Acute medication (includes 100% of the Malcor Medication Rate funded from Annual limit per Annual limit per Overall annual
homeopathic medication, overall annual out-of-hospital benefit DSP applies family based family based out-of-hospital
vaccines*, pharmacy on number of on number of benefit limit
assisted treatment, TTO *
Vaccines and immunisation to be funded based dependants: dependants:
obtained at a pharmacy on State EPI vaccines for infants and children up M– R15,932 M– R7,752
and over-the-counter to the age of 12 years
medication) M1 – R22,773 M1 – R11,062
M2 – R29,594 M2 – R14,380
M3 – R38,718 M3 – R18,821
M4+ – R43,270 M4+ – R21,047
Over-the-counter sub limits M– R3,180 M– R2,120 No sub-limit. Subject
M1+ – R9,540 M1+ – R6,360 to overall annual
out-of-hospital
benefit limit
37
BASIS OF COVER
Chronic Illness Benefit CHRONIC DISEASE LIST
Maximum Medical Aid Price (MMAP) Funded from Funded from the Funded from the
Subject to medicine list (formulary). DSP applies the overall annual overall annual overall annual
in-hospital benefit in-hospital out-of-hospital
Subject to review and approval by CIB benefit benefit limit
based on benefit entry criteria
ADDITIONAL DISEASE LIST
Maximum Medical Aid Price (MMAP) Funded from the No benefit No benefit
Subject to medicine list (formulary). DSP applies overall annual in-
hospital benefit
Subject to review and approval by CIB
based on benefit entry criteria
Contraceptives Oral contraceptives

100% of the Malcor Medication Rate funded R186 per beneficiary R182 per beneficiary R182 per beneficiary
from the overall annual out-of-hospital benefit, per month per month per month
subject to the acute medicine limit
DSP applies
MIRENA DEVICE
100% of the Scheme Rate funded from the One every 5 years One every 5 years One every 5 years
overall annual out-of-hospital benefit
Subject to the acute medicine limit
DSP applies
ASSOCIATED GYNAECOLOGY COSTS FOR INSERTION AND REMOVAL IN THE DOCTOR’S ROOMS
Plan A: 120% of the Scheme Rate funded from the Subject to the Subject to the Overall annual out-
overall annual out-of-hospital benefit specialist annual specialist annual of-hospital benefit
Plan B and C: 100% of the Scheme Rate funded limit per family limit per family
from the overall annual out-of-hospital benefit
ASSOCIATED GYNAECOLOGY COSTS FOR MIRENA INSERTION AND REMOVAL IN THEATRE

100% of the Scheme Rate Overall annual out- Overall annual out- Overall annual out-
Subject to preauthorised and benefit of-hospital benefit of-hospital benefit of-hospital benefit
entry criteria limit limit limit
Contraceptives IMPLANON NXT
100% of the Scheme Rate funded from One every 3 years One every 3 years One every 3 years
the overall annual out-of-hospital benefit
Subject to the acute medicine limit
DSP applies
ASSOCIATED GYNAECOLOGY COST FOR IMPLANON NXT IMPLANT OR REMOVAL
Plan A: 120% of the Scheme Rate funded from the Subject to the Subject to the Overall annual out-
overall annual out-of-hospital benefit specialist annual specialist annual of-hospital benefit
Plan B and C: 100% of the Scheme Rate funded limit per family limit per family
from the overall annual out-of-hospital benefit
Subject to the specialist annual limit per family
Musculo-skeletal 100% of the Malcor Medication Rate funded from 65g per fill, limited 65g per fill, limited 65g per fill, limited
topical agents overall annual out-of-hospital benefit, subject to to two fills per to two fills per to two fills per
(Topical Analgesic Agents) the acute medicine limit beneficiary beneficiary annum
DSP applies per annum per annum
Screening for Adults: 100% of the Scheme Rate funded from the 1 x Mammogram 1 x Mammogram 1 x Mammogram
Mammogram Screening Benefit funded from the overall annual for female for female for female
Pap smears in-hospital benefit beneficiaries from beneficiaries from beneficiaries from
Prostate 40 years+ and, at- 40 years+ and, at- 40 years+ and, at-
HIV risk females under risk females under risk females under
Colorectal cancer 40 years, every 40 years, every 40 years, every
Bone density 2-years 2-years 2-years
1 x Pap smear for 1 x Pap smear for 1 x Pap smear for

female beneficiaries female beneficiaries female beneficiaries
over 18 years, every over 18 years, every over 18 years, every
3-years 3-years 3-years
1 x Prostate antigen 1 x Prostate antigen 1 x Prostate antigen

test for male test for male test for male
beneficiaries, once beneficiaries, once beneficiaries, once
per annum per annum per annum
Unlimited HIV test Unlimited HIV test Unlimited HIV test

