FLEXICARE PLUS PRIMARY HEALTHCARE BENEFITS AND SERVICES

2022 BENEFIT INFORMATION AND TERMS & CONDITIONS

We have collaborated with the largest private healthcare network in South Africa, Prime Cure, to bring you
valuable day-to-day private medical care.

This is not a medical scheme and the cover is not the same as that of a medical scheme. This policy is not a
substitute for medical scheme membership.

Registration, benefits and premiums work just like any standard medical insurance product.

• When you need to see a GP or dentist, make an appointment at your nearest Prime Cure Contracted Service
Provider (make sure telephonically that they are part of the Network.) All Prime Cure Contracted Service
Providers can be found online at www.primecure.co.za.
• On the day of your appointment, show your Flexicare membership card to the healthcare provider before
the appointment.
• The GP or Dentist will submit their claims directly to Prime Cure for payment.

The policy provides you with unlimited consultations with Prime Cure General Practitioners and also covers a
specific list of treatments from other healthcare providers.

You will not need to pay for approved treatments received from a Prime Cure Contracted Service Provider.
However, if you use a provider that is not a part of the Prime Cure Network, or if an unapproved treatment is
provided, you will be responsible for 100% of the costs.

ACCEPTANCE
Unless otherwise approved the following will apply:
• 1-month general waiting period on all services except accidental harm and those listed below
• 3-month general waiting period on dentistry and optometry
• 12-month condition specific waiting period for any condition (includes chronic illnesses and HIV) which
existed prior to the inception date

No waiting periods apply to treatments as a result of bodily injury caused by violent, unintentional, external or
physical means (Accidental Harm), unless these occur as a result of the exclusions, as defined in the policy
agreement.

No waiting periods apply to membership that is implemented on a compulsory basis by an employer on behalf
of their employees.

Underwritten by Auto and General is an authorized insurer and financial services provider
Registration number: 1973/016880/06
1 Telesure Lane, Riverglen, Dainfern 2191
 SERVICE PROVIDERS
All products are underwritten by Auto & General Insurance Company Limited, an authorised insurer and financial
services provider. The product is distributed by Hippo Advisory Services (Pty) Ltd, an authorised financial services
provider (FSP No: 36088).

Administrator details:
Kaelo Risk (Pty) Ltd
Registration no: 2008/019335/07 FSP no: 36931
E-mail: info@kaelo.co.za Website: www.kaelo.co.za
Physical address: 2nd Floor, The Oval, East Wing, Wanderers Office Park, 52 Corlett Drive, Illovo, 2196
Tel: 0861 493 587

SUMMARY OF SERVICES AND BENEFITS

SERVICE DESCRIPTION FLEXICARE +

Cover for GP consultations at 100% of the Agreed Rate. Contracted
Services Providers only.

GP Visits Unlimited
You can substitute your Contracted Service Provider - Doctor (GP) visits
with a virtual Consultations i.e. GP visits can either be face-to-face or a
virtual Consultation via a Contracted Service Provider.
Unlimited at 100% of the Agreed Rate. Acute Medication on the Formulary
Acute Medicine
is available without a Co-Payment.
Two sonar scans per Pregnancy per Insured Party. Contracted Service
Maternity
Providers only.
Limited to R105 per quarter to a maximum of R420 per Insured Party Per
Over the Counter (OTC)
Annum. Subject to the formulary.
Immunisations One flu vaccination Per Annum for qualifying Insured Parties.
100% of Agreed Rate for Chronic Medication on the Formulary at Network 27 conditions
Chronic Medication
Provider contracted pharmacy.
Unlimited HIV Medication is covered from date of registration of your
HIV Programme
Chronic Medication.
Full mouth examination, preventative Treatments, cleaning, scaling,
Dentistry polishing and fluoride Treatment, pain and sepsis, Infection control and
Extractions. Contracted Service Providers only.

Limited to one visit

Dentistry After-hour visits Emergency after-hours visits for pain and sepsis at any dentist. per Family Per
Annum.

Underwritten by Auto and General is an authorized insurer and financial services provider
Registration number: 1973/016880/06
1 Telesure Lane, Riverglen, Dainfern 2191
 Eye examinations at a Contracted Service Provider. Limited to one per
Insured Party Per
Annum.
Optometry
Limited to one pair
Spectacles and lenses. in a 24 month-
period.

Limited to a single
Frames frame in a 24
month-period.
100% of the Agreed Rate black and white X-rays and soft tissue
Radiology ultrasounds. Must be requested by a Contracted Service Provider subject Unlimited
to the available number of GP visits.
100% of the Agreed Rate. Limited to approved Pathology Codes. Must be
Pathology requested by a Contracted Service Provider (GP) and performed by a Unlimited
Contracted Service Provider.
Contracted Service Providers only.
Maternity Two 2D sonar scans per Pregnancy per Insured Party. Contracted Service
Providers only.
COVID-19 Testing Maximum of R850 if the result is positive.
Cover for screening tests at contracted pharmacy for: Height, Weight,
Wellness Screening BMI, Glucose, Blood Pressure, Cholesterol, HIV (incl pre and post
counselling). Limited 1 claim per beneficiary per annum.

