Resolution Health plan options are HOSPITAL, PROGRESSIVE FLEX, CLASSIC, MILLENNIUM, SUPREME and FOUNDATION

Subject to Scheme
Protocols

Subject to Scheme
Protocols

Subject to Scheme
Protocols

Subject to Scheme
Protocols

Subject to Scheme
Protocols

Unlimited subject 
to PMB’s and only
at DSP.

Subject to Scheme
Protocols and specific
exclusion list.

Including:
Surgical operations & procedures
Theatre fees
Labour and recovery wards
Ward accommodation
Intensive care and high care units
Visits and consultations by a GP
X-rays and pathology
Physiotherapy
Ultrasound scans (other than for pregnancy)
Blood transfusions 

Maximum of 7 days supply.

Covered at DSP.

Diagnosis and treatment in respect of
the Prescribed Minimum Benefits
(PMB) package (as per Government 
Regulations)

Subject to Scheme Protocols.

Note: Pre-authorisation must be obtained in advance for all non-emergency hospital admissions. In the case of true emergency admissions, pre-authorisation must be obtained within 48 hours or on the first
working day after admission. The authorisation will be subject to case management protocols and formularies.
Laparoscopic and similar endoscopic procedures are excluded from benefits, unless pre-authorised under Scheme protocols.Members need to pay an amount upfront to the Hospital when they are admitted.
(Not applicable if performed out-of Hospital)

Confinements (Normal Vaginal Delivery)

Length of stay: 3 days & 2 nights.

Maternity Programme (Registration required)

R480 as per Reso
baby.

R600 as per Reso
baby.

R740 as per Reso
baby.

Max 3 Specialist visits,
or 9 midwife visits.

Subject to day to day
limits.

Subject to MSA
and ATB.

9 consultations – any
Provider.

Subject to Scheme
Protocols.     

Psychiatric Disorders

Limited to Network
Provider and subject
to PMB and Scheme
Protocols.

Providers and subject
to PMB and Scheme
Protocols. Non PMB
limited to R12 100 per
family per annum.

Providers and subject
to PMB and Scheme
Protocols. Non PMB
limited to R15 000 per
family per annum.

Limited to Network
Providers and subject
to PMB and Scheme
Protocols. Non PMB
limited to R24 000 per
family per annum.

Limited to Network
Provider and subject
to PMB and Scheme
Protocols.

R60 000 per family per
annum.

R100 000 per family
per annum.

8 (3) of the Act.

R90 000 per family
per annum. Subject
to PMB and Scheme
Protocols.

Unlimited subject to
PMB and Scheme
Protocols.

Provincial Hospital in
accordance with Public
Sector Protocols and
waiting lists and Regulation
8 (3) of the Act.

family per annum. No
benefit other than PMB
for joint replacements
and back procedures.

Subject to Prosthesis
Sub-Limits, Scheme
Protocols and PMB.

Limited to R45 000 per
family per annum. No
benefit other than PMB
for joint replacements
and back procedures.

Subject to Prosthesis
Sub-Limits, Scheme
Protocols and PMB.

Limited to R45 000 per
family per annum.

Subject to Prosthesis
Sub-Limits.

Limited to R50 000 per
family per annum.

Subject to Prosthesis
Sub-Limits.

Limited to R50 000 per
family per annum.

Subject to Prosthesis
Sub-Limits.

Limited to R30 000 per
family per annum.

Subject to Prosthesis
Sub-Limits, Scheme
Protocols and PMB.

Trauma Counselling
(Assault, Rape, Hijacking and Armed Robbery) 

Includes the following if prescribed by a registered
Healthcare practitioner and obtained from a supplier
registered with the Board of Healthcare Funders (BHF):
Artificial eyes
Artificial larynx
Artificial limbs / Back supports

R3 125 per family per annum. Subject to PMB and Scheme
Protocols and appliance sub-limits.

