Sapphire

Key Benefits

Hospital: Major medical expenses

AHB Cover: GPs and specialists in-hospital services payable to a maximum of 150% of the NAMAF tariff

Benefit	Cover
Accommodation and Theatre	100%
Physiotherapy and Biokinetics (In-hospital)	100%
Post Rehabilitation Physiotherapy, Biokinetics and Occupational Therapy	100%
MRI and CT Scans	100%
Internal Appliances and Materials	100% of Cost
Oncology Consultations and Procedures Out-of-Hospital MRI/CT Scans and Other Specialised Radiology Procedures In and Out-of-Hospital Radiation Oncology (Referral from a medical specialist only) Oncology Medication (Chemotherapy, radiotherapy and hormone therapy) Hospitalisation and Related Procedures In-Hospital	100%
Dialysis/Organ Transplant	100%
Corrective Eye Surgery – All-inclusive Refractive Surgery Cataract Surgery and Lens Implants	100%
Maternity - Confinement – Full Procedure Confinement – full procedure 12 Ante-natal consultations per Beneficiary Six sessions, ante-/post-natal classes and education Three sonar scans per Beneficiary per pregnancy	100%

Day-to-Day Benefits

Benefit	Cover
General Practitioners and Specialists	100%
Medicine and Injections Acute and Chronic Essential Vaccination/Immunisation (As per WHO guidelines) Self-Medication	100%
Primary Health Care Services	100%
Dentistry	100%
Optical	100%
Auxiliary Services	100%
Specified Illness Conditions	100%

Contributions

Individuals
Age Band		Main	Adult	Child
0	25	3, 914	3,133	1,393
26	30	4,436	3,545	1,393
31	35	4,954	3,933	1,393
36	40	5,639	4,475	1,393
41	45	6,273	4,952	1,393
46	50	6,833	5,377	1,415
51	55	7,525	5,895	1,415
56	60	8,103	6,341	1,415
61	65	8,705	6,807	1,415
66+		9,327	7,258	1,415

Groups
Age Band		Main	Adult	Child
0	25	3,591	2,736	1,192
26	30	3,946	3,016	1,192
31	35	4,249	3,255	1,192
36	40	4,785	3,688	1,192
41	45	5,354	4,104	1,192
46	50	5,756	4,435	1,205
51	55	6,278	4,833	1,205
56	60	6,940	5,338	1,205
61	65	7,363	5,647	1,205
66+		7,372	5,659	1,205