Transportation to an appropriate state hospital for any Medical

Ambulance Services Limited to road
Emergencies, by Netcare 911.
transportation only

Underwritten by Auto and General is an authorized insurer and financial services provider
Registration number: 1973/016880/06
1 Telesure Lane, Riverglen, Dainfern 2191
 DETAILS OF SERVICES AND BENEFITS
This brochure which is also the Detail of Services and Benefits annexure to your Policy, should be read together
with your Policy and Policy Schedule as they all form part of your agreement with the Insurer. Please ensure that
you familiarise yourself with all the terms and conditions contained in all the documents you have received.

BENEFIT NAME BENEFIT DESCRIPTION LIMIT

PRIMARY HEALTHCARE
General Practitioner This Benefit provides access to visit a Contracted Service The number of visits to
(GP) Visits Provider -Doctor (GP) and such visits will be covered at a Contracted Service Provider
100% of the Agreed Rate in the following instances: (GP) is unlimited per Insured
Party Per Annum.
Doctor (GP) visits during office hours (Monday to
Friday: 08h00 - 17h00, Saturdays: 08h00 - 12h00)
are 100% covered at the Agreed Rate when using
a Contracted Service Provider.

You can substitute your Contracted Service

Provider -Doctor (GP) visits with virtual Consultations

All out-of-Hospital consultations of a medical nature,

including minor procedures as listed in the Contracted
Service Provider approved codes, performed in the Doctor’s
rooms.

We will only cover at 100% of Agreed Rate if a Contracted

Service Provider is used. Per Annum
General Practitioner Pre-Authorisation is required in respect of the following:
(GP) Visits –
Pre-Authorisation Pre-Authorisation is required via a My TeleHealth Virtual Consultation with a Kaelo Virtual
Healthcare Practitioner from the fifth visit to a Contracted Service Provider (GP) per Insured
Party.
My TeleHealth - Virtual This Benefit provides access to a Virtual Consultation via My Unlimited visits.
Consultations TeleHealth Platform with a Kaelo Virtual Healthcare
Practitioner (GP). You can substitute your Contracted
Service Provider -Doctor (GP) visits with My TeleHealth
Virtual Consultations. Contact us on 0861 493 587 or
www.kaelo.co.za.
How to Find Your Contact the call centre 0861 493 587 or visit the Network Provider website at
Doctor or GP? www.primecure.co.za.
MEDICATION
Acute Medication This Benefit provides access to Acute Medication for This Benefit is unlimited.
(Short-term Insured Parties covered
Medication) at 100% of the Agreed Rate if the following In order for the Benefit to be
conditions are met: covered, Authorisation must
be

Underwritten by Auto and General is an authorized insurer and financial services provider
Registration number: 1973/016880/06
1 Telesure Lane, Riverglen, Dainfern 2191
 BENEFIT NAME BENEFIT DESCRIPTION LIMIT
All Acute Medication must be prescribed by a Contracted obtained per Insured Party
Service Provider (GP). from the fifth visit via a My
The medication must be on the Network Provider Acute TeleHealth Virtual Consultation
Medication formulary and will be available without a Co- with a Kaelo Virtual Healthcare
Practitioner.
Payment.

The Acute Medication must be provided by either a

dispensing Contracted Service Provider (GP) or by a
Network Provider contracted pharmacy if the prescribing
Doctor is a contracted but non-dispensing Doctor.

The Acute Medication will not be covered if it is

prescribed by a GP that is not contracted to the
Network Provider contracted pharmacy or if obtained from
a non-contracted pharmacy.
Over the Counter OTC Medication may only be obtained at a The OTC Medication Benefit is
(OTC) Network Provider contracted pharmacy and on advice by limited to R105 per quarter up
the pharmacist. Medicine obtained is subject to the to a maximum of R420 per
formulary. Insured Party Per Annum on
Flexicare Plus only
Limited to R105 per quarter to a maximum of R420 per
Insured Party Per Annum. Subject to the formulary.

Immunisation The following Insured Parties may obtain one flu vaccination This Benefit is Limited to one
Per Annum flu vaccination

• Children between six months and six years of age.