R3 125 per family per
annum. Subject to
PMB and Scheme
Protocols and
appliance sub-limits.

R6 000 per family per
annum. Subject to
PMB and Scheme
Protocols and
appliance sub-limits.

R9 000 per family per
annum. Subject to
PMB and Scheme
Protocols and
appliance sub-limits.

R12 000 per family
per annum. Subject to
appliance sub-limits.

R1 590 per family per
annum. Subject to
PMB and Scheme
Protocols and
appliance sub-limits.

Disposable bladder and intestinal excretion bags
Elastic stockings for control of varicose veins
External breast prosthesis after mastectomy
Glucometers
Hearing aids
Home oxygen
Leg, arm and neck supports
Nebulisers
Orthopaedic footwear
Sleep apnoea monitors
Oncology
· Oncologist
· Chemotherapy
· Radiotherapy
· Oncology – related blood tests

Limited to R65 000
per beneficiary per annum.
Subject to ICON
Network and protocols,
pre-auth required.

Limited to R100 000
per beneficiary per annum,
subject to ICON
Network and protocols,
pre-auth required.

Limited to R150 000
per beneficiary per annum,
subject to ICON
Network and protocols,
pre-auth required.

Limited to R200 000
per beneficiary per annum,
subject to ICON
Network and protocols,
pre-auth required.

Unlimited, subject to
Scheme Protocols
and preferred provider
network, pre-auth
required.

Limited to R65 000
per beneficiary per annum.
Subject to ICON
Network and protocols,
pre-auth required.

Primary Care including Voluntary Counselling and Testing
and Treatment

Hospitalisation if Member is on the HIV Management
Programme (Careworks – must register)

Hospitalisation if Member is not on the HIV Management
Programme, subject to Reg 8 (3)

HIV Management
Programme.

Hospitalisation at
Network Provider
hospitals and subject
to Scheme Protocols
and PMB.

Limited to Provincial
Facility.

5 days per family
per annum. 100% of
Scheme Rate.

12 days per family
per annum. 100% of
Scheme Rate.

No Benefit except in
lieu of hospitalisation
subject to pre-auth.

10 days per family
per annum. 100% of
Scheme Rate.

12 days per family
per annum. 100% of
Scheme Rate.

15 days per family
per annum. 100% of
Scheme Rate.

18 days per family
per annum. 100% of
Scheme Rate.

21 days per family
per annum. 100% of
Scheme Rate.

R6 000 per family
per annum subject to
Scheme Protocol.
(In-and-out of hospital).
Deductible of
R1 500 per incident.
Pre-auth required.
100% of Scheme Rate. 

R8 000 per family
per annum subject to
Scheme Protocol.
(In-and-out of hospital).
Deductible of
R1 500 per incident.
Pre-auth required.
100% of Scheme Rate. 

R10 000 per family
per annum subject to
Scheme Protocol.
(In-and-out of hospital).
Deductible of
R1 500 per incident.
Pre-auth required.
100% of Scheme Rate. 

R12 000 per family
per annum subject to
Scheme Protocol.
(In-and-out of hospital).
Deductible of
R1 500 per incident.
Pre-auth required.
100% of Scheme Rate. 

R15 000 per family
per annum subject to
Scheme Protocol.
(In-and-out of hospital).
Deductible of
R1 500 per incident.
Pre-auth required.
100% of Scheme Rate. 

Covered at Network
Provider and subject to
Scheme Protocols and
PMB.

Unlimited, subject to
Scheme Protocols.

NOTE:
· Authorisation must be obtained in advance from the Scheme for all hospitalisation and other insured benefits.
· No benefits shall be granted for (1) the replacement of existing External Medical Appliance items, without satisfactory proof that the existing item is obsolete, (2) costs of maintenance, spares or accessories.
· Hospice, rehab and step down facility: Includes accommodation and visits by a medical practitioner, except where inclusive global fees are applicable.