per beneficiary per per beneficiary per per beneficiary per
annum annum annum
Screening for Adults: 100% of the Scheme Rate funded from the
Mammogram Screening Benefit funded from the overall annual 1 x Colorectal 1 x Colorectal 1 x Colorectal
Pap smears in-hospital benefit cancer faecal cancer faecal cancer faecal
Prostate occult blood test occult blood test occult blood test
HIV (FOBT) or faecal (FOBT) or faecal (FOBT) or faecal
Colorectal cancer immunochemical immunochemical immunochemical
Bone density test (FIT)) for all test (FIT)) for all test (FIT)) for all
beneficiaries beneficiaries beneficiaries
between ages between ages between ages
45 and 75, every 45 and 75, every 45 and 75, every
2-years. 2-years. 2-years.
1 x Colonoscopy 1 x Colonoscopy 1 x Colonoscopy

for members with for members with for members with
a positive faecal a positive faecal a positive faecal
occult test (FOBT) occult test (FOBT) occult test (FOBT)
1 x Bone density 1 x Bone density 1 x Bone density

testing for all testing for all testing for all
beneficiaries over beneficiaries over beneficiaries over
the age of 50 year the age of 50 year the age of 50 year
once per annum once per annum) once per annum
Screening Benefit 100% of the Scheme Rate funded from the overall Combined benefit Combined benefit Combined benefit
Dis-Chem WellScreen annual out-of-hospital benefit of two screening of one screening of one screening
tests per beneficiary test per beneficiary test per beneficiary
per annum* per annum** per annum**
Screening Benefit 100% of the Scheme Rate funded from overall Combined benefit Combined benefit Combined benefit
annual out-of-hospital benefit of two screening of one screening of one screening
tests per beneficiary test per beneficiary test per beneficiary
per annum* per annum** per annum**
Annual health check (blood Annual health check to be carried out at
glucose test, blood pressure the Wellness network pharmacy/provider
test, cholesterol test and
Body Mass Index (BMI))
Screening Benefit - 100% of the Scheme Rate funded from overall One test per One test per One test per
Children’s screening check. annual out-of-hospital benefit qualifying child qualifying child qualifying child
Applies to children between Children’s screening tests to be carried out per annum per annum per annum
the ages of two years and at a network pharmacy/provider
18 years (Body Mass Index
and counselling, where
appropriate, hearing
screening, dental screening
and milestone tracking for
children under the age
of eight)
* Member may claim for a maximum of two screening tests per annum and may choose to use either the Dis-Chem WellScreen test or the Health Check or both.
** Member may claim for a maximum of one screening test per annum and may choose to use either the Dis-Chem WellScreen test or the Health Check.
W O R L D HE A LTH O R G ANIS ATION ( WHO) GL OBAL OUT BREAK BENEFI T

BASIS OF COVER
World Health Organisation Baskets of care which includes in-hospital and Subject to Subject to Subject to
(WHO) Global Outbreak out-of-hospital management and supportive Prescribed Prescribed Prescribed
Benefit treatment of global World Health Organisation Minimum Benefit Minimum Benefit Minimum Benefit
recognised disease outbreaks guidelines or as guidelines or as guidelines or as
DSP applies where applicable otherwise otherwise otherwise
legislated legislated legislated
39
40
THE MALCOR
MEDICAL AID SCHEME
B E N E F I T T A B L ES
HOS P I T A L B ENEF ITS : PLAN D
otherwise stated. Preauthorisation required, except in the case of an emergency. In all instances,
Prescribed Minimum Benefits (PMBs) are paid at cost and are unlimited.
SERVICE BENEFITS/ANNUAL LIMITS BENEFIT REQUIREMENTS/CONDITIONS

