Sapphire - Namibia Medical Care (NMC)

If you are looking for more benefits and want to ensure that you have above average benefits when visiting the doctor, Sapphire is your option. It provides extensively comprehensive benefits to ensure that you have coverage when you need it. The Sapphire option pays 100% of NAMAF tariffs and the overall annual cover is unlimited. Sapphire also provides high chronic medication benefits to assist you in properly managing those chronic ailments. Good individual benefit amounts are provided for and contributions are competitive.

Key Benefits

Hospital: Major Medical Expenses
AHB Cover: GP & Specialist in-hospital services payable to a maximum of 225% of NAMAF Tariff

Benefit	Cover
Accommodation – private ward	100%
Accommodation – other than a recognised hospital	100% of cost
MRI & CT Scans	100%
Internal Appliances & Materials	100% of cost
Oncology – Active Therapy (Surgery, Chemotherapy, Radiotherapy and Hormone Therapy)	100%
Organ Transplant	100%
Refractive Surgery	100%
Maternity - Confinement – Full Procedure 12 Ante-natal Consultations 3 Sonar Scans per Beneficiary per Pregnancy	100%

Ambulance and Evacuation Services

Benefit	Cover
Emergency Ambulance & Flights	100%
Ambulance/Inter-hospital transfer	100%
Other Transport	80% of cost

International Medical Travel Insurance

Benefit	Cover
Medical cover when travelling to foreign countries. For emergency cases only	100% of cost

Day-to-Day Benefits

Benefit	Cover
General Practitioners	100%
Dentistry	100%
Medicine & Injections Acute Chronic Self-medication	80% 80 100%
Optical	100%
Primary Health Care Services	100%
Auxiliary Services	100%
Specified Illness Conditions	100%

Contributions

Individuals
Age Band		M0	M1	M2	M3	M4	M5+
0	25	2 649	4 771	5 705	6 646	7 585	8 536
26	30	3 003	5 402	6 344	7 294	8 230	9 171
31	35	3 354	6 017	6 960	7 898	8 852	9 787
36	40	3 818	6 847	7 805	8 772	9 734	10 697
41	45	4 246	7 599	8 570	9 538	10 518	11 485
46	50	4 625	8 265	9 229	10 192	11 157	12 115
51	55	5 093	9 084	10 044	11 032	12 003	12 976
56	60	5 485	9 778	10 739	11 706	12 677	13 631
61	65	5 892	10 500	11 455	12 407	13 366	14 314
66+		6 313	11 226	12 179	13 108	14 067	15 009

Groups
Age Band		M0	M1	M2	M3	M4	M5+
0	25	2 348	4 138	4 948	5 748	6 548	7 352
26	30	2 580	4 553	5 336	6 115	6 889	7 670
31	35	2 779	4 908	5 659	6 421	7 177	7 925
36	40	3 130	5 541	6 302	7 074	7 836	8 603
41	45	3 500	6 184	6 974	7 751	8 529	9 310
46	50	3 765	6 666	7 421	8 190	8 956	9 731
51	55	4 107	7 268	8 044	8 807	9 578	10 347
56	60	4 538	8 029	8 815	9 589	10 380	11 161
61	65	4 816	8 509	9 285	10 044	10 809	11 572
66+		4 822	8 522	9 294	10 063	10 823	11 587

Individuals: Single Parent Contributions
Age Band		M0	M1	M2	M3	M4	M5+
0	25	2 318	4 175	4 992	5 815	6 637	7 469
26	30	2 628	4 727	5 551	6 382	7 201	8 025
31	35	2 935	5 265	6 090	6 911	7 746	8 564
36	40	3 341	5 991	6 829	7 676	8 517	9 360
41	45	3 715	6 649	7 499	8 346	9 203	10 049
46	50	4 047	7 232	8 075	8 918	9 762	10 601
51	55	4 456	7 949	8 789	9 653	10 503	11 354
56	60	4 799	8 556	9 397	10 243	11 092	11 927
61	65	5 156	9 188	10 023	10 856	11 695	12 525
6+		5 524	9 823	10 657	11 470	12 309	13 133

