| PATHFINDER TERRACE PLAN 2008 | ||
| Major medical expenses | ||
| SERVICE | BENEFIT | LIMIT |
| Hospitalisation* General ward accomodation, Surgical operations and procedures, Theatre fees, Intensive care and High care wards, Visits and consultations by a General Practitioner whilst hospitalised, X-rays and pathology, Physiotherapy, Ultrasound scans (other than for pregnancy), Blood Transfusions, Medicine diagnosed in hospital, professional fees i.e. Surgeon and Anesthetist, incl. visits and consultations by a Specialist | Agreed tariff to a maximum 300% of NHRPL (Private rate) | Unlimited in any Private Hospital |
| Medicine to take home | 100% PNT/ Cost | Limited to painkillers and antobiotics and a five (5) day supply |
| ANNUAL SUB LIMITS | ||
| Ante Natal Classes* | 100% Cost | R600 per family per annum |
| Amniocintecis* for female patients over the age of 35 | Agreed tariff to a maximum 300% of NHRPL (Private rate) | R5 000 per pregnancy |
| Ultrasound scans* (Pregnancy related) | Agreed tariff to a maximum 300% of NHRPL (Private rate) | Limited to 6 scans per pregnancy. Including 3D scans |
| Confinements* (Normal/Vaginal Delivery/Ceaserean Section) | Agreed tariff to a maximum 300% of NHRPL (Private rate) | Unlimited |
| Neonatal Intensive Care* | Agreed tariff to a maximum 300% of NHRPL (Private rate) | Unlimited |
| Phychiatric Disorders* | Agreed tariff to a maximum 300% of NHRPL | 21 days in Hospital per beneficiary per annum |
| Oncology* and all related thereto | Agreed tariff to a maximum 300% of NHRPL | Unlimited |
| Cochlear implants* and all related thereto | Agreed tariff to a maximum 300% of NHRPL | R100 000 per family per annum |
| Organ Transplants*. Includes the transportation of the organ, surgically related procedures and services as well as immunosuppresant drugs | Agreed tariff to a maximum 300% of NHRPL | R300 000 per family per annum |
| Organ Transplants, Harvesting of organs* | Agreed tariff to a maximum 300% of NHRPL | R15 000 per beneficiary per annum from a cadevar donar. R50 000 per beneficiary per annum from living donar. No benefit for travelling and accomodation expenses |
| Internal prosthesis* incl. 1. Vascular prosthesis (mitral valves, pacemakers and related functional appliances) and health essential prosthesis which replaces a part or performs an essential function of the body |
Agreed tariff to a maximum 300% of NHRPL | R60 000 per family per annum |
| 2. Non-functional prosthesis* implanted during reconstructive surgery and dental implants | Agreed tariff to a maximum 300% of NHRPL | R20 000 per family per annum |
| Specialised Dentistry* | Agreed tariff to a maximum 300% of NHRPL | Unlimited subject to essential list of benefits |
| AUXILLIARY SERVICE | ||
| External Medical appliances* Incl. the following if prescribed by a registered medical practitioner and obtained from a supplier who is registered with the Board of Healthcare Funders (BHF): Artificial eyes, Artificial larynx, Artificial limbs, Back, leg, arm and neck supports, crutches, Disposable bladder and intestinal excretion bags, Elastic stockings for control of varicose veins, External breast prosthesis after mastectomy, Glucometers, Home oxygen, Nebulisers, Orthopaedic footwear, Sleep apnoea monitors, Speech and hearing aids, Sphygnomanometers, Syringes and needles for the treatment of a chronic illness. | Agreed tariff to a maximum 300% of NHRPL | R25 000 per family per annum with the
following sub-limits: Nebuliser R1 500 Glucometer R1 500 Wheelchairs R15 000 Hearing Aids R15 000 CPAP R7 000 Insulin Pump R14 000 Orthopeadic items to R5 000 |
| HIV/AIDS treatment* | 100% PNT/ Costs | Unlimited subject to registration on the Aganang HIV/AIDS Management programme All benefits subject to pre-authorisation |
| Mammograms* and pap smears* and Prostate Specific Antigen* (PSA) | Agreed tariff to a maximum 300% of NHRPL | R15 000 per family per annum |
| Home Nursing* | Agreed tariff to a maximum 300% of NHRPL | R20 000 per family per annum |
| Hospice care* | Agreed tariff to a maximum 300% of NHRPL | R20 000 per family per annum |
| MRI and CT scans* | Agreed tariff to a maximum 300% of NHRPL | R20 000 per family per annum |
| Haemodiasis* | Agreed tariff to a maximum 300% of NHRPL | R15 000 per family per annum |
| Emergency services* | 100% Cost | Unlimited at preferred provider Netcare 911 |
| International travel benefit* | 100% Cost | R1 000 000 per family per annum at preferred provider Netcare 911, subject to authorisation by Netcare |
| * Subject to pre-authorisation | ||
| Day-to-day benefits | ||
| General Practitioners | Agreed tariff to a maximum 300% of NHRPL | R10 000 per principal member R2 500 per adult dependant R1 500 per child dependant to a maximum of R16 500 per family per annum To view benefits per family size please refer to page 11 Optometry and Dentistry subject to Pathfinder Network provider and essential list of benefits Pharmacy advised therapy limited to R250 per beneficiary per month |
| Out of Network GP visits | Agreed tariff to a maximum 300% of NHRPL | |
| Specialists | Agreed tariff to a maximum 300% of NHRPL | |
| Optometry | 100% PNT | |
| Basic Dentistry | 100% PNT | |
| Specialised Dentistry | 100% PNT | |
| Acute Medication | 100% PNT | |
| Pharmacy Advised Therapy | 100% PNT | |
| Procedures performed in Doctor’s and Specialist rooms | Agreed tariff to a maximum 300% of NHRPL | |
| Alternative Healthcare services: Biokenetics, Chiropodists, Chiropractors, Dieticians, Homeopaths, Naturopaths, Occupational Therapists, Osteopaths, Podiatrists | Agreed tariff to a maximum 300% of NHRPL | |
| Radiology and Pathology (excl. MRI and CT scans) | 100% PNT | |
| Physiotherapy | Agreed tariff to a maximum 300% of NHRPL | |
| Speech therapy and Audiology | Agreed tariff to a maximum 300% of NHRPL | |
| Psychology | Agreed tariff to a maximum 300% of NHRPL | |
| CHRONIC MEDICATION BENEFIT | ||
| Chronic Medicine | 100% PNT | 62 Conditions covered limited to R15 000 per beneficiary and R30 000 per family subject to medicine formulary. PMB conditions unlimited |
| PNT = PATHFINDER Negotiated Tariff | ||
To make the products and benefits easier to understand, the language in this brochure has been simplified and some of the detail left out. The complete rules of the scheme apply. A complete set of rules is available from PATHFINDER Medical Scheme on request.
FREE Healthwise Handbook for Terrace members
As one of our valued
PATHFINDER members, we provide you with a free copy upon joining
the Scheme.
The Healthwise Handbook offers comprehensive, on-the-spot medical advice in a format
that’s easy to read and understand
| « previous | [ index ] | next » |