2026 Rules Active
2026 Strategy Validated
Maximum Cover for Biological Medicines
Funding for High-Cost Biological Medicine strategy verified
Covering 0 family members
2026 rates applied
Compare Alternatives
Actuarial Strategy Reference
This strategy is generated based on the 2026 Council for Medical Schemes (CMS) registered rules and actuarial pricing matrices.
VERIFIED: 2025-12-20 | SOURCE: SCHEME_BENEFIT_GUIDE_2026
Similar Situations
Key Terms Explained
Key Terms for this Strategy
- Medical Savings Account (MSA)
- A fund of R16,908 included in your premium. You use this for day-to-day expenses like GP visits and scripts. [Source: Council for Medical Schemes Official Benefit Rules]
Common Questions
Is there a penalty if I have a gastroscopy in a normal hospital? [Funding for High-Cost Biological Medicine]
Yes. You will be charged a co-payment of R2,872 if you choose to have a day procedure (like a scope) in an acute hospital instead of a Day Hospital. Strategy reference: ing-2026.
Does the plan cover MRI scans in full? [Funding for High-Cost Biological Medicine]
No. While covered at 100% of Scheme tariff, you must pay a R1,500 co-payment per scan, unless it is for a Prescribed Minimum Benefit (PMB) condition. Strategy reference: ing-2026.
Do I have unlimited cancer cover? [Funding for High-Cost Biological Medicine]
Yes, oncology is covered at 100% of Scheme tariff, but you must strictly adhere to the ICON Network protocols to avoid out-of-pocket costs. Strategy reference: ing-2026.
Will the scheme pay for my emergency room visit? [Funding for High-Cost Biological Medicine]
Only if you have funds available. Casualty visits are paid from your Medical Savings Account (Savings) first, not from the Scheme's risk benefit. Strategy reference: ing-2026.
Is there a limit on hip or knee replacements? [Funding for High-Cost Biological Medicine]
Yes. Internal prostheses are limited to R147,394 per family, with specific sub-limits of R66,108 for hips and R77,001 for knees. Strategy reference: ing-2026.
Does Pace 3 cover depression medication? [Funding for High-Cost Biological Medicine]
Yes. Major depression is covered as one of the 20 Non-CDL chronic conditions, subject to the non-CDL chronic medicine limit of R17,654 (Member) or R35,310 (Family). Strategy reference: ing-2026.
How many pregnancy scans can I get? [Funding for High-Cost Biological Medicine]
The plan covers two 2D ultrasound scans: one in the first trimester (10-12 weeks) and one in the second trimester (20-24 weeks). Strategy reference: ing-2026.
Do I have to use a specific network for glasses? [Funding for High-Cost Biological Medicine]
Yes. The optometry benefit uses the PPN Network. If you use a non-network provider, your consultation refund is capped at R420 and you may face significant co-payments on lenses. Strategy reference: ing-2026.