DAY-TO-DAY BENEFIT OPTION
DAY-TO-DAY BENEFIT OPTION
To find your nearest provider, download the Unity Health mobile app from Google Play Store or the App Store, refer to the Stratum Benefits Health Insurance App Download Guide or contact us on 011 781 4488 for assistance.
Unity Health has contracted with the following pharmacies:
OPEN ENROLMENT, COMMUNITY RATING AND CROSS-SUBSIDISATION
Health insurance policies are subject to open enrolment, community rating and cross-subsidisation. This means that cover is available to everyone, there’s no discrimination based on factors like race and gender, and all premiums received are paid into one risk pool from where claims are paid.
This policy isn’t a medical aid plan, doesn’t provide similar cover as that of a medical aid, and can’t be substituted for a medical aid membership.
PREMIUMS FOR EMPLOYER GROUPS
Employer groups are covered if 2 or more employees join through their employer.
Ask your employer if your spouse and dependants may also join.
Premiums for employer groups are determined by factors like the employer group’s size, average age and if cover is compulsory or voluntary.
Joining as a family? This health insurance benefit option covers you, your spouse, and any child dependant as long as you’re their parent or legal guardian.
If you’re 56 or older and apply for cover on this option, you’ll pay a higher premium. If you can prove that you’ve been on medical aid or primary healthcare insurance cover for 15 or more consecutive years from the age of 35 onward, a 55 or younger premium will apply.
Children who are 20 years or younger pay child dependant premiums.
Children who are 21 years or older pay adult dependant premiums if they’re full-time students, or if they’re financially dependent on you and proof is submitted every year.
What proof can be submitted? Proof from the educational facility, or stamped copies of your child’s bank account statements of the past 3 months together with an affidavit.
GP CONSULTATIONS AND MEDICAL PROCEDURES
You can visit any network GP as many times as needed.
Basic medical and surgical procedures can be performed in the rooms, like stitching of a wound or applying a cast to a broken arm, as long as it’s on the approved list of tariff codes.
Pre-authorisation is required for the 10th network GP, nurse or virtual GP consultation and for every consultation thereafter.
The nurse at your nearest Alpha Pharm, Clicks, Dis-Chem, Local Choice, Medicare or Pick n Pay pharmacy clinic can treat minor ailments. In many practices, the nurse can prescribe up to schedule 2 medication.
You can see the nurse as many times as needed, and prescribed medication has no rand amount limit if it’s on the approved formulary.
Pre-authorisation is required for the 10th nurse, network GP or virtual GP consultation and for every consultation thereafter.
VIRTUAL GP CONSULTATIONS
Virtual GP consultations can be arranged during one of your nurse consultations. The nurse will determine if it’s necessary to consult with a GP and help set up a virtual consultation through a video conference link.
You can have as many virtual GP consultations as needed through approved pharmacy clinics only, namely Alpha Pharm, Dis-Chem and Medicare.
Pre-authorisation is required for the 10th virtual GP, nurse or GP consultation and for every consultation thereafter.
PRE-AUTHORISATION FOR CONSULTATIONS
Remember… you must get pre-authorisation for the 10th visit with either your network GP, nurse or for a virtual GP consultation, and for every consultation thereafter.
Call us on 011 781 4488 for authorisation before you see the doctor or nurse.
When medical treatment provided by your network GP fails and you need to see a specialist, your network GP must refer you and you must get pre-authorisation before you see the specialist.
You’ll be refunded for the cost of a consultation up to R 1 350 per visit to a maximum of R 2 800 per family per year.
If the specialist refers you for blood tests or x-rays that are on the list of approved codes, it will be covered from the BLOOD TESTS AND X-RAYS BENEFIT.
The ACUTE MEDICATION BENEFIT will cover medication that the specialist prescribes if it’s on the approved formulary.
If it’s not on the formulary, it will be covered from the SPECIALIST CONSULTATIONS BENEFIT up to the available benefit limit.
Hey, soon-to-be-mommy! Visit any gynaecologist of your choice for your check-ups. You’ll be refunded for 2 visits and
2 ultrasound scans limited to R 3 425 per family per year.
Call us on 011 781 4488 for pre-authorisation before you see the gynaecologist.
DISPENSING NETWORK GP
Have a chest infection or flu? Your network GP can provide medication for every-day illnesses and will give you the medication that you need.
Acute medication that you get in the rooms has no rand amount limit.
NON-DISPENSING NETWORK GP
If your network GP doesn’t provide medication in the rooms, you’ll be given a prescription.
Go to any Mediscor pharmacy, like Alpha Pharm, Clicks, Dis-Chem, Local Choice, Medicare or Pick n Pay to collect your medication.
Acute medication that your non-dispensing network GP prescribes has no rand amount limit.
APPROVED MEDICINE FORMULARY
The medication that your network GP, the nurse or specialist prescribes will be covered if it’s on the approved Mediscor formulary.