Included. Subject
to Hospital Chronic
Formulary. Reference
and MMAP® pricing
applies.

Included. Subject
to Progressive Flex
Chronic Formulary.
Reference and
MMAP® pricing
applies.

Included. Subject to
Chronic Formulary.
Reference and
MMAP® pricing
applies.

Included. Subject
to Hospital Chronic
Formulary. Reference
and MMAP® pricing
applies.

Included. Subject
to Hospital Chronic
Formulary. Reference
and MMAP® pricing
applies.

Included. Subject
to registration by a
Network Provider.
Subject to Foundation
Chronic Formulary.
Reference and
MMAP® pricing
applies.

NOTE: Pro-rated for members who join during the year.

M R2 120
M+ R4 240
Benefits subject to
stated sub-limits and
thereafter to PMB
CDL’s.

M R4 400
M+ R8 800
Benefits subject to
stated sub-limits and
thereafter to PMB
CDL’s.

NOTE: Chronic medication
· Should be obtained from Preferred Provider.
· Is restricted to formularies, clinical entry criteria and disease management protocols where applicable.
· Requires a script from a person legally entitled to prescribe and the relevant ICD 10 diagnosis code.
· Must be registered by the doctor or pharmacy through Swift Online (SOL) on 0800 132 345.
· Reference pricing and Maximum Medical Aid Price (MMAP®) may apply.

Not limited to OAL

Principal
Member: R4 220
Adult Dep: R3 600
Child Dep: R1 010

Principal
Member: R12 000
Adult Dep: R9 000
Child Dep: R1 260

General Practitioners
Consultations outside Networks may incur
a co-payment

M 4 visits per
annum.
M+1 7 visits per
annum.
M+2+ 9 visits per
annum.
100% of Scheme Rate

CDL consultations
covered separately,
subject to Disease
Management
Protocols.

Subject to day to day
limits.

CDL consultations
covered separately,
subject to Disease
Management
Protocols.

Subject to MSA and
ATB.

CDL consultations
covered separately,
subject to Disease
Management
Protocols.

Unlimited.

CDL consultations
covered separately,
subject to Disease
Management
Protocols.

Limited to Network
Provider.

· Consultations.

Limited to PMB at
Network Providers.

100% of Scheme
Rate for Non-Contracted
Providers.
150% of Scheme
Rate for Contracted
Providers.

100% of Scheme
Rate for Non-Contracted
Providers.
150% of Scheme
Rate for Contracted
Providers.

100% of Scheme
Rate for Non-Contracted
Providers.
220% of Scheme
Rate for Contracted
Providers.

Subject to PMB
and referral by GP
Provider. Subject to
Pre-authorisation, and
limited to Specialist
Network Providers.

Limited to PMB at
Network Providers.

100% of Scheme
Rate for Non-Contracted
Providers.
150% of Scheme
Rate for Contracted
Providers.

100% of Scheme
Rate for Non-Contracted
Providers.
150% of Scheme
Rate for Contracted
Providers.

100% of Scheme
Rate for Non-Contracted
Providers.
220% of Scheme
Rate for Contracted
Providers..

M 2 visits per
annum.

M+1 3 visits per
annum.

M+2+ 3 visits per
annum.

Subject to day to day
limits.

Subject to MSA
and ATB.

M 4 visits per
annum.

M+1 5 visits per
annum.

M+2+ 6 visits per
annum.

Additional visits
subject to PMB and
Pre-authorisation.

Dentistry
Conservative Dentistry
Subject to Scheme Protocols 

Subject to annual
limits of:

M R2 500
M+ R4 000

Limited to the following
services:

Subject to Day to Day
limits and sub-limits of:

M R3 000
M+ R6 000

Limited to Network
Providers and the
following services:

Subject to MSA and
ATB and sub-limits of:

M R4 700
M+1 R6 500

Limited to Network
Providers and the
following services:

Covered as stated
below.