• Pregnant women.
• Insured Party 65 years of age and older.
• Adults and children who are registered for Chronic
Medication for the following conditions: Chronic
pulmonary disorders (including Asthma), Cardiovascular
disorders (except isolated hypertension), Renal or
Metabolic disorders (including diabetes mellitus),
Patients with immunosuppression.
Chronic Medication Chronic Medication will be covered in full (100% of Chronic Medication is
(Long-term Agreed Rate) if: Prescribed Medication forms part of the available only on Flexicare
Medication) Chronic Medication formulary. You have registered for the Plus and for the following
Chronic Medication with the Contracted Services Provider. conditions:
Chronic Medication formulary can also be found on the Addison’s disease,
website. (www.primecure.co.za). Asthma,
Bipolar mood disorder,
To register for this Benefit: Bronchiectasis,
Cardiac failure,
1. You can obtain the chronic application form from your Cardiomyopathy,
Contracted Service Provider (GP) Chronic renal disease,
(www.primecure.co.za). COPD (chronic obstructive

Underwritten by Auto and General is an authorized insurer and financial services provider
Registration number: 1973/016880/06
1 Telesure Lane, Riverglen, Dainfern 2191
 BENEFIT NAME BENEFIT DESCRIPTION LIMIT
pulmonary disease),
2. A Contracted Service Provider (GP) needs to email the Coronary artery disease,
completed chronic application form to Crohn’s disease,
pcauth@mediscor.co.za Diabetes insipidus,
Diabetes mellitus type 1,
After approval of the Chronic Medication, you Diabetes mellitus type 2,
can obtain your Chronic Medication at a Network Dysrhythmias,
Provider contracted pharmacy or contracted courier Epilepsy,
pharmacy who will deliver your Chronic Glaucoma,
Medication to the address you selected at no additional Haemophilia,
cost. HIV (see details below),
Hyperlipidaemia (high
cholesterol),
Hypertension,
Hypothyroidism,
Multiple sclerosis,
Parkinson’s disease,
Rheumatoid arthritis,
Schizophrenia,
Systemic lupus erythematosus,
Ulcerative colitis.
HIV
HIV Programme The HIV Programme is designed to optimise the Unlimited HIV Medication is
health and wellbeing of HIV positive patients. covered from date of
registration of your Chronic
The HIV management Programme includes: Medication by your
• Voluntary counselling and testing. Contracted
• Antiretroviral therapy, prophylactic antibiotics and Service Provider (GP) and/or
supplements. Allocated Provider.
• Treatment support and guidance.
• Pathology and monitoring (including CD4, viral load,
liver enzymes, cholesterol,
• glucose, urine tests) according to protocols.
• Treatment of related infections, according to the
Contracted Service Provider procedures and
specifications.
• Emergency post exposure Medication is provided if the
accidental exposure us brought to the attention of the
Contracted Service Provider within 72 hours.
• Prevention of mother-to-child-transmission (PMTCT).

You must register for the Benefit.

To do so you can obtain:
1. The Network Provider HIV registration form from the
Network Provider website (www.primecure.co.za) or
from Contracted Service Provider (GP)

Underwritten by Auto and General is an authorized insurer and financial services provider
Registration number: 1973/016880/06
1 Telesure Lane, Riverglen, Dainfern 2191
 BENEFIT NAME BENEFIT DESCRIPTION LIMIT
2. A Contracted Service Provider (GP) needs to email the
completed chronic application form to
HIVDMP@primecure.co.za.
DENTISTRY
Dentistry The Benefit is only covered when making use of a Dentist contracted by the Network
Provider.
Dentistry Consultations A single consultation for a full
mouth examination per
Insured
Party Per Annum.
Dentistry Preventative Treatments include cleaning, scaling, polishing Limited to one
and fluoride Treatment (for children under the age of 12 per Insured Party Per Annum.
years only).
Dentistry Restorations and composite fillings Pre-Authorisation is required
for four or more restorations
(repairs to teeth), or five or
more composite fillings per
Family Per Annum.
Dentistry Extractions Pre-Authorisation
required for five or more
extractions.
Dentistry Oral radiography Pre-Authorisation is needed
for three or more X-rays,
maximum four per Family Per
Annum.
Dentistry Emergency root canal Emergency root canal only for
pain and sepsis.
Dentistry Additional Dentistry Benefits • Diagnosis and Treatment
for pain and sepsis.
• Infection control.
• Oral hygiene advice on
how to keep the mouth
and teeth clean to
prevent dental problems.
• Local anaesthetic.
Dentistry After-hours Treatment After-hours
Treatments are limited to one
visit per Family in the Per
Annum for pain and sepsis,
although you may visit any
dentist. You may have to pay
cash and claim back from the
Network Provider. The
Network Provider will refund
the
Policyholder according to the
Agreed Rate.