A formulary is an approved list of medicines that Unity Health has agreed to cover in full. Visit Mediscor’s website at
www.mediscor.co.za to see which acute medication is covered.
You’re covered for chronic medication that your network GP prescribes from the Mediscor formulary for the following chronic conditions or diseases:
|• Addison’s disease;||• asthma;|
|• bi-polar mood disorder;||• bronchiectasis;|
|• cardiac failure;||• cardiomyopathy disease;|
|• chronic renal disease;||• coronary artery disease;|
|• Crohn’s disease;||• chronic obstructive|
|• diabetes insipidus;||• pulmonary disorder;|
|• dysrhythmia;||• diabetes mellitus type 1 & 2;|
|• epilepsy;||• glaucoma;|
|• HIV/AIDS;||• haemophilia;|
|• hypertension;||• hyperlipidaemia;|
|• hypothyroidism;||• multiple sclerosis;|
|• Parkinson’s disease;||• rheumatoid arthritis;|
|• schizophrenia;||• systemic lupus erythematosus;|
|• tuberculosis; and||• ulcerative colitis.|
Your network GP will help to get you registered on the Chronic Medication Programme with Mediscor. To see which chronic medication is covered, visit Mediscor’s website at www.mediscor.co.za.
Once you’re registered to receive chronic medication, delivery of your medication will be arranged with you.
If you prefer, you can collect your chronic medication from any Mediscor pharmacy, like Alpha Pharm, Clicks, Dis-Chem,
Local Choice, Medicare or Pick n Pay.
BLOODS, X-RAYS, DENTAL AND EYE CARE COVER
BLOOD TESTS AND X-RAYS
When you need a blood test, like a cholesterol or glucose test, your network GP will refer you to the nearest Ampath, Lancet or PathCare pathology facility.
You’ll also be covered for a Covid-19 PCR screening test if your network GP refers you, pre-authorisation is obtained and if you test positive for Covid-19.
Limited to 1 positive test per person per year.
Basic black-and-white x-rays, like a chest x-ray, are covered when your network GP refers you to a radiology facility during one of your visits.
There is no rand amount limit on blood tests and x-rays, as long as it’s on the approved list of codes.
Specialised radiology, like MRI and CT scans, aren’t covered.
You can go to any dentist for basic dental treatment, like extractions and fillings.
For all dental fillings, you must get pre-authorisation.
When you need emergency dental treatment, like draining an abscess or root canal treatment, or when you’ve lost a tooth because of an accident, you’re covered.
Dental procedures are covered according to an approved list of codes, limited to R 1 350 per person per event.
If you prefer to use a recommended dentist on the Unity Health dentist network, call us on 011 781 4488 and we’ll help you find the nearest dentist. No matter which dentist you use, dental procedures will be covered according to an approved list of codes and agreed rates.
You can visit your nearest PPN optometrist for:
- 1 eye test per person every 2 years;
- 1 standard frame to the value of R 254 per person every 2 years; and
- 1 pair of clear, standard spectacle lenses per person every 2 years.
Eye care benefits are provided through PPN, the largest optical network in the country.
To find your nearest provider, visit www.ppn.co.za or call us on 011 781-4488.
Optional extras, like tinting or scratch resistant coatings, aren’t covered.
Alpha Pharm, Clicks, Dis-Chem, Local Choice, Medicare and Pick n Pay pharmacy clinics are approved network providers for your wellness assessment, preventative tests, and vaccinations.
As an employee of a registered employer group, you’re covered for 1 wellness assessment for the following on-site basic health checks when an Employee Wellness Day is scheduled for 15 or more employees:
|• blood pressure;||• body mass index;||• cholesterol;|
|• glucose levels;||• waist circumference; and|
|• HIV/AIDS, that includes counselling before and after testing.|
Additional health checks can be done during the Wellness Day:
- breast screening using a BreastlightTM device for all female employees;
- eye test;
- rapid prostate specific antigen (PSA) screening once every 2 years for male employees aged 50 years or older; and
- tuberculosis rapid test for all high-risk employees.
If you miss the Wellness Day, you can visit your nearest Alpha Pharm, Clicks, Dis-Chem, Local Choice, Medicare or Pick n Pay pharmacy clinic to have the basic health checks and PSA screening done.
Good to know: Your registered dependants can have their basic health checks and PSA screening done at their nearest Alpha Pharm, Clicks, Dis-Chem, Local Choice, Medicare or Pick n Pay pharmacy clinic.
Go to your nearest Alpha Pharm, Clicks, Dis-Chem, Local Choice, Medicare or Pick n Pay pharmacy clinic for the following preventative tests and vaccinations:
- 1 flu vaccination per person per year to be administered by the 31st of May;
- 1 pneumococcal vaccination once every 5 years for individuals 60 years or older, or for individuals with a medically proven compromised immune system. Call us on 011 781 4488 for pre-authorisation before you go for this vaccination;
- 1 hepatitis A and B vaccination once-off per person; or
- 1 tetanus vaccination per person once every 10 years.
