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	3,745	2,998	1,333
26	30	4,245	3,392	1,333
31	35	4,741	3,764	1,333
36	40	5,396	4,282	1,333
41	45	6,003	4,739	1,333
46	50	6,539	5,145	1,354
51	55	7,201	5,641	1,354
56	60	7,754	6,068	1,354
61	65	8,330	6,514	1,354
66+		8,925	6,945	1,354

Groups
Age Band		Main	Adult	Child
0	25	3,436	2,618	1,141
26	30	3,776	2,886	1,141
31	35	4,066	3,115	1,141
36	40	4,579	3,529	1,141
41	45	5,123	3,927	1,141
46	50	5,508	4,244	1,153
51	55	6,008	4,625	1,153
56	60	6,641	5,108	1,153
61	65	7,046	5,404	1,153
66+		7,055	5,415	1,153

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$10 900 per Beneficiary N$23 900 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$5 250 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$41 500 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$6 800 per Beneficiary Overall Annual Limit
6.	Oncology (Subject to Case Management and MHC guidelines)	100%	N$787 500 per Beneficiary Overall Annual Limit
	6.1 Consultations and Procedures Out-of-Hospital
	6.2 MRI/CT Scans and Other Specialised Radiology Procedures In and Out-of-Hospital - Additional Hospital Benefit cover excluded - Referral from a medical specialist only
	6.3 Radiation Oncology (Referral from a medical specialist only)
	6.4 Oncology Medication (Chemotherapy, radiotherapy and hormone therapy)
	6.5 Hospitalisation and Related Procedures In-Hospital		Overall Annual Limit
7.	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
	7.1 Refractive Surgery		N$24 250 per Beneficiary once-off N$29 600 per Family
	7.2 Cataract Surgery and Lens Implants		N$26 250 per eye per Beneficiary once-off
8.	Reconstructive Surgery (Medical necessity only) (Subject to prior approval and subject to strict MHC Guidelines)	100%	Overall Annual Limit
	8.1 Consultation and Procedure		N$15 250 per Family
	8.2 Hospitalisation		Overall Annual Limit
9.	Private Nursing/Frail Care/Hospice (Subject to Case Management)		N$40 600 per Family Overall Annual Limit
10.	Psychiatric Treatment – Hospitalisation (Subject to prior approval and MHC Guidelines)	100%	N$34 500 per Family Overall Annual Limit
11.	Alcoholism/Drug Addiction (Subject to prior approval and MHC guidelines)	100%	N$34 500 per Family Overall Annual Limit
12.	Specialised Dental Surgery Additional Hospital Benefit cover excluded (Subject to pre-authorisation)	100%	Overall Annual Limit
	12.1 Maxillo-Facial and Oral Surgery (trauma/non-elective) All-inclusive		N$138 000 per Family
	12.2 Maxillo-Facial, Oral Surgery and Dental Implants (other/ elective) All-inclusive		N$41 000 per Beneficiary N$51 000 per Family N$5 000 per dental implant component
	12.3 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)
	12.4 Maxillo-Facial and Oral Surgery - Internal Prosthesis (excluding dental Implant component)	100% of Cost	Payable from Internal Appliances under Hospital Benefit
13.	Stomal therapy (All-inclusive) (Subject to prior approval)	100%	N$28 750 per Family Overall Annual Limit
14.	Ambulance and Evacuation Services	100%	Overall Annual Limit
	14.1 Emergency Ambulance and Flights (Territory: SADC Countries) (Subject to prior approval)		Unlimited Benefit
	14.2 Ambulance/Inter-hospital Transfer (Subject to prior approval)		N$5 780 per Beneficiary
15.	Medical Referral (Subject to prior approval and accommodation and travelling reimbursement protocols)		Overall Annual Limit
	15.1. Transport	70% of Cost	N$10 150 per Family
	15.2 Accommodation Other than a Recognised Hospital/Medical Institution (Maximum of two days)	100% of Cost	N$620 per day per Family
16.	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