OVERALL ANNUAL BENEFIT (OVERALL ANNUAL LIMIT)			Unlimited Benefit
Category A: Hospitalisation Benefit		% NAMAF Tariff	Pre-authorisation: 100% of the tariff will be paid. Without Pre-authorisation: No benefit will be paid except in the case of emergency hospital admissions and emergencies after-hours, weekends and public holidays.
Additional Hospital Benefit Cover: GPs and specialists in-hospital services are paid up to a maximum of 150% of the NAMAF tariff. OVERALL LIMIT
		COVER	M	M1	M2	M3	M4	M5+
1.	Hospitalisation	100%	Overall Annual Limit
	1.1. Accommodation and Theatre		Overall Annual Limit
	1.2. Accommodation in Private Wards (Difference between the general and private ward tariffs)		N$11 285 per Beneficiary N$24 750 per Family
	1.3. Intensive and high care (Maximum three days, then motivation)		Overall Annual Limit
	1.4 Blood Transfusions
	1.5. Radiology and Pathology (in-hospital) Additional Hospital Benefit cover excluded
	1.6. Physiotherapy and Biokinetics Additional Hospital Benefit cover excluded (Subject to prior approval)
	1.7. Post Rehabilitation Physiotherapy, Biokinetics and Occupational Therapy Additional Hospital Benefit cover excluded Additional benefit once the patient is out of hospital or transferred to rehabilitation facility Benefit available within three months from hospital discharge (Subject to prior approval)		N$5 435 per Beneficiary Overall Annual Limit
	1.8 Medicine, Fixed Tariff Procedures, Hospital Apparatus, and To Take Out Medicine (Seven days supply only)		Overall Annual Limit
	1.9 Dialysis (Subject to Case Management and MHC guidelines)
	1.10 Organ Transplant (Subject to Case Management and MHC guidelines) Including medical expenses incurred by the donor if the recipient is a Fund member
	1.11. Internal Appliances and Materials (As per NMC protocol)	100% of Cost
2.	General Practitioners and Specialists (In-Hospital Services) Additional Hospital Benefit cover included except the use of equipment and equipment hire fees	100%	Overall Annual Limit
3.	Specialised Radiology Procedures (In and Out-of-Hospital) Additional Hospital Benefit cover excluded A referral is only acceptable from a medical specialist (referral from a GP acceptable in places where there is no medical specialist) (Subject to prior approval)	100%	Overall Annual Limit
	3.1 MRI and CT Scans		N$42 960 per Family
	3.2 Nuclear Medicine		Overall Annual Limit
4.	Maternity (Groups have cover from the date of joining. Individuals have a nine-month waiting period)	100%	Overall Annual Limit
	4.1. Confinement – full procedure		Overall Annual Limit
	4.2. Antenatal Consultation 12 consultations per Beneficiary (Prorated from the date of joining) Additional Hospital Benefit cover excluded		Payable from the Maternity Benefit
	4.3. Ante/Postnatal Classes and Education Six sessions per Beneficiary (Prorated from the date of joining) Additional Hospital Benefit cover excluded
	4.4. Sonar Scans (Excluding 3D) Three scans per Beneficiary per Pregnancy Additional Hospital Benefit cover excluded
	4.5. Tests for Chromosonal and Foetal Abnormalities Additional Hospital Benefit cover excluded
	4.6. Midwifery Service Additional Hospital Benefit cover excluded
5.	Insertion of Intrauterine Device w/ Hormone (All-inclusive) (Subject to prior approval) (Prorated from the date of joining)	100%	N$7 040 per Beneficiary Overall Annual Limit
6.	Infertility Treatment (All-inclusive) (Subject to prior approval and MHC Guidelines)
