Necesse Student in 2021

Service provider networks
You must use your option's network hospitals and day procedure facilities, pharmacies, doctors and specialists when you require medical treatment. By using network providers, you will avoid additional expenses and ensure that the treatment is considered for benefits. To find a network provider, use the provider search function on this website.

• Spinal column surgery – R15 000 per admission (non-surgical back treatment at a DBC clinic is a prerequisite)
• All endoscopic procedures (in hospital/ day clinic) – R4 500 (services should be rendered in a day procedure network to avoid a further 35% deductible)
• Hospital network: Use the Necesse network hospitals for all planned hospital admissions or a 35% deductible will apply to voluntary admissions to non-network hospitals for procedures not mentioned at the day procedure network
• Day procedure network:  Use the day procedure network when you need to undergo ophthalmological, endoscopic and ear, nose and throat procedures, as well as skin lesion removal, dental procedures and circumcisions to avoid 35% co-payment.
• Medihelp Preferred Pharmacy Network: Have your prescribed medicine dispensed at a network pharmacy to qualify for benefits
• GP network: Use a network GP for day-to-day treatment and for referrals to specialists, including for radiology and pathology
• Specialist network: Use network specialists, as they have been matched to our network hospitals

Explanation of terms

An emergency medical condition means any sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's life in serious jeopardy. An emergency medical condition must be certified as such by a medical practitioner. Emergencies qualify for PMB and must therefore also be registered for PMB (see also "PMB").

Hospital benefits refer to benefits for services rendered by a network hospital during a patient's stay in hospital. Services include ward accommodation and ward medicine, standard radiology, pathology and consultations during hospitalisation. Hospital benefits are subject to pre-authorisation and an 80% benefit will apply to the hospital account if the admission is not pre-authorised. Emergency admissions must be registered on the first workday following the admission. A 65% benefit applies for voluntary admission to a non-network hospital/day procedure facility.

PMB – Prescribed minimum benefits are paid for 26 chronic conditions on the Chronic Diseases List (CDL) and 270 diagnoses with their treatments as published in the regulations under the Medical Schemes Act 131 of 1998. In terms of these Regulations, medical schemes are compelled to grant benefits for the diagnosis, treatment and care costs of any of these conditions as well as emergency medical conditions (that meet the published definition) without imposing any limits, PMB are subject to pre-authorisation, protocols and the utilisation of designated service providers where applicable, e.g. Lancet/ PathCare for pathology tests and a specialist in the Necesse specialist network. PMB services are first funded from the related day-to-day benefits .