Groups: Single Parent Contributions
Age Band		M0	M1	M2	M3	M4	M5+
0	25	2 055	3 621	4 330	5 030	5 730	6 433
26	30	2 258	3 984	4 669	5 351	6 028	6 711
31	35	2 432	4 295	4 952	5 618	6 280	6 934
36	40	2 739	4 848	5 514	6 190	6 857	7 528
41	45	3 063	5 411	6 102	6 782	7 463	8 146
46	50	3 294	5 833	6 493	7 166	7 837	8 515
51	55	3 594	6 360	7 039	7 706	8 381	9 054
56	60	3 971	7 025	7 713	8 390	9 083	9 766
61	65	4 214	7 445	8 124	8 789	9 458	10 126
66+		4 219	7 457	8 132	8 805	9 470	10 139

OVERALL ANNUAL BENEFIT			Unlimited Benefit
Category A: Hospital		% NAMAF Tariff	Pre-authorisation: 100% of tariff will be paid out. Without Pre-authorisation: No benefit will be paid out 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 225% of Tariff \|OVERALL LIMIT
		COVER	M	M1	M2	M3	M4	M5+
1.	Hospitalisation 1.1 Accommodation and Theatre	100%	Overall Limit
	1.2 Accommodation in Private Ward (Difference between general ward and private ward tariffs)	100%	Limited to N$10 500 per Beneficiary and N$23 000 per Family
	1.3 Accommodation Other than a Recognised Hospital/Medical Institution (Subject to prior approval & accommodation expenses reimbursement policy)	100% of cost	Limited to N$600 per day per family (Maximum 2 days)
	1.4 Blood Transfusions	100%	Overall Limit
	1.5 Intensive and High Care (Maximum of 3 days, then motivation)	100%	Overall Limit
	1.6 Medicine, Fixed Tariff Procedures, Hospital Apparatus and To Take Out medicine (7 days supply only)	100%	Overall Limit
	1.7 Radiology and Pathology (In-Hospital) – (Additional Hospital Benefit Cover excluded)	100%	Overall Limit
2.	Specialised Radiology Procedures (In and Out of Hospital) Additional Hospital Benefit Cover excluded – Referral from a medical specialist only (referral from GP acceptable in places where there is no medical specialist) (Subject to prior approval)
	2.1 MRI and CT Scans	100%	Limited to N$31 500 per Family
	2.2 Nuclear Medicine	100%	Overall Limit
	2.3 Radiation Oncology	100%	Overall Limit
3.	General Practitioners and Specialists (In-Hospital Services) – Additional Hospital Benefit Cover included	100%	Overall Limit
4.	Internal Appliances and Materials	100% of cost	As per NMC Protocol
5.	Dialysis (Subject to Case Management and MHC guidelines)	100%	Overall Limit
6.	Oncology – Active Therapy (Surgery, Chemotherapy, Radiotherapy and Hormone Therapy) (Subject to Case Management and MHC guidelines)	100%	Overall Limit
7.	Organ Transplant (Subject to Case Management and MHC guidelines)	100%	Overall Limit
8.	Refractive Surgery – All-inclusive (Subject to prior approval and MHC guidelines)	100%	Limited to N$21 250 per Beneficiary once off Limited to N$27 250 per Family Groups have cover from date of joining Individuals have a one-year waiting period
9.	Reconstructive Surgery (Medical necessity only) (Subject to prior approval and subject to strict MHC guidelines)
	9.1 Consultation and Procedure	100%	Limited to N$14 000 per Family
	9.2 Hospitalisation	100%	Overall Limit
10.	Private Nursing (Subject to Case Management)	100%	Limited to N$37 250 per Family
11.	Frail Care (Subject to Case Management)	100%	Sub-limit 10
12.	Psychiatric Treatment – Hospitalisation (Subject to prior approval and MHC Guidelines)	100%	Limited to N$30 250 per Family