7.	Oncology (Subject to Case Management and MHC guidelines)	100%	N$815 100 per Beneficiary Overall Annual Limit
	- Consultations and Procedures Out-of-Hospital (Exluding Allied and Complimentary Health Professionals)
	7.1 MRI/CT Scans and Other Specialised Radiology Procedures In and Out-of-Hospital - Additional Hospital Benefit cover excluded - Referral from a medical specialist only
	7.2 Radiation Oncology (Referral from a medical specialist only)
	7.3 Oncology Medication (Chemotherapy, radiotherapy and hormone therapy)
	7.4 Hospitalisation and Related Procedures In-Hospital		Overall Annual Limit
8.	Corrective Eye Surgery – All-inclusive (Subject to prior approval and MHC guidelines) Groups have cover from the date of joining Individuals have a one-year waiting period	100%	Overall Annual Limit
	8.1 Refractive Surgery		N$25 100 per Beneficiary once-off N$32 200 per Family
	8.2 Cataract Surgery and Lens Implants		N$27 200 per eye per Beneficiary once-off
9.	Reconstructive Surgery (Medical necessity only) (Subject to prior approval and subject to strict MHC Guidelines)	100%	Overall Annual Limit
	9.1 Consultation and Procedure		N$15 800 per Family
	9.2 Hospitalisation		Overall Annual Limit
10.	Private Nursing/Frail Care/Hospice (Subject to Case Management)		N$42 050 per Family Overall Annual Limit
11.	Psychiatric Treatment (Subject to prior approval and MHC Guidelines)	100%	Overall Annual Limit
	11.1 Consultations and Procedures		Sub-limit 11
	11. 2 Hospitalisation		N$35 710 per Family Sub-limit 11
12.	Alcoholism/Drug Addiction (Subject to prior approval and MHC guidelines)		Sub-limit 11.2
13.	Specialised Dental Surgery Additional Hospital Benefit cover excluded (Subject to pre-authorisation)	100%	Overall Annual Limit
	13.1 Maxillo-Facial and Oral Surgery (trauma/non-elective) All-inclusive		N$143 450 per Family
	13.2 Maxillo-Facial, Oral Surgery and Dental Implants (other/ elective) All-inclusive		N$42 450 per Beneficiary N$52 800 per Family N$5 175 per dental implant component
	13.3 Maxillo-Facial and Oral Surgery (Including Dental Implants)(other/non-elective) In-practice (surgical procedures performed in a doctor’s room)	150%	Payable from Maxillo-facial, Oral Surgery and Dental Implants (other/elective)
	13.4 Maxillo-Facial and Oral Surgery - Internal Prosthesis (excluding dental Implant component)	100% of Cost	Payable from Internal Appliances under Hospital Benefit
14.	Stomal therapy (All-inclusive) (Subject to prior approval)	100%	N$29 800 per Family Overall Annual Limit
15.	Ambulance and Evacuation Services	100%	Overall Annual Limit
	15.1 Emergency Ambulance and Flights (Territory: SADC Countries) (Subject to prior approval)		Unlimited Benefit
	15.2 Ambulance/Inter-hospital Transfer (Subject to prior approval)		N$5 985 per Beneficiary
16.	Medical Referral (Subject to prior approval and accommodation and travelling reimbursement protocols)		Overall Annual Limit
	16.1. Transport	70% of Cost	N$10 150 per Family
	16.2 Accommodation Other than a Recognised Hospital/Medical Institution (Maximum of two days)	100% of Cost	N$642 per day per Family
17.	International Medical Travel Insurance Medical cover when travelling to foreign countries For emergency cases only (not for elective surgery or procedure)	100% of Cost	N$10 000 000 per incident
18.	Lifestyle Management Tests	100%	N$15 000 per Family
	18.1 Screening Tests	100%	Sub-limit 18
	18.2 Rapid Tests	100%	N$1 500 per Family Sub-limit 18