Subject to annual
limits of:

M R1 500
M+ R2 500

Limited to Network
Providers and the
following services:

2 Emergency consultations
per beneficiary
per annum.

Covered at 100%
Scheme Rate.   

Intra-Oral: 8 per beneficiary
per annum.

Extra-Oral:1 per beneficiary
per annum. 

A treatment plan and
x-rays will be requested
for treatment plans
of more than 5 fillings.
Benefits for fillings are
available where such
fillings are clinically
indicated and will be
granted once per tooth
in a 1 year benefit
cycle. There are no
benefits for Amalgam
(silver) fillings to be
replaced with composite
fillings (white filling
material). Covered at
100% Scheme Rate.

Subject to Scheme
Providers. A treatment
plan and x-rays will be
requested for treatment
plans of more
than 5 fillings. Benefits
for fillings are available
where such fillings
are clinically indicated
and will be granted
once per tooth in a
1 year benefit cycle.
There are no benefits
for Amalgam (silver)
fillings to be replaced
with composite fillings
(white filling material).
Covered at 100%
Scheme Rate.

2 Annual scale and
polish treatments per
beneficiary.

No benefits for oral
hygiene instructions.

No benefit for adult
fluoride.

1 Annual scale and
polish treatments per
beneficiary.

No benefits for oral
hygiene instructions.

No benefit for adult
fluoride.

Fissure sealants
programme.

Benefit for one fissure
sealant per molar
tooth in a 3 year cycle.
Limited to individuals
younger than 16 years. 

Subject to Scheme
Protocols and Network
Providers.

1 Fluoride treatments
per beneficiary younger
than 12 years.

Covered at 100% of
Scheme Rate.   

More than 4 requires
pre-authorisation.

Emergency root canal
only.

1 set of plastic
dentures
(Upper and Lower)
per beneficiary. Benefit
for plastic dentures
granted only once
in a 4 year cycle.

1 set of plastic
dentures
(Upper and Lower)
per beneficiary. Benefit
for plastic dentures
granted only once
in a 4 year cycle.
Benefit for metal
dentures granted only
once in a 5 year cycle.
Full metal dentures are
not covered.

Subject to Scheme
protocols and Network
Providers. 1 set of
plastic dentures
(Upper and Lower)
per beneficiary. Benefit
for plastic dentures
granted only once
in a 4 year cycle.

Advanced Dentistry
Pre-authorisation required

R4 250 per family
per annum.

Subject to Day to Day
limits and sub-limits of:
M R3 000
M+ R6 000

Subject to
MSA and ATB
and sub-limits of:
M R4 700
M+1 R6 500
M+2+ R7 750

R8 500 per family per
annum.

1 per jaw per beneficiary
every 3 years.

1 per lifetime, for
beneficiaries under the
age of 18.

1 per lifetime, for
beneficiaries under the
age of 18.

Benefits on
pre-authorisation will
be applied to cases
accessed as treatment
mandatory, as per
orthodontic indices.
Limited to individuals
younger than 38 years.
Orthognathic surgery
is not covered.

Surgery, Dental Hospitalisation, and Anaesthetics
and Associated Costs

R3 500 per family per
annum for impacted
wisdom teeth and associated
costs. Subject
to Scheme Protocols.

Impacted wisdom teeth
and associated costs.
Surgery in the dental
chair: Covered at
100% of Scheme Rate.
Only approved dental
surgery will be covered
in hospital. Pre-authorisation
is required
and protocols apply.
General anaesthetic
benefits are available
for children younger
than 5 years of age for
extensive dental treatment.
Multiple hospital
admissions are not
covered. 

Impacted wisdom teeth
and associated costs.
Surgery in the dental
chair: Covered at
100% of Scheme Rate.
Only approved dental
surgery will be covered
in hospital. Pre-authorisation
is required
and protocols apply.
General anaesthetic
benefits are available
for children younger
than 5 years of age for
extensive dental treatment.
Multiple hospital
admissions are not
covered.

