If you need to visit a general practitioner, specialist, radiologist, dentist, hospital or optometrist for medical services, find out what the rules are so that you will be covered and get the correct care.
Find out what the rules are about visiting healthcare providers
You need to visit general practitioners (GPs) in the POLMED GP Network.
You are allowed two visits to a GP who is not part of the network for emergency or out-of-town situations.
GP consultations are paid for from your out-of-hospital benefit.
For chronic, acute and over-the-counter (OTC) medication, please make use of any of the retail or courier pharmacies in the POLMED open pharmacy network.
A 20% co-payment will be levied in the event of voluntary utilisation of an out-of-network pharmacy.
Marine and Aquarium Plan members need to be admitted to a POLMED Network hospital to avoid a co-payment.
All admissions to hospitals, day clinics and out-patient units must be pre-authorised. A penalty of R5 000 will be imposed if pre-authorisation is not obtained. In the case of emergency, the Scheme must be notified within 48 hours or on the first working day after an admission.
All products and services received in hospital are paid from the in-hospital benefit category, provided pre-authorisation is obtained. Important: Managed healthcare protocols are applied.
You can go to any radiologist.
Pre-authorisation is required for specialised scans. In case of emergencies, the Scheme must be notified within 24 hours or on the first working day afterwards. If you do not obtain pre-authorisation, the Scheme will impose a co-payment of R500 per procedure.
- Radiology (basic)
- Radiology (specialised)
You need to visit specialists in the POLMED Specialist Network.
Before visiting a specialist you need to be referred by a general practitioner (GP). The Scheme will impose a co-payment of up to R1000 if the specialist’s account does not reflect the referring general practitioner’s information.
The co-payment will be payable by the member to the specialist and is not refundable by the Scheme. (This co-payment is not applicable to the following specialities/disciplines: Gynaecologists, psychiatrists, oncologists, ophthalmologists, nephrologists (chronic dialysis), dental specialists, pathology, radiology and auxiliary services.)
However, the Scheme will not cover the cost of audiology tests if there is no referral from the GP/ear, nose and throat (ENT) specialist.
The Scheme will allow two specialist visits per beneficiary per year without a GP referral to cater for those who require annual and/or bi-annual specialist visits. POLMED would like to encourage members to make use of the POLMED Specialist Network where possible.
Specialist consultations are accrued towards members’ in- and out-of-hospital benefits.
POLMED has contracted eye care network Preferred Provider Negotiators (PPN) optometrists.
PPN optometrists charge PPN rates, which are up to 75% lower than the rates charged by optometrists outside the PPN network for certain lens prescriptions.
Find out more about the optometry benefit under “Optical” in the guide to your health.
POLMED makes use of designated service providers (DSPs); these are groups of providers that charge POLMED rates. To access some benefits, it is required to visit these providers.