Overall annual limit No annual limit Subject to protocols and sub-limits not being exceeded
Statutory Prescribed Minimum Benefit No annual limit
services rendered by public hospitals
payable at 100% of cost
Emergency medical cover while travelling 100% of SA tariff rates payable
outside of South Africa in RSA currency
BENEFIT REQUIREMENTS/
SERVICE BENEFITS ANNUAL LIMITS
CONDITIONS
1. HOSPITALISATION AND ASSOCIATED COSTS - PROVINCIAL AND PRIVATE
Items 1.01 – 1.21: All admissions to hospitals and services listed below must be preauthorised by the Designated Service Provider. Tel: 0860 00 24 02.
The Scheme will pay the costs of Prescribed Minimum Benefits in full for the involuntary use of a non-Designated Service Provider and 100% of the
Scheme Rate for services obtained from a Designated Service Provider.
Overall annual limit R600,000 per family Subject to sub-limits
per annum not being exceeded
1.01 Accommodation, theatre fees medicines, 100% of Managed Care Subject to PMBs Medicine dispensed on discharge limited
intensive care Rate as prescribed to a five-day supply
1.02 Surgical procedures in hospital 100% of Managed Care Subject to PMBs
including GP and specialist consultations Rate as prescribed
Hip Arthroscopy not Private wards
covered not covered
1.03 Diagnostic investigations 100% of Managed Care Authorisation must be Subject to clinical protocols
e.g. Radiology, Pathology, MRI/CAT scans etc. Rate obtained prior to the and PMBs as prescribed
examination or within MRI and CT Scans must be authorised
24 hours in case of an by the Scheme, or the Managed Health
emergency Care Organisation
Limited to R12,390 per
family per annum
1.04 Blood transfusions 100% of cost
1.05 Oncology treatment 100% of Managed Care Limit of R278,000 per Subject to PMBs as prescribed
Rate family per annum
Subject to ICON
protocols
1.06 Accommodation for confinements 100% of Managed Care NVD – Subject to PMBs as prescribed
Note: Waiting period may be applied, subject Rate Limited to two days
to the rights of interchangeability Caesar –
Limited to three days
Limited to two sonars
per confinement
1.07 Psychiatric treatment and clinical No benefit Subject to PMBs as prescribed
psychology Drug and alcohol treatment at SANCA
affiliated facilities only
41
CONDITIONS
1.08 Organ transplants 100% of Managed Care Limited to R133,000 per Subject to PMBs as prescribed
Rate family per annum and preauthorisation. Only locally
Cornea transplants: harvested corneas will be covered
only locally harvested
corneas will be covered
1.09 Renal dialysis 100% of Managed Care Subject to PMBs as Subject to preauthorisation from the
Rate prescribed. Scheme’s designated Managed Health
Care Service Provider
1.10 Dental hospitalisation No benefit
1.11 Sterilisation / vasectomy No benefit (Revisions excluded)
1.12 Internal prosthesis 100% of cost Limited to R28,900 per Subject to PMBs as prescribed
case per annum and preauthorisation
Cardiac stents – one Cardiac stents are reimbursed at the
per lesion, maximum cost of bare metal stents (BMS) and
three lesions not drug eluting stents (DES).
Aphakic Lenses – (Revisions excluded)
R5,780 per lens
1.13 Physiotherapy 100% of Managed Care Subject to PMBs as prescribed
Rate and preauthorisation
1.14 Step down facilities 100% of Managed Care Limited to a maximum Subject to PMBs as prescribed
Instead of hospitalisation Rate of two weeks per and preauthorisation
person per annum
1.15 Private nursing 100% of Managed Care Limited to a maximum Subject to PMBs
Instead of hospitalisation Rate of two weeks per as prescribed and
person per annum preauthorisation
1.16 Rehabilitation facilities 100% of Managed Care Limited to a maximum Subject to PMBs
Rate of two weeks per as prescribed and
person per annum preauthorisation
1.17 Circumcision 100% of Managed Care Limited to R1,500 per
In- and out-of-hospital Rate person per annum
1.18 Hyperbaric Oxygen Therapy No benefit

1.19 Back surgery 100% of Managed Care Refer to the limit as per Subject to PMBs as prescribed
Rate item 1.12 and preauthorisation Subject to back
treatment protocols as per DBC
1.20 Stereotactic Radiosurgery No benefit
1.21 Laparoscopic Procedures No benefit Subject to PMBs as prescribed
and preauthorisation
42
O U T - O F -HO S PITAL B ENEF ITS : PL A N D
otherwise stated. In all instances, PMBs are paid at cost and are unlimited.
CONDITIONS
2. GENERAL PRACTITIONERS AND SPECIALISTS
2.01 Consultations
General Practitioners 100% of Managed Care No annual limit Subject to member’s choice
Rate of nominated GP
Specialists 100% of Managed Care Limited to four visits Subject to referral from nominated GP
Rate per family per annum
Outpatient facilities 100% of Managed Care Two visits per family
Rate per annum
2.02 Antenatal care 100% of Managed Care Limited to two sonars Note: waiting periods may apply subject
Included in sub limits for consultations Rate per pregnancy to the rights of interchangeability
and medication
2.03 Diagnostic investigations Subject to PMBs as prescribed
Pathology 100% of Managed Care Limited to R1,240 per
Rate person per annum
Radiology 100% of Managed Care Limited to R1,240 per
Rate person per annum
MRI/Cat Scans No benefits
3. MEDICINES
3.01 Acute medicines 100% of Designated Unlimited subject to
(including homeopathic medicine) Service Provider medicine dispensed by
reference price the nominated GP and
medicine formulary
3.02 PMB Chronic Disease List (CDL) 100% of Designated Unlimited, but subject PMBs subject to registration and
medicines Service Provider to Designated Service preauthorisation of the medicine
reference price Providers’ treatment with the Scheme’s Preferred Provider
protocols and Tel: 0860 00 24 02
medicine formulary
3.03 Other chronic (non-CDL) medicines 100% of Designated Unlimited, but subject Non-CDL PMBs subject
Service Provider to Designated Services to registration and
reference price Providers’ treatment preauthorisation of the medicine with
protocols and the Scheme’s Preferred Provider,
medicine formulary Tel: 0860 00 24 02
3.04 Pharmacy Advised Treatment (PAT) 100% of Managed Care R464 per family
Over the counter medication. Rate per annum at R154
In consultation with pharmacist, per event
restricted to schedule 0, 1 and
2 medicines
4. OPTICAL BENEFITS
Contact the Designated Service Provider for availability of contracted optometrists. Tel: 0860 00 24 02
4.01 Spectacle lenses 100% of cost Limited to R1,255 per Subject to using the Scheme’s
In Network Benefits person payable every Designated Service Provider
24 months
4.02 Spectacle lenses Included in limit
Out of Network Benefits 4.01 above
Applicable to members who choose to

utilise a non-Preferred Provider Network
Optometrists
4.03 Contact lenses No benefit
In and Out of Network
4.04 Frames Included in limit
In and Out of Network 4.01 above
4.05 Eye tests Included in limit