13.	Alcoholism / Drug Addiction (Subject to prior approval and MHC guidelines)	100%	Sub-limit 12
14.	Specialised Dental Surgery – Hospitalisation (Subject to pre-authorisation)
	14.1 Maxillo-Facial and Oral Surgery – Hospitalisation (Trauma/Non-elective)	100%	Limited to N$132 000 per Family
	14.2 Maxillo-Facial and Oral Surgery – Hospitalisation (Other/Elective)	100 %	Limited to N$12 250 per Beneficiary Limited to N$19 750 per Family
	14.3 Dental Implant – Hospitalisation	100%	Sub-limit 14.2
	14.4 Maxillo-Facial and Oral Surgery - Internal Prosthesis	100% of cost	Sub-limit 4
15.	Maternity		Groups have cover from date of joining. Individuals have a 9-month waiting period.
	15.1 Confinement – Full Procedure	100%	Overall Limit
	15.2 Ante-natal Consultation – Additional Hospital Benefit Cover excluded	100%	Limited to 12 Consultations per Beneficiary (Pro-rated from date of joining)
	15.3 Sonar Scans(Excluding 3D) – Additional Hospital Benefit Cover excluded	100%	Limited to 3 scans per Beneficiary per Pregnancy
	15.4 Amniocentesis – Additional Hospital Benefit Cover excluded	100%	Overall Limit
	15.5 Midwifery Service – Additional Hospital Benefit Cover excluded	100%	Overall Limit
16.	Insertion of Intrauterine Device w/ Hormone (Mirena) (All-inclusive) (Subject to prior approval)	100%	Limited to N$6 000 per Beneficiary
17.	Stomaltherapy (All-inclusive) (Subject to prior approval)		Limited to N$28 750 per Family Sub-limit is pro-rated from date of joining
18.	Ambulance and Evacuation Services	100%
	18.1 Emergency Ambulance and Flights (Coverage Territory: Angola, Botswana, Eswatini, Kenya, Lesotho, Malawi, Mozambique, Namibia, South Africa, Tanzania, Zambia and Zimbabwe) (Subject to prior approval)	100%	Unlimited Benefit
	18.2 Ambulance/Inter-hospital Transfer (Subject to prior approval)	100%	Overall Limit
	18.3 Other Transport (Subject to prior approval & accommodation expenses reimbursement policy)	80%of cost	Limited to N$9 800 per Family Overall Limit
19.	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+
20.	General Practitioners and Specialists		N$13 250	N$16 750	N$18 750	N$19 000	N$19 250	N$19 500
	20.1 Consultations/Visits (Out-of-hospital, including casualties)	100%	Sub-limit 20
	20.2 Procedures/Services (Out-of-hospital, including casualties)	100%	Sub-limit 20
	20.3 Materials and Disposable Items	100%	Sub-limit 20
	20.4 Radiology and Pathology (Out-of-hospital, including Radiography, Sonography, Medical Laboratory Technology and Chemical Biochemistry) (Referral from a Medical Practitioner)	100%	Sub-limit 20
	20.5 MRI and CT Scans	100%	Sub-limit 2
	Benefit Booster applicable (Additional benefit once limit is exceeded)		Refer to Sub-limit 33
21.	Dentistry
	21.1 Conservative and Specialised Dentistry (Including Dental Therapy)	100%	N$14 750	N$17 500	N$19 250	N$19 750	N$20 250	N$20 750
			Limited to N$14 750 per Beneficiary
	21.2 Dental Implants – Consultation, procedure and cost of dental implant components (Subject to pre-authorisation)		The available benefits are for either in-hospital or in-practice
	21.2.1 In-Hospital	100%	Limited to N$13 500 per Beneficiary Limited to N$22 000 per Family Limited to N$3 500 per dental implant component