Impacted wisdom teeth
and associated costs.
Surgery in the dental
chair: Covered at
100% of Scheme Rate.
Only approved dental
surgery will be covered
in hospital. Pre-authorisation
is required
and protocols apply.
General anaesthetic
benefits are available
for children younger
than 5 years of age for
extensive dental treatment.
Multiple hospital
admissions are not
covered. Deductible of
R1 800 will apply
to in-hospital dental
admission.

Impacted wisdom teeth
and associated costs.
Surgery in the dental
chair: Covered at
100% of Scheme Rate.
Only approved dental
surgery will be covered
in hospital. Pre-authorisation
is required
and protocols apply.
General anaesthetic
benefits are available
for children younger
than 5 years of age for
extensive dental treatment.
Multiple hospital
admissions are not
covered. Pre-authorisation
is required for
certain Maxillo – Facial
procedure that are
covered in hospital,
subject to admission
protocols.

Subject to PMB’s only.
Pre-authorisation is
required and protocols
apply. Multiple hospital
admissions are not
covered.

Dental Anaesthetics in rooms
(Laughing gas and IV sedation)

Pre-authorisation
required. Covered at
100% of Scheme Rate.
Clinical protocols apply.

Covered only for
benefits as stipulated.
Covered at 100% of
Scheme Rate.

Optometry
Limited to Network Provider and 24 month benefit cycle
Consultations / Examination

1 consultation per
beneficiary.

Subject to MSA and
ATB and Sublimit of:
R2 120 per beneficiary.

1 consultation per
beneficiary.

1 pair of single vision
spectacles inclusive of
a frame and consultation
per beneficiary
limited to R920.

Or

1 pair of single vision
spectacles inclusive of
a frame and consultation
per beneficiary
limited to
R1 000.

Or 

1 pair of single vision
spectacles inclusive of
a frame and consultation
per beneficiary
limited to
R1 680.

Or

1 pair of single vision
spectacles inclusive of
a frame and consultation
per beneficiary
limited to R840.

Or 

1 pair of flat top bifocal
spectacles inclusive of
a frame and consultation
per beneficiary,
limited to
R1 400.

Or

1 pair of flat top bifocal
spectacles inclusive of
a frame and consultation
per beneficiary,
limited to
R1 550.

Or 

Or

1 pair of flat top bifocal
spectacles inclusive of
a frame and consultation
per beneficiary,
limited to R1 270.

1 pair of multifocal
spectacles inclusive of
a frame and consultation
per beneficiary
limited to
R1 620.

1 pair of multifocal
spectacles inclusive of
a frame and consultation
per beneficiary
limited to
R1 800.

1 pair of multifocal
spectacles inclusive of
a frame and consultation
per beneficiary
limited to
R2 540.

Limited to R920 per
beneficiary.

Limited to R1 000 per
beneficiary.

Limited to R1 900 per
beneficiary.

R2 000 per family per
annum, Scheme Rate
applies.

R2 000 per family per
annum, Scheme Rate
applies.

R2 000 per family per
annum, Scheme Rate
applies.

R3 000 per family per
annum, Scheme Rate
applies. 

(Excludes consultation)
Blood Pressure
Blood Sugar
Cholesterol
Body Mass Index

R95 per
beneficiary over the
age of 18 years only
at pharmacy.

1 Test per beneficiary
per annum.

1 Examination per
beneficiary per annum
over the age of 25
years.

1 Test per beneficiary
per annum.

1 Test per beneficiary
per annum over the
age of 45 years.

1 dose Flu vaccination
per beneficiary per
annum.

Childhood immunisations
as recommended
by the Department
of Health up to 18
months subject to limit
of R1 500.

Childhood immunisations
as recommended
by the Department
of Health up to 18
months subject to limit
of R1 500.

HPV (cervical cancer)
vaccine – 1.