In and out of Network 4.01 above
43
CONDITIONS
5. DENTISTRY
5.01 Conservative dentistry 100% of Managed Care Subject to overall preauthorisation required from
(e.g. fillings, extractions and X-rays) Rate annual limit Designated Service Provider
Tel: 0860 10 49 25
5.02 Specialised dentistry No benefit
(e.g. crowns, bridge-work, dentures,
orthodontics and periodontics)
5.03 Maxillo facial and oral surgery No benefit
(consultations, surgical procedures
and operations)
6. ALTERNATIVE SERVICES
6.01 Chiropractic, homeopathy, podiatry and No benefit

naturopathy
7. REMEDIAL AND OTHER THERAPIES
7.01 Audiology, dietitians, hearing aid No benefit

acousticians, occupational therapy,
orthoptics, social workers and
speech therapy
8. APPLIANCES
8.01 Appliances No benefit Subject to PMBs as prescribed

(e.g. hearing aids, wheelchairs,
calipers etc.)
9. EXTERNAL PROSTHESIS
9.01 External prosthesis No benefit Subject to overall Subject to PMBs as prescribed

(e.g. artificial limbs, eyes, etc.) annual limit preauthorisation required from
Designated Service Provider
Tel: 0860 10 49 25
10. PHYSIOTHERAPY (out of hospital)
10.01 Physiotherapy No benefit Subject to PMBs as prescribed

(out-of-hospital)
11. OTHER BENEFITS
11.01 Ambulance services 100% of Cost Non-emergency: Subject

LifeMed 0861 086 911 to preauthorisation beforehand. Failure
to
(air/road ambulance and do this could result in the member being
emergency services) liable for
the costs incurred
Emergency: Subject to authorisation
within 72 hours after the emergency
Inter-hospital transfers: must be done by
the Designated Service Provider only
11.02 HIV/AIDS and sexually 100% of Managed Care Hospitalisation payable Subject to Regulation 8(3)
transmitted diseases Rate as a PMB. Subject to treatment protocols, medicine
formulary and registration of chronic
medicine by the member’s nominated GP
11.03 Infertility 100% of Cost Subject to PMBs
as prescribed
44
REPORTING FRAUD OR MALPRACTICE
Be part of the solution and not the problem. FRA UD HOT L I N E ( A N ONYM OU S )
Report any fraudulent or unethical practice to us
To report any crime related activity, call anonymously on the
and take an active role in combating crime.
toll-free number 0800 004 500 or SMS your report
to 43477. This is a totally independent, professional hotline
service.
KEY INFORMATION
The Scheme pays the applicable Malcor Rate directly to 2. The Scheme Rate is set by the Scheme for reimbursement
providers as standard practice. If medical providers charge or it is the rate agreed between the Scheme and the
in excess of Malcor Rates, the member will then have to settle provider. Discovery Health has been mandated to
the balance with the relevant provider. negotiate certain rates on behalf of the Scheme.
Should a member pay a provider directly and submit his claim

with proof of receipt, the Scheme will refund the Malcor Rate HOW T O CL A I M
to the member.
Email and fax
NB! All medical aid refunds are done electronically and members
You can fax your claims to us on 0860 FAX CLAIMS
are urged to ensure their banking details with the Scheme
(0860 329 252), or scan and email your claim
are always updated.
to [email protected]
You can scan and email your Plan D claim to

IM P OR T A N T TIPS W HEN
[email protected]
CLAIMING
Post
When claiming from the Scheme for your medical costs,
You can post your claims to the following address:
whether these are hospital, chronic or out-of-hospital,
PO Box 8012
these steps apply:
Greenstone

When sending claims, please make sure the following 1616
details are clear:
– Your membership number USI N G T HE MOBI L E A PP
– The service date
You can take a picture or scan your claim using the mobile
– Your doctor’s details and practice number
App. For step by step instructions on how to do this refer
– The amount charged to page 18 of this Benefit Guide. This functionality is only
– The relevant consultation, procedure or NAPPI codes available to Plans A, B and C.
and diagnostic (ICD-10) codes
– The name and birth date of the dependant for whom CL A I M DROP- OFF BOXES
the service performed
You can drop your claims in the Discovery Health claims
– If paid, attach your receipt or make sure the claim
drop-off boxes situated around the country, in convenient
says ‘paid’.
places such as pharmacies and medical practices, as well

Check with your healthcare providers if they have sent your as most Virgin Active or Planet Fitness gyms.
claims to us to avoid duplicates.
The Malcor Medical Aid Scheme claims boxes will remain
Send your claims within four months of the date of service,
in place at the various employer groups and you may continue
otherwise they will be treated as expired and will
to use these.
not be paid.