	21.2.2 In-Practice	150%	Limited to N$24 000 per Beneficiary Limited to N$36 250 per Family Limited to N$3 500 per dental implant component
	Benefit Booster applicable (Additional benefit once limit is exceeded)		Refer to Sub-limit 33
	21.3 Orthodontics (Subject to prior approval and MHC guidelines)	100%	Limited to N$21 250 per Beneficiary once-off
	21.4 Maxillo-Facial and Oral Surgery (Elective and Non-Elective) – Consultation and Procedure (Subject to pre-authorisation)		The available benefits are for either In-hospital or In-practice
	21.4.1 In-Hospital	100 %	N$5 750	N$6 750	N$7 250	N$7 750	N$8 250	N$8 750
			Limited to N$5 750 per Beneficiary
	21.4.2 In-Practice	150 %	N$8 750	N$10 250	N$11 000	N$11 750	N$12 500	N$13 000
			Limited to N$8 750 per Beneficiary
22.	Medicine and Injections		N$28 250	N$43 900	N$47 800	N$48 700	N$49 350	N$50 000
	22.1 Acute Medicine and Injections Paid at maximum Namibia medicine price list on generics	80%	N$7 750	N$11 750	N$14 500	N$15 000	N$15 250	N$15 500
			Limited to N$7 750 per Beneficiary
	22.2 Chronic Medicine and Injections Paid at maximum Namibia medicine price list on generics	80 %	N$18 750	N$30 250	N$31 250	N$31 500	N$31 750	N$32 000
	22.2.1 Members aged 65 and below 22.2.2 Members aged 66 and above	80% 100%	No Limit per Beneficiary
	22.3 Essential Vaccination/Immunisation (As per WHO Guidelines) Paid at maximum Namibia medicine price list on generics	100%	Sub-limit 22
	Benefit Booster applicable (Additional benefit once limit is exceeded)		Refer to Sub-limit 33
	22.4 Self-medication Paid at maximum Namibia medicine price list on generics	100%	N$1 750	N$1 900	N$2 050	N$2 200	N$2 350	N$2 500
			Limited to N$210 per claim per Beneficiary per day Sub-limit 22
23.	Optical Benefits		N$4 750	N$8 250	N$9 000	N$9 500	N$9 750	N$10 000
			Limited to N$4 750 per Beneficiary every 2 years (including frame) (2019-2020)
	23.1 Optical Tests	100%	Sub-limit 23
	23.2 Spectacles and Lenses	100%	Sub-limit 23
	23.3 Frame	100% of cost	Limited to N$1 800 per Beneficiary Sub-limit 23
	23.4 Readers Spectacles	100% of cost	Limited to N$100 per Family Sub-limit 23
24.	Primary Health Care Services 24.1 Consultations	100%	Sub-limit 20
	24.2 Medicine and Injections Paid at maximum Namibia medicine price list on generics	100%	Sub-limit 22.1
	Benefit Booster applicable (Additional benefit once limit is exceeded)		Refer to Sub-limit 33
25.	Auxiliary Services		N$14 250	N$22 750	N$24 750	N$26 000	N$26 500	N$27 000
			Limited to N$14 250 per Beneficiary
	25.1 Art Therapy	100%	Sub-limit 25
	25.2 Audiology/Speech Therapy	100%	Sub-limit 25
	25.3 Biokinetics	100%	Limited to N$7 000 per Beneficiary Sub-limit 25
	25.4 Chiropractor 25.4.1 Consultation and Procedure 25.4.2 Medicine	100% 80%	Sub-limit 25 Sub-limit 22.1
	25.5 Clinical Psychology/Psychological Counsellor	100%	Limited to N$7 000 per Beneficiary Sub-limit 25
	25.6 Clinical Technology	100%	Sub-limit 25
	25.7 Dietician	100%	Sub-limit 25
	25.8 Hearing Aid Acoustician	100%	Sub-limit 25
	25.9 Homeopathy/Naturopathy/Phytotherapy 25.9.1 Consultation and Procedure 25.9.2 Medicine	100% 80%	Sub-limit 25 Sub-limit 22.1
	25.10 Occupational Therapy	100%	Sub-limit 25
	25.11 Orthotist/Prosthetist	100%	Sub-limit 25