Advice and information
regarding any
emergency
medical condition.
Call 086 1112162.

R1 200 per female
beneficiary per
annum – R100
per month.

Subject to Day to Day
limits.

Subject to MSA
and ATB.

M R5 960
M+1 R10 450
M+2+ R11 350

Provider Benefits.

· Biokineticists
· Chiropodists
· Chiropractors
· Dieticians
· Homeopaths
· Naturopaths
· Occupational Therapists
· Osteopaths
· Podiatrists
· Social workers
· Acupuncture

Limited to Flexi-
Benefit.

Subject to day to day
limits.

Subject to MSA
and ATB.

M R2 540
M+1 R3 760
M+2+ R4 980
100% of Scheme Rate.
Subject to annual limit.

Radiology and Pathology
(excluding Specialised Radiology)

Limited to Flexi-
Benefit.

Subject to day to day
limits.

Subject to MSA and
ATB.

M R2 540
M+1 R3 125
M+2+ R3 760
100% of Scheme Rate
Subject to annual limit.

Limited to PMB and
Subject to Network
Provider Formulary list.

Subject to relevant plan formulary
Reference and MMAP® pricing may apply
Benefit protocols apply
Use preferred provider Pharmacies.

M R1 800
M+ R2 330
With a sub-limit on
Schedule 0-2 drugs of:
M R500
M+ R700

Subject to Day
to Day limits and sublimits
of:
M R3 000
M+ R6 000
With a sub-limit on
Schedule 0-2 drugs of:
M R900
M+ R1 800

Subject to MSA and
ATB and sub-limits of:
M R4 700
M+1 R6 500
M+2 R7 750
With a sub-limit on
Schedule 0-2 drugs of:
M R1 400
M+1 R1 950
M+2 R2 300

M R5 960
M+1 R10 450
M+2+ R11 350
With a sub-limit on
Schedule 0-2 drugs of:
M R1 800
M+1 R3 100
M+2+ R3 400
Subject to annual limit.

Limited to Network
Providers. Scheme
protocols and
formularies to apply.

Limited to Flexi-
Benefit.

Subject to day to day
limits.

Subject to MSA
and ATB.

R1 110 per family.
100% of Scheme Rate
Subject to annual limit.

Limited to Flexi-
Benefit.

Subject to day to day
limits

Subject to MSA
and ATB.

R1 270 per family.
100% of Scheme Rate
Subject to annual limit.

Limited to PMB at
Provincial Facilities.

Limited to Flexi-
Benefit.

Subject to day to day
limits

Subject to MSA
and ATB.

R1 270 per family.
100% of Scheme Rate
Subject to annual limit.

PROGRESSIVE
FLEX 2013

· Biokinetists
· Chiropodists
· Chiropractors
· Dieticians
· Homeopaths
· Naturopaths
· Occupational Therapists
· Osteopaths
· Podiatrists
· Social workers
· Acupuncture
Radiology and pathology
(excluding MRI and CAT scans)
Physiotherapy
Speech Therapy and Audiology
Psychology and Psychiatric Treatment

M R1 800 per annum.
M+ R2 280 per annum.

Savings (MSA) and ATB levels
for MILLENNIUM 2013

A: R4 956
C: R1 452
(first three children only) 

P: R8 560
A: R6 860
C: R1 910
(per child)

P: R4 220
A: R3 600
C: R590
(per child)

Day-to-Day limits for
CLASSIC 2013

P: R4 220
A: R3 600
C: R1 010

Sublimits
(where applicable)

M: R3 000
M+: R6 000

Gap (SPG) for
MilleNnium
2013

P: R2 512
A: R1 904
C: R458
(per child)

R3951 - R6100

R6101 - R8400

Progressive Flex

PROGRESSIVE FLEX

SUPREME 2013
(Prestige
incorporated)

Procedure specific co-payments still apply if alternative to endoscopic or laparoscopic surgery is stated in protocol.