Always remember to keep copies of your claims
for your records.
CL A I M QUERI ES

To see the status of your claim, you can go to For any claim queries, call the Scheme on 0860 100 698
www.malcormedicalaid.co.za or email [email protected]. Note this email
address should not be used to submit your claims.
IM P OR T A N T NO TES
1. Healthcare practices must be appropriately registered with
CHA N GI NG PL ANS
the Board of Healthcare Funders (BHF) and must have a Members have freedom of choice between the four plans.
valid practice number in order for claims to be considered. Members may change plans with effect from January each
year. Members may request a plan change at the end of
the year when the year-end communication is sent out
by the Scheme.
45
GENERAL EXCLUSIONS
1 . P R E S CR I BED MINIMUM 2.5.3. its cost-effectiveness
BE N E F I T S 2.5.4. its affordability
2.5.5. its value relative to existing services

The Scheme shall pay in full, without any co-payment or
or supplies;
use of deductibles, the diagnosis, treatment and care costs
of the Prescribed Minimum Benefits as per Regulation 8 of 2.5.6. its safety.
the Act. Furthermore, where a protocol or formulary drug
2.6. New technology is defined as any clinical intervention
preferred by the Scheme has been ineffective or would
of a novel nature as well as those with which the
cause harm to a beneficiary, the Scheme will fund the
Scheme has not had previous experience.
cost of the appropriate substitution treatment without a
penalty to the beneficiary as required by Regulation 15H 2.7. The Scheme reserves the right to impose and apply
and 15I of the Act. exclusions and limits to the benefits that will be
paid for medicines/procedures/interventions which
2 . L I M I T A T I O NS AND have been accepted into the practice of clinical
R E S T R I CT IO NS O F B ENEF ITS medicine through a process of health technology.
2.8. Benefits in respect of the cost of emergency

Unless otherwise decided by the Trustees, the following
medical treatment whilst abroad are covered
limitations and restrictions will be applied to the
at the applicable Malcor Rate using the then
application of benefits:
prevailing exchange rate into RSA currency.
2.1. The Scheme may require a second opinion in respect
of proposed treatment or medication which may 3 . BENEFI T S EXCL UDED
result in a claim for benefits and for that purpose
the relevant beneficiary shall consult a dental General exclusions mentioned in this paragraph are
or medical practitioner nominated by the Scheme not affected by medicines or treatment approved and
and at the cost of the Scheme. authorised in terms of any Scheme approved managed
healthcare programme. Expenses incurred in connection
2.2. In cases where a specialist is consulted without
with any of the following will not be paid by the Scheme:
the recommendation of a general practitioner,
the benefit allowed by the Scheme may, at its 3.1. all costs that exceed the maximum allowed for
discretion, be limited to the amount that would benefits to which the member is entitled in terms
have been paid to the general practitioner for the of the rules
same service.
3.2. all costs for operations, medicines, and procedures
2.3. Unless otherwise decided by the Scheme, benefits for cosmetic purposes or for non-clinical reasons
in respect of medicines obtained on a prescription
3.3. if, in the opinion of the medical advisor, the
are limited to one month’s supply (or to the nearest
healthcare service in respect of which a claim
broken pack) for every such prescription
is made is not appropriate and necessary for any
or repeat thereof.
aspect of the management of the medical condition
2.4. If the Scheme does not have funding guidelines
3.4. all costs for treatment, if the efficacy and safety
or protocols in respect of benefits for services
of such treatment cannot be proved
and supplies referred to in Annexure B, beneficiaries
will only qualify for benefits in respect of those 3.5. purchase of the following:
services and supplies if the Scheme or its managed
homemade remedies; and
healthcare organisation acknowledges them
alternative medicines.
as medically necessary, and then subject to such
conditions as the Scheme or its managed 3.6. beneficiaries admitted during the course
healthcare organisation may impose. of a financial year are entitled to the benefits
set out in the relevant benefit option chosen,
2.5. The Scheme reserves the right not to pay for any
with the maximum benefits being adjusted in
new technology. Coverage of new technology will
proportion to the period of membership calculated
be assessed by the Scheme with due consideration
from the date of admission to the end of the
given to:
particular financial year
2.5.1. medical necessity
2.5.2. clinical evidence of its use in clinical