	25.12 Physiotherapy	100%	Limited to N$7 000 per Beneficiary Sub-limit 25
	25.13 Podiatry/Chiropody	100%	Sub-limit 25
	25.14 Social Worker	100%	Limited to N$7 000 per Beneficiary Sub-limit 25
	Benefit Booster applicable (Additional benefit once limit is exceeded )		Refer to Sub-limit 33
26.	Wheelchair (Subject to prior approval) – Inclusive of repair and maintenance	100% of cost	Limited to N$17 000 per Beneficiary every 4 years(2016-2019)
27.	Artificial Limbs (Subject to prior approval)	100% of cost	Limited to N$34 000 per Beneficiary every 2 years (2018 - 2019)
28.	Artificial Eyes (Subject to prior approval)	100% of cost	Limited to N$16 500 per Beneficiary every 4 years (2016-2019)
29.	Hearing Aid Apparatus (Subject to prior approval) – Inclusive of repair and maintenance	100% of cost	Limited to N$30 000 per Family every 2 years (2018- 2019)
30.	Appliances (External) (Subject to MHC guidelines)	80% of cost	Limited to N$4 750 per Family every 2 years
31.	Medical Devices for Diabetes Management (Insulin Pumps, Glucose Reader and Related Consumables) (Subject to prior approval and MHC Guidelines)	80% of cost	Limited to N$56 000 per Family (Insulin Pumps limited to every 4 years per Beneficiary)
32.	Specified Illness Conditions		N$33 250	N$66 500	N$66 500	N$66 500	N$66 500	N$66 500
	32.1 HIV/AIDS (As per National Guidelines for antiretroviral therapy)	100%	Limited to N$33 250 per Beneficiary
	32.1.1 Medicine (Paid at maximum Namibia medicine price list on generics)	100%	Sub-limit 32.1
	32.1.2 First Full HIV Consultation/Assessment	N$440	Once-off benefit Sub-limit 32.1
	32.1.3 Consultation (after the first full HIV consultation/assessment)	N$405	Limited to 6 Consultations per Beneficiary Sub-limit 32.1
	32.1.4 HIV Counselling	100%	Limited to N$1 200 per Beneficiary Sub-limit 32.1
	32.1.5 Pathology Tests	100%	Limited to N$7 250 per Beneficiary Sub-limit 32.1
	32.1.6 HIV Resistance Test (Subject to prior approval)	100%	Sub-limit 32.1
	32.2 Prevention of Mother-to-Child Transmission (PMTCT)	100%	Sub-limit 32.1 As per National Guidelines
	32.3 Post-Exposure Prophylaxis (PEP)	100%	Sub-limit 32.1 As per National Guidelines
	32.4 Pre-Exposure Prophylaxis (PrEP)	100%	Sub-limit 32.1 As per National Guidelines
33.	Benefit Booster Applicable if Medicine and Injections, Dentistry, GP’s and Specialists, Primary Health Care and Auxiliary Services benefits are depleted		Limited to N$3 150 per Beneficiary Limited to N$5 800 per Family
	33.1 Medicine and Injections (Acute and Chronic) – Excluding Self-Medication	70%	Sub-limit 33
	33.2 Dentistry and Dental Implant (Excluding Orthodontics)	70%	Sub-limit 33
	33.3 General Practitioners and Specialists (Consultations/Visits and Procedures/Services out-of-hospital, including casualties)	80%	Sub-limit 33
	33.4 Primary Health Care	80%	Sub-limit 33
	33.5 Auxiliary Services	70%	Sub-limit 33
34.	Health SmartCard	No additional costs. Each dependant receives his/her own SmartCard. Benefits can be verified at service providers 24/7. Next of kin can be contacted immediately.

Download Detailed Benefits

Key Benefits

Ambulance and Evacuation Services

International Medical Travel Insurance

Day-to-Day Benefits

Contributions

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