CATEGORY B: DAY-TO-DAY BENEFIT		COVER	Sub-limits are pro-rated from date of joining, except the Optical Benefit. OVERALL LIMIT
CATEGORY B: DAY-TO-DAY BENEFIT		COVER	M	M1	M2	M3	M4	M5+
19.	General Practitioners and Specialists (out-of-hospital, including casualties) Telephonic/Virtual Consultations (telephonic/virtual writing of prescriptions not payable) Seven virtual/telephonic consultations per Beneficiary	100%	N$17 650	N$22 700	N$24 900	N$25 900	N$26 850	N$27 800
	19.1. Consultations/Visits (Out-Of-Hospital, Including Casualties)		Payable from General Practitioners and Specialists Benefit
	19.2. Procedures (Out-Of-Hospital Services, Including Casualties)
	19.3. Materials and Disposable Items
	19.4. Radiology and Pathology (Out-of-hospital, including radiography, sonography, medical laboratory technology and chemical biochemistry) (Referral from a medical practitioner)
	19.5 MRI and CT Scan		Payable from the MRI and CT Scan Benefit
	Benefit Booster Applicable (additional benefit once limit is exceeded)
20.	Medicine and Injections	SEP + 40%	N$33 950	N$53 030	N$57 390	N$59 600	N$61 830	N$64 000
	20.1. Acute Paid at the maximum Namibia medicine price list on generics	85%	N$9 350	N$14 200	N$17 300	N$18 250	N$19 250	N$20 200
		85%	N$9 350 per Beneficiary
	20.2. Chronic Paid at the maximum Namibia medicine Price List on generics		N$22 500	N$36 500	N$37 550	N$38 600	N$39 600	N$40 600
	20.2.1. Members aged 65 and below	85%	No Limit per Beneficiary Payable from Medicine and Injections
	20.2.2. Members aged 66 and above	100%
	20.3. Essential Vaccination/Immunisation (As per WHO guidelines) Paid at the maximum Namibia medicine price list on generics	100%	Payable from Medicine and Injections
	Benefit Booster Applicable (additional benefit once limit is exceeded)
	20.4. Self-medication Paid at the maximum Namibia medicine price list on generics	100%	N$2 100	N$2 330	N$2 540	N$2 750	N$2 980	N$3 200
		100%	N$250 per claim per Beneficiary per day
21.	Primary Health Care Services		N$1 360	N$1 625	N$1 845	N$2 060	N$2 280	N$2 500
21.	Primary Health Care Services		N$1 360 per Beneficiary
	21.1. Consultations and Procedures	100%	Payable from Primary Health Care Services
	21.2. Medicine and Injections (Paid at the maximum Namibia medicine price list on generics)	100%	Payable from Acute Medication
	Benefit Booster Applicable (additional benefit once limit is exceeded)
22.	Dentistry
	22.1 Conservative and Specialised Dentistry (Including Dental Therapy)	100%	N$17 200 per Beneficiary N$24 350 per Family
	22.2. Maxillo-Facial, Oral Surgery and Dental Implants In-practice consultation and non-surgical procedures		Payable from Dentistry Benefits
	Benefit Booster Applicable (additional benefit once limit is exceeded)
	22.3 Orthodontics (Subject to prior approval and MHC Guidelines)	100%	N$32 100 per Beneficiary once-off
23.	Optical Benefits Every two years (Including frame) (2023-2024)		N$5 150	N$9 800	N$10 100	N$10 400	N$10 700	N$11 000
23.			N$5 330 per Beneficiary Limited to N$12 000 per Family per Annum
	23.1 Optical Tests	100%	Payable from Optical Benefits
	23.2 Spectacles and Lenses	100%	Payable from Optical Benefits
	23.3 Frame	100% of Cost	N$2 040 per Beneficiary
	23.4 Readers Spectacles	100% of Cost	N$114 per Beneficiary
24.	Auxiliary Services		N$16 665	N$26 655	N$28 850	N$30 150	N$30 700	N$31 250
24.	Auxiliary Services		N$16 665 per Beneficiary
	24.1 Art Therapy	100%	Payable from Auxiliary Services
	24.2 Audiology/Speech Therapy	100%	Payable from Auxiliary Services
	24.3 Biokinetics	100%	N$8 220 per Beneficiary
	24.4. Chinese Medicine	100%	N$8 220 per Beneficiary
	24.5 Chiropractor		Payable from Auxiliary Services
	24.5.1 Consultation and Procedure	100%	Payable from Auxiliary Services
	24.5.2 Medicine	85%	Payable from Acute Medicine and Injections
	24.6 Clinical Psychology/Psychological Counsellor	100%	N$8 220 per Beneficiary
	24.7 Clinical Technology	100%	Payable from Auxiliary Services
	24.8 Dietician	100%
	24.9 Hearing Aid Acoustician	100%
	24.10 Homeopathy/Naturopathy/Phytotherapy
	24.10.1 Consultation and Procedure	100%
	24.10.2 Medicine	85%	Payable from Acute Medicine and Injections
	24.11 Occupational Therapy	100%	Payable from Auxiliary Services