medicine including outcome studies
46
3.7. all costs for services rendered by: 3.30. dental procedures or devices which are not
regarded by the relevant managed healthcare
3.7.1. persons not registered with a recognised
programme as clinically essential or clinically
professional body constituted in terms
desirable; and costs for
of an Act of Parliament; or
3.30.1. anaesthetics in respect of dental services,
3.7.2. any institution, nursing home or similar
except where approved by the Scheme’s
institution, not registered in terms of the
dental advisor
applicable law
3.30.2. general anaesthetics, conscious analog-
3.8. abdominoplasties (including the repair
sedation and hospitalisation for dental work
of divarication of the abdominal muscles)
except in the case of patients under the
3.9. accommodation and services provided in a geriatric age of 12 years and bony impaction of third
hospital, old age home, frail care facility, or the like molars.
3.10. acupuncture 3.31. labial frenectomies in respect of beneficiaries

under the age of 12 years
3.11. anabolic steroids, immunostimulants (except for
immunoglobulin and growth hormones, which 3.32. orthodontic treatment over the age of 21 years
are subject to preauthorisation by the relevant
3.33. use of high impact acrylic and precious metal
managed healthcare programme)
in dentures or the cost of precious metal as an
3.12. ante and postnatal exercises alternative to semi-precious or non-precious metal
in dental prosthesis
3.13. appointments which a beneficiary fails to keep
3.34. osseo-integrated tooth implants in a hospital
3.14. appliances, devices and procedures not
setting, (including related sinus lift or bone graft
scientifically proven or appropriate
procedures) except where approved by the
3.15. aromatherapy Scheme’s dental advisor
3.16. autopsies 3.35. diagnostic kits, agents and appliances except

for diabetic accessories
3.17. ayurvedics
3.36. sleep therapy
3.18. leg rests, back rests and chair sets
3.37. treatment for erectile dysfunction and loss
3.19. bandages and dressings (except medicated
of libido
dressings subject to authorisation by the relevant
managed healthcare programme) 3.38. tonics, evening primrose oil, fish liver oils,
nutritional supplements, minerals and food and
3.20. beds and mattresses
nutritional supplements including baby food
3.21. bilateral gynaecomastia in beneficiaries under and special milk preparations unless usage is
the age of 18 years (in beneficiaries over 18 years specifically recommended by a Scheme approved
Scheme protocols will apply) managed healthcare programme of which the
3.22. blepharoplasties beneficiary is a member or allowed by Scheme
(benefit is confined to single and multivitamins
3.23. breast augmentation and iron prescribed by a doctor and vitamins
3.24. breast reconstruction (unless necessitated by for members receiving authorised HIV and /or
preauthorised surgical mastectomy, traumatic Oncology treatment and/or vitamins for women
mastectomy or congenital unilateral absence that are pregnant)
of a breast which is subject to Scheme protocols) 3.39. gender reassignment treatment
3.25. breast reductions 3.40. genioplasties
3.26. nasal surgery done by a plastic surgeon, nasal 3.41. oral appliances and the ligation of temporal artery
cautery (procedure code 1069) if done with other and its branches for the treatment of headaches
intranasal procedures
3.42. hirsutism
3.27. external cardiac assistive devices
3.43. holidays for recuperative purposes
3.28. coloured or cosmetic effect contact lenses, and
contact lens accessories and contact lens solutions 3.44. humidifiers
3.29. cosmetic preparations, emollients, moisturisers, 3.45. hyperbaric oxygen therapy

medicated or otherwise, soaps, scrubs and 3.46. infertility treatment
other cleansers, sunscreen and sun tanning
3.47. ionisers and air purifiers
preparations, medicated shampoos and
conditioners, not including coal tar products
and the treatment of lice infestation, scabies
and other microbial infections
47
3.48. iridology
3.49. surrogate pregnancy
3.50. k
eloid surgery, except for burns and functional
impairment deemed by the Scheme to be
medically necessary
3.51. laxatives
3.52. medication in connection with substance abuse

treatment unless specifically authorised by the
relevant managed healthcare programme
3.53. medicines not included in a prescription from

a medical practitioner or other healthcare
professional who is legally entitled to prescribe
such medicines
3.54. medicine not approved by the Medicine Control

Council or other statutory body empowered
to approve/register medicine
RI, CT scans and PET scans ordered

3.55. M
by a non-accredited general practitioner
3.56. obesity treatment
3.57. orthopaedic shoes and boots
3.58. osteopathy
3.59. otoplasties
3.60. pain relieving machines, e.g. TENS, APS machines
3.61. refractive eye surgery/excimer laser treatment

except on Plan A
3.62. reflexology
3.63. revision of scars
3.64. rhinoplasties
3.65. smoking cessation treatment and

anti-smoking preparations
3.66. stethoscopes
3.67. sphygmomanometers/blood pressure monitors
3.68. sunglasses
3.69. travelling expenses
3.70. uvulopalatalpharyngoplasty (UPPP) and laser –

assisted uvuloplatoplasty (LAUP)
3.71. pharmacy service and facility fees
3.72. services rendered during any waiting periods

that are imposed on a member or any dependant
joining the Scheme
3.73. all claims where ICD10 codes are missing on the

related account or are, invalid or incomplete
3.74. Rhizotomy and/or facet joint injections of the

