Insured Out-of-Hospital benefits 

Out-of-hospital healthcare services will be covered from the insured out-of-hospital benefits, healthcare services covered from this benefit are general practioners visits, acute and chronic medicine, pathology, radiology, conservative dentistry and optometry.

Remedi Standard Option Medical Scheme uses a preferred provider network

A list of these service providers can be obtained by using the maps tool available on the Remedi Medical Scheme website at  www.yourremedi.co.za or by calling 0860 116 116.

You must choose the doctor best suited to your needs (taking into account accessibility) at the beginning of the year and then remain with that specific doctor. You are entitled to recommend the appointment of a doctor of your choice where there is no contracted. Remedi Standard Option GP network doctor available. Such an appointment will be subject to sufficient demand for the service.

Medicine is available from a fixed formulary

Acute medication is covered from out-of-hospital limits when dispensed by a GP in the Remedi Standard GP network or where the script is obtained from the network pharmacies (Dischem, Clicks or Independent pharmacies). Medicine prescribed by a non-chosen GP will be covered from the out-of-area benefit.The acute medication formulary must be applied.

Approved chronic medication for the 26 chronic conditions on the Chronic Disease List (CDL) will be funded from out-of-hospital risk unlimited up to 100% of the network rate.

Emergency, out-of-area and after-hours visits

Members are entitled to 3 out-of-area visits per family per year up to a limit of R1 425 for practices that are not part of the Remedi Standard Option network, these include pharmacies, radiology, general practitioners and pathology. The out-of-area benefit is for providers that are not contracted with Remedi Medical Scheme, any facility fee charged will be for the member’s own account.

Pathology and radiology

These are covered up to 100% of the network rate, the pathology and radiology formulary is applicable.

Optical benefits

Optical benefits are provided through PPN. Once every 24 months every registered beneficiary is entitled to one pair of clear, standard bi-focal lenses and a standard frame. Contact lenses may also be provided in the place of a pair of glasses. Eye tests may be done every year.

Dentistry

This Option provides basic dental benefits, excluding dentures and specialised dentistry, provided that you obtain services from a dentist on the Remedi Standard Option Network which is managed by the Dental Risk Company. You have access to consultations, extractions and fillings (includes a maximum of three resin fillings per tooth).

Specialists

Treatment is covered from the Insured out-of-hospital benefit. 

Hospital Benefits

In-hospital benefits are subject to an overall annual limit for the use of private healthcare facilities.

The Option provides cover for Prescribed Minimum Benefits (PMBs), as set out in the Medical Schemes Act. The diagnosis and treatment of PMBs, as set out in the Medical Schemes Act and Regulations, are unlimited if these services are obtained in a public hospital.

Medical expenses on the Standard option are covered at 100% of the Scheme Rate (unless otherwise indicated).

Prescribed Minimum Benefits Chronic Disease List

Remedi Medical Scheme will provide cover to members suffering from one or more of the chronic conditions listed on the PMB Chronic Disease List. The benefit includes cover for the diagnosis, medical management and treatment of these CDL conditions.

Benefits for the diagnosis and treatment of Prescribed Minimum Benefits, as set out in the Medical Schemes Act and Regulations, are unlimited if these services are obtained in a public hospital.

Medical expenses on the Classic option are covered at 100% of the Scheme Rate, unless otherwise indicated.

Benefits for the diagnosis, treatment and care of Prescribed Minimum Benefits, as set out in the Medical Schemes Act and Regulations, are unlimited if these services are obtained in a public hospital.

The Comprehensive option is the only option that provides a Personal Medical Savings Account (PMSA) to cover certain out-of-hospital expenses once the Insured Out-of-Hospital limits have been reached.

Medical expenses on the Comprehensive option are covered at 100% of Scheme Rate, unless otherwise indicated.

Personal Medical Savings Account (PMSA)

The PMSA is a savings account in the member’s own name and provides an annual benefit amount to members and their dependants. This is only applicable on the Comprehensive option. The compulsory savings level, as a percentage of the total contribution payable, is set at 10%.

The PMSA provides an annual benefit amount to cover certain out-of-hospital expenses. Claims for these expenses will be settled at cost until the annual benefit amount available has been depleted. In addition, for claims that are paid from the Insured Out-of-Hospital benefit or from the Hospital benefit, any shortfall between the cost of the treatment and the Scheme Rate covered by Remedi, will be paid from the member’s available PMSA, unless the member indicates otherwise.

Any co-payment or deductible relating to Prescribed Minimum Benefits may not be paid from the PMSA.

Any unused funds in members’ PMSAs as at 31 December will be carried over for future use, provided the member remains registered on the Comprehensive option. These funds will be credited to members’ PMSA’s in May of the following year, when all outstanding claims for the previous year have been settled, plus any interest earned, as declared by Remedi.

However, should the member at the start of a new benefit year choose an Option that does not make provision for a PMSA, any credit balances from previous years will be paid out to the member after the required claiming period has elapsed.

When a member resigns from Remedi, all funds in the PMSA will be retained for a period of four to six months to allow for the submission and processing of all valid outstanding claims. After this period, surplus funds will either be paid out to the former member or transferred to his new scheme, subject to the stipulations of the Medical Schemes Act (1998).