what it covers
Managed unlimited GP consultations through a Network GP Provider. These services include certain in-room procedures. In the event that the Network is not used, benefit is limited to R250, reimbursed directly to member on a pay and claim basis. Out of network benefits are limited to 2 consultations per policy per annum.
Limited to R2 000 per beneficiary per annum. Specialist benefits are available on a pay and claim basis. The member must be referred by a Network GP to a specialist
Unlimited acute medication available, either through the Dispensing GP or via the Pharmacy Network, these benefits are directly linked and limited to the Wesmart Formulary
OVER THE COUNTER AND HEALTH Screening
Sub-limit of R150 per policy per month as per formulary. Limited to R600 per policy per annum.
Unlimited chronic medicine restricted to 24 Chronic Diseases as listed. All chronic medicine has to be applied for by the Prescribing Medical Expert. These benefits include anti-anxiety or anti-depression medication, limited to R100 per month.
Unlimited. Limited to 1 and 2 sided, black and white x-rays. Member must be referred by a Network GP Provider, directly linked and limited to the Wesmart Formulary.
Unlimited as per the Wesmart Formulary. Covers basic blood tests.
Limited to 2 consultations per beneficiary per annum, including cleaning, polishing, extractions and fillings. No specialised dental benefits available.
Network Service Provider, Specsavers, must be used. Alternatively contact us for a provider in your area. Optometry services including 1 annual eye test, limited to single vision spectacles, every 24 months per beneficiary.
Individual members have a sub-limit of R200 000 per event, limited to R400 000 per policy per annum. Families have a sub-limit of R400 000 per event, limited to R800 000 per policy per annum. All associated costs for follow-up treatments post discharge, also accumulate to the initial event sub-limit.
Limited to R6 000 per policy per annum for all after-hour illness emergency-related events only. Must be pre-authorised.
DAILY ILLNESS BENEFIT
Day 1: R10 000 Day 2: R6 500 Day 3: R5 000 Day 4 onwards: R3 000 per day. Limited to 21 days per admission. Paid up to a maximum of the stated benefits, which includes all costs related to the admission.
SPECIFIC STATED CONDITIONS BENEFITS
Hernia: R20 000. Appendectomy, Gallbladder and Kidney Stones R35 000. Miscarriage: R10 000. Hysterectomy R45 000. These benefit limits include all costs related to the admission. This benefit cannot be used in combination with the daily illness benefit.
Up to a maximum of R30 000 per confinement. Limited to 1 event per policy every 12 month
Limited to R10 000 per policy per annum and is available if the sub-limit is reached. Must be authorised, illness-related admissions
R15 000 for illness admissions. Limited to a maximum of 3 days in hospital.
24 HOUR EMERGENCY MEDICAL SERVICES
Preauthorised by Africa Assistance. R50 000 per policy per annum
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Wesmart is a medical insurance product and therefore may review the premium on an annual basis. In the event of this occurring, we will notify you 30 days in advance of any changes to benefits or premium.The benefits mentioned are a summary and the full terms, conditions and limitations.Where we make mention of “Formulary”, we make reference to an approved list agreed to by Wesmart relating to the specific benefit.
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