spine, except where approved by the Scheme’s
medical advisor
48
49 49
CONTACT US
HOW T O CO NTACT THE ABBREVI A T I ONS A N D
SCHE M E ( P L AN A, B AND C) DEFI NI T I ON S
For any queries, call the Scheme on 0860 100 698 or visit The following is a list of abbreviations used in the booklet:
the Scheme’s website www.malcormedicalaid.co.za.
Visit the Discovery Store at the following places:
TERM WHAT
Sandton The MalcorMedical
Scheme or Malcor
Aid Scheme
1 Discovery Place, Sandton
Telephone: 011 529 4483 The Board of Trustees
Trustees
Opening hours: of the Scheme
Monday – Friday: 08:00 – 17:00
Hospitals, Private Nursing
Saturday: 08:00 – 15:00 Hospital/s
Homes, and Day Clinics
Sunday: Closed
Public holidays: Closed Chronic Disease List
– A legislated list of 27
Pretoria CDL chronic diseases forming
part of the Prescribed
Menlyn Maine Central Square, Shop 35, Corner of Dallas Minimum Benefits
Ave and Aramist Ave, Menlyn
MMAP® Maximum Medical Aid Price
Telephone: 012 676 4221 | 012 676 4222
Opening hours:
The rate at which the
Monday – Saturday: 09:00 – 18:00 Scheme Rate / Tariff
Scheme reimburses claims
Sunday and public holidays: 09:00 – 14:00
The Malcor Medication
Rate is MMAP® reference
Cape Town
pricing. In the absence of
Sable Park, Bridgeways Precinct, Century City 7446 MMAP®, the single exit
Malcor Medication Rate
Telephone: 021 527 1262 price plus the appropriate
Opening hours: professional fee as
Monday – Friday: 08:00 – 17:00 determined by the Scheme,
Saturdays: 08:00 – 13:00 will be applied
Public Holidays: 08:00 – 13:00
PMB Prescribed Minimum Benefit
Sundays: Closed
The Point shopping centre,

76 Regent Road, Sea Point
Telephone: 021 527 1073
Opening hours:
Saturday and Sundays : 09:00 – 14:00
Public holidays: Closed
Durban
Shop 7, 16 Chartwell Drive,
Granada Square, Umhlanga
Telephone: 031 576 7308 | 031 576 7276
Opening hours:
Saturday: 09:00 – 14:00
Sunday and public holidays: 09:00 – 14:00
How to contact enablemed

(plan D)
24 hour preauthorisations: 0860 002 402
Dentistry: 0860 104 925
24 hour medical emergency: 0861 086 911
50
5151
THE COUNCIL FOR
MEDICAL
SCHEMES
FO R Y OU , F O R HEALTH, F O R L I FE.
What? Who? How?
The Council for Medical Schemes The CMS governs the medical Complaints against your medical
(CMS) is a statutory body established schemes industry and therefore your scheme can be submitted by letter,
in terms of the Medical Schemes Act complaint should be related to your fax, email or in person at our Offices
131 of 1998 to provide regulatory medical scheme. Any beneficiary or from Mondays to Fridays (08:00-
oversight to the medical scheme any person who is aggrieved with 17:00).The complaint form is available
industry. The CMS’ vision is to the conduct of a medical scheme can from www.medicalschemes.com
promote vibrant and affordable submit a complaint.
Your complaints should be in writing,
healthcare cover for all.
It is however very important to note detailing the following: Full names,
Why? that a prospective complainant membership number, benefit option,
It is our mission to regulate the should always first seek to resolve contact details and full details of
medical schemes industry complaints through the complaints the complaint with any documents
in a fair and transparent manner. mechanisms in place at the or information that substantiate
respective medical scheme before the complaint.

We protect the public, informing approaching the CMS for assistance.
them about their rights, The CMS’ Customer Care Centre
obligations and other matters, You can contact your scheme by and Complaints Adjudication Unit
in respect of medical schemes; phone or if not satisfied with the also provides telephonic advice
outcome, in writing to the Principal and personal consultations,

We ensure that complaints Officer of the scheme, giving her/him when necessary.
raised by members of the public full details of your complaint. If you
are handled appropriately Our aim is to provide a transparent,
are not satisfied with the response
and speedily; equitable, accessible, expeditious,
from your Principal Officer, you can
as well as a reasonable and

W e ensure that all entities ask the matter to be referred to the
procedurally fair dispute resolution
conducting the business Disputes Committee of your scheme.
process. The CMS will send a written
of medical schemes, and other If you are not satisfied with the acknowledgement of a complaint
regulated entities, comply with decision of the Disputes Committee, within three working days of its
the Medical Schemes Act; you can appeal against the decision receipt, providing the name, reference

We ensure the improved within 3 months of the date of the number and contact details of the
management and governance decision to the CMS. The appeal person who will be dealing with
of medical schemes; should be in the form of an affidavit a complaint.
directed to the CMS. We are for you.