Underwritten by Auto and General is an authorized insurer and financial services provider
Registration number: 1973/016880/06
1 Telesure Lane, Riverglen, Dainfern 2191
 BENEFIT NAME BENEFIT DESCRIPTION LIMIT
OPTOMETRY
Optometry Eye examinations: Eye examinations are limited
The Optometry Benefit is subject to availability at to one per Insured Party Per
Contracted Service Providers only. Annum and includes a visual
evaluation, screening and
a diagnosis.
Optometry Spectacles and lenses: Spectacles and lenses will be
The Optometry Benefit is subject to availability at limited to one pair per Insured
Contracted Service Providers only. Party in a 24 month-period
and include standard, high
quality clear plastic lenses
(CR39 lenses), single vision
and bi-focal lenses.
Qualifying Norms will apply.
Optometry Frames: The Optometry Benefit is subject to availability at Frames will be limited to a
Contracted Service Providers only. single
frame per Insured Party in a
24 month-period.
The choice of frame is
specified to be from a quality
selection of
the Contracted Service
Provider approved range of
frames - any frames
not in the range will result in
the Policyholder paying the
difference in costs.
RADIOLOGY
Radiology The Radiology Benefit provides access to black and white X- This Benefit is unlimited.
rays and soft tissue ultrasounds according to a list of the
approved codes and are paid at 100% of the Agreed Rate.

A Contracted Service Provider (GP) must request the

Radiology tests and you have to take the Radiology request
form to the radiologist.
Radiology Authorisation: Pre-Authorisation from the fifth GP visit per Insured Party must have been
obtained.
PATHOLOGY
Pathology Pathology tests are limited to the Network Provider list of This Benefit is unlimited.
approved pathology codes and are paid at 100% of the In order for the Benefit to be
Agreed Rate. covered, Authorisation is
The tests must be requested by a Contracted Service required per Insured Party
Provider (GP) and the test must be done by a Network from the fifth visit.
contracted Pathology laboratory - Ampath, Lancet, Pathcare
or Lab24.

Underwritten by Auto and General is an authorized insurer and financial services provider
Registration number: 1973/016880/06
1 Telesure Lane, Riverglen, Dainfern 2191
 MATERNITY
Maternity This can be provided by a Contracted Service Provider (GP) This Benefit covers two sonar
and/or Allocated Provider, or a Network Provider scans per Pregnancy per
contracted radiologist as referred to by the Doctor (GP). Insured Party.
Only 2D scans are covered.
HEALTH SCREENING
COVID-19 Testing The process works as follows: The Insurer will cover the cost
1. Pay cash upfront for the test. of the Pathology test for
2. If the result is positive, complete the refund form (can be COVID - 19 (up to a maximum
found on ww.primecure.co.za) of R850) if the result is
and submit together with the claim, a copy of the test positive.
results and proof of payment, for reimbursement.

AMBULANCE SERVICES
Ambulance Services
• All Insured Parties are required to access these Transportation to an
services via the Netcare 911 toll-free line on 082 appropriate state hospital for
911 (24/7/365). any Medical Emergencies, by
• This is limited to road transport. Netcare 911.
• All medical emergencies requiring ambulances
services will be transported to an appropriate Limited to road transport only
state facility only. by Netcare 911.
• The transportation is restricted and limited to road
transport only.

EXCLUSIONS – FLEXICARE AND FLEXICARE PLUS

No benefits are offered for any services or claims that are caused by, or related to the following:
• Cosmetic surgery
• Suicide (or attempted suicide)
• Use of any drugs or narcotics
• Failure to follow medical advice
• Use of alcohol
• Nuclear incidents
• Services relating to Defence, Police, Rescue, Firefighting or Correctional Facilities
• Aviation activities
• Hazardous sports
• Motor racing
• Use of firearms
• Riots, wars, public disorder, terrorism and related events
• Criminal (or attempted criminal) activities
• Intentional exposure to danger

Underwritten by Auto and General is an authorized insurer and financial services provider
Registration number: 1973/016880/06
1 Telesure Lane, Riverglen, Dainfern 2191
 The following treatments, conditions and services are not covered:
• External prosthesis
• Specialised dentistry
• Rehabilitation, Frail-care and Hospice services
• Step-down facilities
• Non Netcare 911 ambulance and related emergency services
• Balance billing and split billing from providers
• Major medical expenses
• Specialist consultations

CONTACT DETAILS
Telephone number (All Enquires): 0861 472 580

Sales/quotes information
Email: info@hippoadvice.co.za

Premium collections / Policy changes / Network provider queries / Benefit information

Email: support@flexicare.co.za

Membership queries (new members / resignations / change of banking details / debit orders)
Email: applications@flexicare.co.za

Claims
Email: claims@flexicare.co.za

Service escalations
Email: escalations@flexicare.co.za

Underwritten by Auto and General is an authorized insurer and financial services provider
Registration number: 1973/016880/06
1 Telesure Lane, Riverglen, Dainfern 2191