	24.12 Orthotist/Prosthetist	100%	Payable from Auxiliary Services
	24.13 Physiotherapy	100%	N$8 220 per Beneficiary
	24.14 Podiatry/Chiropody	100%	Payable from Auxiliary Services
	24.15 Social Worker	100%	N$8 220 per Beneficiary
	Benefit Booster is Applicable (additional benefit once limit is exceeded)
25.	Wheelchair (Subject to prior approval) Inclusive of repair and maintenance	100% of Cost	N$19 350 per Beneficiary every four years (2024-2027)
26.	Artificial Limbs (Subject to prior approval)	100% of Cost	N$39 950 per Beneficiary every two years (2026-2027)
27.	Artificial Eyes (Subject to prior approval)	100% of Cost	N$18 750 per Beneficiary every four years (2024-2027)
28.	Hearing Aid Apparatus (Subject to prior approval) Inclusive of repair and maintenance	100% of Cost	N$38 050 per Family every three years for both ears (2026-2028)
29.	Appliances (External) (Subject to MHC guidelines)	80% of Cost	N$5 600 per Family
30.	Medical Devices for Diabetes Management (Subject to prior approval and MHC Guidelines)
	30.1 Insulin Pumps	80% of Cost	N$43 470 per Beneficiary every four years (2023– 2026)
	30.2 Other Diabetes Devices and Related Consumables	80% of Cost	N$60 900 per Beneficiary
31.	Specified Illness Conditions		N$39 250	N$78 500	N$75 800	N$75 800	N$75 800	N$75 800
	31.1 HIV/AIDS (As per national guidelines for antiretroviral therapy)		N$39 250 per Beneficiary
	31.1.1 Medicine Paid at the maximum Namibia medicine price list on generics	100%	Payable from Specified Illness Conditions
	31.1.2 First Full HIV Consultation/Assessment Once-off benefit	$510
	31.1.3 Consultation (after the first full HIV Consultation/Assessment) Six consultations per Beneficiary	$465
	31.1.4 HIV Counselling	100%	N$1 420 per Beneficiary
	31.1.5. Pathology Tests	100%	N$8 500 per Beneficiary
	31.1.6. HIV Resistance Test (Subject to prior approval)	100%	Payable from Specified Illness Conditions
	31.2. Prevention of Mother-to-Child Transmission (PMTCT) As per national guidelines	100%
	31.3. Post-Exposure Prophylaxis (PEP) As per national guidelines	100%
	31.4. Pre-Exposure Prophylaxis (PrEP) As per national guidelines	100%
32.	Benefit Booster Applicable if Medicine and Injections, Dentistry, GPs’ and Specialists, Primary Health Care & Auxiliary Services benefits are depleted		N$2 780 per Beneficiary N$4 130 per Family
	32.1. Medicine and Injections (Acute and Chronic) Excluding self-medication	70%	Payable from Benefit Booster
	32.2. Dentistry (Excluding orthodontics)	70%
	32.3. General Practitioners and Specialists (Consultations/visits and procedures/services out-of-hospital, including casualties)	80%
	32.4. Primary Health Care	80%
	32.5. Auxiliary Services	70%
33.	Benefit Booster “Up” (Voluntary Buy-up Benefit) Members can choose to enrol in the voluntary Benefit Booster Up each year before 15 January. Members who join the Fund during the year can also opt for the Benefit Booster Up, with prorated adjustments. Once opted in, the Extended Benefit Booster cannot be cancelled for the rest of the year. The available benefit is equal to the voluntary contributions paid (accumulative). 95% of the accumulated voluntary contributions will roll over to the next financial year. Any unused Benefit Booster Up will be forfeited and will not be refunded if the principal member resigns from the fund or passes away. Members who choose to switch to a Traditional or Hospital Plan can use their remaining voluntary contributions to fund the Traditional or Hospital Plan Day-to-Day Back Up Benefit. Similarly, the remainder can be transferred to any other traditional option. The Extended Benefit Booster can be used to cover depleted benefits, charges exceeding benchmark tariffs, exclusions, and other claims that were validly rejected.	100% of Cost	Monthly Voluntary Contribution			Extended Benefit per Annum
			N$300			N$3 600
			N$600			N$7200
			N$900			N$10 800
			N$1 200			N$14 400
			N$1 500			N$18 000

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Sapphire - Our Benefits - Options and Benefits | NMC

Key Benefits

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Sapphire - Our Benefits - Options and Benefits | NMC

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