We advise the Minister of Health In terms of Section 47 of the Medical
of appropriate regulatory and When? Schemes Act 131 of 1998, a written
policy interventions that will assist When you need us! The CMS complaint received in relation to any
in attaining national health policy protects and informs the public matter provided for in this Act will be
objectives; and about their medical scheme rights referred to the medical scheme. The
and obligations, ensuring that medical scheme is obliged to provide

We collaborate with other entities in
complaints raised are handled a written response to the CMS within
executing our regulatory mandate. 30 days.
appropriately and speedily.
We are for health. The CMS shall within four days of
receiving the complaint from the
scheme or its administrator, analyse
the complaint and refer the complaint
to the relevant medical scheme
for comments.
52
Y OU CA N CO NTACT THE CMS
Customer Care Centre

0861 123 267
0861 123 CMS
Reception
Tel: 012 431 0500
Fax: 012 430 7644
General enquiries
Email enquiries: [email protected]
www.medicalschemes.co.za
Complaints
Fax: (086) 673 2466
Email: [email protected]
Postal address
Private Bag X34
Hatfield
0028
Physical address
Block A, Eco Glades 2 Office Park
420 Witch-Hazel Avenue
Eco Park, Centurion
0157
53 53
NOTES
54
Call Centre 0860 100 698 | [email protected] | www.malcormedicalaid.co.za
Malcor Medical Aid Scheme, registration number 1547. Administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07,
an authorised financial services provider.
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Malcor Medical Aid Scheme | 2024

04 Who can join the Malcor Medical Aid Scheme

04 Who may join as your dependant

05 General guidelines on the Malcor Medical Aid

09 Helping you get the most out of your cover

11 Patient Management Programme and Chronic

27 Cover for emergencies

28 Advanced technology and convenience

29 Your health plan at your fingertips

31 The Malcor Medical Aid Scheme benefit tables

41 The Malcor Medical Aid Scheme benefit tables

45 Reporting fraud or malpractice

52 The Council for Medical Schemes

Malcor Medical Aid Scheme provides excellent healthcare benefits

ABOUT THIS BENEFIT GUIDE

This brochure gives you a brief outline of the benefits

Detailed benefit documents may be obtained from

Membership is available to all employees of approved

 our children can be added as dependants on your health

You have 30 days in which to register a new spouse.

You have 60 days in which to register a newborn baby.

 embers and their dependants are entitled to benefits from

FO U R I N N O VATIVE CO VER PLA N S

Step-down and rehabilitation facilities in the

Specialised dentistry in hospital

Registered nursing services

Ear, nose and throat procedures Suction curettage

Anorectal procedures (treatment of haemorrhoids,

M AK E THE F ULL CO VE R CHOI CE

We offer members the choice to be covered in full for hospitalisation, specialists

We will refer to the networks and payment arrangements throughout the

M E M B E R S O N THE MALCO R MEDI CA L AI D

CO MPR EHENS IVE MAT ERN I T Y AND POST - BI RT H BENEFI T S

Benefits during Pregnancy Post-birth Benefits

CO VER F O R G O ING T O CA SUAL T Y

A D V A N CE D ILLNES S B ENEF IT Chronic Disease List (CDL) conditions (all plans)

C O V E R F OR CHR O NIC MED ICINES Addison’s Disease Dysrythmia

Your Diabetes Cardiometabolic Care Programme is based

If you visit a doctor who is not part of the Premier Plus GP

The devices used with the CGM sensors for qualifying

All members with a history of depression have access to

Additional psychotherapy sessions with your psychologist

Mental Health Relapse Prevention Programme

Members enrolled on the Relapse Prevention Programme,

The relapse prevention basket of care includes:

Two psychiatrist visits

Should the care coordinator identify that the member is

To access this benefit, your treating specialist must identify

Admissions to Hospital at Home are subject to preauthorisation

While receiving care at home, members have 24/7 access

All treating physicians will be made aware of the programme.

Treating providers, in conjunction with Discovery Health’s

All services offered as part of the Hospital at Home

This unlocks risk-based funding for approved devices and

Patient specific eligibility criteria applies for use of certain

Qualifying members will have funding for a defined list of

The applicable registered remote monitoring devices will be

STEP 01 STEP 03 STEP 05

The patient confirms that

our children can be added as dependants on your health

You have 30 days in which to register a new spouse.

You have 60 days in which to register a newborn baby.

embers and their dependants are entitled to benefits from

Step-down and rehabilitation facilities in the

Ear, nose and throat procedures Suction curettage

Anorectal procedures (treatment of haemorrhoids,

C O V E R F OR CHR O NIC MED ICINES Addison’s Disease Dysrythmia

Additional psychotherapy sessions with your psychologist

The patient confirms that

he doctor completes the Hospital at Home

– Discharge planning services

The patient receives daily visits from their treating

As part of their treatment plan, the patient also

A discretionary benefit which a medical aid scheme

Please download the international

2.5.5. its value relative to existing services