TESTS AND SCREENINGS
- 1 pap smear once every 3 years for females aged 21 years or older (ask your network GP about having this procedure done in the rooms during one of your visits); or
- 1 rapid prostate specific antigen screening once every 2 years for males aged 50 years or older.
ESSENTIAL ASSISTANCE PROGRAMME (EAP)
Get unlimited 24/7 telephonic advice and counselling services through Reality Wellness Group for:
|• financial advice;||• legal advice;|
|• HIV/AIDS counselling; and||• trauma counselling.|
Good to know: Skype counselling sessions can be arranged.
Face-to-face counselling isn’t covered and will be for your own pocket.
Our Lifestyle Benefit is complimentary and doesn’t cost you a cent.
EXTRA HIGH SCHOOL LEARNING SUPPORT
Based on the CAPS curriculum, your Gr.8 to Gr.12 high school child gets instant access to content that’ll help them study, improve their knowledge and boost their marks. Read more…
This value-add benefit is offered by Stratum Benefits. It’s not administered by Unity Health or underwritten by Constantia Insurance Company Limited.
WAITING PERIODS AND GENERAL EXCLUSIONS
When 20 or less employees join, or when it’s voluntary for employees to join, the following waiting periods will apply.
Waiting periods don’t apply to the Essential Assistance Programme (EAP).
1 MONTH GENERAL WAITING PERIOD
You don’t have cover during this period for the Day-to-Day, Wellness Assessment and Preventative Care Benefits.
9 MONTH PRE-BIRTH CONSULTATION WAITING PERIOD
12 MONTH CHRONIC MEDICATION WAITING PERIOD
12 MONTH EYE CARE WAITING PERIOD
We don’t cover healthcare or service providers’ accounts related to any medical procedure, treatment, hospitalisation, illness, disease, loss, damage, death, bodily injury or liability for:
1. events that occurred when you weren’t an insured person.
2. events that occur during a policy waiting period unless it’s for accidental events or medical emergencies, where applicable.
3. events where your policy’s benefit limits have been reached.
4. events where your policy doesn’t provide an appropriate benefit to claim from.
5. events where you didn’t obtain pre-authorisation, or where an appropriate healthcare provider referral wasn’t obtained.
6. events where the healthcare or service providers that you’ve used don’t form part of the provider network, unless your policy has a benefit that covers it.
7. healthcare services, procedures or medication that don’t form part of the list of approved tariff codes or formularies, where applicable.
8. out-patient consultations related to allied healthcare providers, like physiotherapists and speech therapists, under the Specialist Consultations Benefit.
9. eye care, other than an eye test, a frame or spectacle lenses covered under the Eye Care Benefit.
10. costs that, in the opinion of the Underwriting Manager’s clinical review team:
10.1 aren’t medically necessary or clinically appropriate;
10.2 don’t meet the healthcare needs of the insured person; or
10.3 aren’t consistent in type, frequency, or duration of treatment.
11. reconstructive cosmetic or maxillo-facial surgery, including related medical conditions or procedures.
12. obesity or its sequel, cosmetic surgery or surgery directly or indirectly caused by, related to, or in consequence of cosmetic surgery.
13. external prosthetic devices or external medical items, like artificial limbs and wheelchairs.
14. artificial insemination, infertility treatment or contraceptives.
15. robotic surgery, specialised mechanical or computerised appliances, or equipment.
16. routine physical, procedures of a purely diagnostic nature or any other examination where there’s no objective indication of impairment in normal health, including laboratory diagnostic or x-ray examinations, unless in the course of a medical condition or disability established by prior call or attendance of a medical practitioner.
17. riots, wars, political acts, public disorder, terrorism, civil commotions, labour disturbances, strikes, lock-out, or any attempted such acts.
18. deliberate criminal or fraudulent acts, or any illegal activity conducted by you or a member of your household which directly or indirectly results in loss, damage or injury.
19. attempted suicide, intentional self-injury or deliberate exposure to exceptional danger unless it’s in an attempt to save a human life.
20. events where the use of drugs, narcotics or alcohol are involved, including any illness or addiction caused by using such substances.
21. participation in:
21.1 active military, police or police reservist duty;
21.2 aviation, other than as a passenger;
21.3 any competitive or professional sport or activity; or
21.4 any form of race or speed test, unless it’s on foot or involves any non-mechanically propelled vehicle, vessel, craft or aircraft.
22. nuclear weapons material, ionising radiations or contamination by radioactivity from any nuclear fuel, nuclear waste or from the combustion of nuclear fuel that includes any self-sustaining process of nuclear fission.
23. events that occur for which the actual damage is provided for by legislation, including contractual liability and consequential loss.
24. non-disclosure of material information that is likely to affect the assessment or acceptance of risk.
25. dual insurance where cover is provided by more than one health insurance policy through different insurers, or through the same insurer.