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+
17.	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$15 750	N$20 250	N$22 250	N$21 500	N$22 750	N$23 000
	17.1. Consultations/Visits (Out-Of-Hospital, Including Casualties)		Payable from General Practitioners and Specialists Benefit
	17.2. Procedures (Out-Of-Hospital Services, Including Casualties)
	17.3. Materials and Disposable Items
	17.4. Radiology and Pathology (Out-of-hospital, including radiography, sonography, medical laboratory technology and chemical biochemistry) (Referral from a medical practitioner)
	17.5 MRI and CT Scan		Payable from the MRI and CT Scan Benefit
	Benefit Booster Applicable (additional benefit once limit is exceeded)
18.	Medicine and Injections	SEP + 40%	N$32 090	N$50 000	N$4 060	N$54 810	N$53 730	N$56 400
	18.1. Acute Paid at the maximum Namibia medicine price list on generics	85%	N$8 800	N$13 400	N$16 300	N$16 750	N$17 100	N$17 350
		85%	N$8 800 per Beneficiary
	18.2. Chronic Paid at the maximum Namibia medicine Price List on generics		N$21 300	N$34 450	N$35 550	N$35 600	N$36 000	N$36 250
	18.2.1. Members aged 65 and below	85%	No Limit per Beneficiary Payable from Medicine and Injections
	18.2.2. Members aged 66 and above	100%
	18.3. 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)
	18.4. Self-medication Paid at the maximum Namibia medicine price list on generics	100%	N$1 990	N$2 150	N$2 310	N$2 460	N$2 630	N$2 800
		100%	N$235 per claim per Beneficiary per day
19.	Primary Health Care Services		N$1 310	N$1 570	N$1 780	N$1 990	N$2 200	N$2 410
19.	Primary Health Care Services		N$1 310 per Beneficiary
	19.1. Consultations and Procedures	100%	Payable from Primary Health Care Services
	19.2. 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)
20.	Dentistry
	20.1 Conservative and Specialised Dentistry (Including Dental Therapy)	100%	N$16 600	N$19 000	N$20 750	N$21 250	N$21 750	N$22 250
		100%	N$16 600 per Beneficiary
	20.2. 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)
	20.3 Orthodontics (Subject to prior approval and MHC Guidelines)	100%	N$31 000 per Beneficiary once-off
21.	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
21.			N$5 150 per Beneficiary Limited to N$11 550 per Family per Annum
	21.1 Optical Tests	100%	Payable from Optical Benefits
	21.2 Spectacles and Lenses	100%	Payable from Optical Benefits
	21.3 Frame	100% of Cost	N$1 970 per Beneficiary
	20.4 Readers Spectacles	100% of Cost	N$110 per Beneficiary
22.	Auxiliary Services		N$16 100	N$25 750	N$27 850	N$29 100	N$29 650	N$30 150
22.	Auxiliary Services		N$16 100 per Beneficiary
	22.1 Art Therapy	100%	Payable from Auxiliary Services
	22.2 Audiology/Speech Therapy	100%	Payable from Auxiliary Services
	22.3 Biokinetics	100%	N$7 940 per Beneficiary
	22.4. Chinese Medicine	100%	N$7 940 per Beneficiary
	22.5 Chiropractor		Payable from Auxiliary Services
	22.5.1 Consultation and Procedure	100%	Payable from Auxiliary Services
	22.5.2 Medicine	85%	Payable from Acute Medicine and Injections
	22.6 Clinical Psychology/Psychological Counsellor	100%	N$7 940 per Beneficiary
	22.7 Clinical Technology	100%	Payable from Auxiliary Services
	22.8 Dietician	100%
	22.9 Hearing Aid Acoustician	100%
	22.10 Homeopathy/Naturopathy/Phytotherapy
	22.10.1 Consultation and Procedure	100%
	22.10.2 Medicine	85%	Payable from Acute Medicine and Injections
	22.11 Occupational Therapy	100%	Payable from Auxiliary Services
	22.12 Orthotist/Prosthetist	100%	Payable from Auxiliary Services
	22.13 Physiotherapy	100%	N$7 940 per Beneficiary
	22.14 Podiatry/Chiropody	100%	Payable from Auxiliary Services
	22.15 Social Worker	100%	N$7 940 per Beneficiary
	Benefit Booster is Applicable (additional benefit once limit is exceeded)
23.	Wheelchair (Subject to prior approval) Inclusive of repair and maintenance	100% of Cost	N$18 650 per Beneficiary every four years (2024-2027)
24.	Artificial Limbs (Subject to prior approval)	100% of Cost	N$38 600 per Beneficiary every two years (2024-2025)
25.	Artificial Eyes (Subject to prior approval)	100% of Cost	N$18 100 per Beneficiary every four years (2024-2027)
26.	Hearing Aid Apparatus (Subject to prior approval) Inclusive of repair and maintenance	100% of Cost	N$36 750 per Family every three years for both ears (N$18 375 per ear) (2023-2025)
27.	Appliances (External) (Subject to MHC guidelines)	80% of Cost	N$5 400 per Family
28.	Medical Devices for Diabetes Management (Subject to prior approval and MHC Guidelines)
	28.1 Insulin Pumps	80% of Cost	N$42 000 per Beneficiary every four years (2023– 2026)
	28.2 Other Diabetes Devices and Related Consumables	80% of Cost	N$58 800 per Beneficiary
29.	Specified Illness Conditions		N$37 900	N$75 800	N$75 800	N$75 800	N$75 800	N$75 800
	29.1 HIV/AIDS (As per national guidelines for antiretroviral therapy)		N$37 900 per Beneficiary
	29.1.1 Medicine Paid at the maximum Namibia medicine price list on generics	100%	Payable from Specified Illness Conditions
	29.1.2 First Full HIV Consultation/Assessment Once-off benefit	$510
	29.1.3 Consultation (after the first full HIV Consultation/Assessment) Six consultations per Beneficiary	$465
	29.1.4 HIV Counselling	100%	N$1 370 per Beneficiary
	29.1.5. Pathology Tests	100%	N$8 200 per Beneficiary
	29.1.6. HIV Resistance Test (Subject to prior approval)	100%	Payable from Specified Illness Conditions
	29.2. Prevention of Mother-to-Child Transmission (PMTCT) As per national guidelines	100%
	29.3. Post-Exposure Prophylaxis (PEP) As per national guidelines	100%
	29.4. Pre-Exposure Prophylaxis (PrEP) As per national guidelines	100%
30.	Benefit Booster Applicable if Medicine and Injections, Dentistry, GPs’ and Specialists, Primary Health Care & Auxiliary Services benefits are depleted		N$2 680 per Beneficiary N$4 950 per Family
	30.1. Medicine and Injections (Acute and Chronic) Excluding self-medication	70%	Payable from Benefit Booster
	30.2. Dentistry (Excluding orthodontics)	70%
	30.3. General Practitioners and Specialists (Consultations/visits and procedures/services out-of-hospital, including casualties)	80%
	30.4. Primary Health Care	80%
	30.5. Auxiliary Services	70%
31.	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
32.	Lifestyle Management Screening Tests (Subject to Clinical Guidelines and Protocols)	100%	N$15 000 per Family

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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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