Sapphire

Key Benefits

Hospital: Major Medical Expenses

AHB Cover: GP & Specialist in-hospital services payable to a maximum of 200% of the NAMAF Tariff

Benefit	Cover
Accommodation and Theatre	100%
Physiotherapy & Biokinetics (post-rehabilitation)	100%
MRI & CT Scans	100%
Internal Appliances & Materials	100% of the Cost
Oncology – (All-inclusive In and Out of Hospital) Consultations and Procedures Hospitalisation Radiation Oncology (A referral is only acceptable from a medical specialist) Oncology Medication (chemotherapy, radiotherapy and hormone therapy)	100%
Dialysis/Organ Transplant	100%
Refractive Surgery	100%
Maternity Confinement – Full Procedure 12 Antenatal Consultations per Beneficiary 6 Sessions, Ante/ Postnatal Classes & Education 3 Sonar Scans per Beneficiary per Pregnancy	100%

Ambulance and Evacuation Services

Benefit	Cover
Emergency Ambulance & Flights	100%
Ambulance/Inter-hospital transfer	100%

International Medical Travel Insurance

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

Day-to-Day Benefits

Benefit	Cover
General Practitioners and Specialists	100%
Dentistry	100%
Medicine & Injections Acute Chronic Essential Vaccination/Immunisation (As per WHO guidelines) Self-Medication	80% 80% 100% 100%
Optical	100%
Primary Health Care Services	100%
Auxiliary Services	100%
Specified Illness Conditions	100%

Contributions

Individuals
Age Band		Main	Adult	Child
0	25	3,298	2,641	1,174
26	30	3,738	2,987	1,174
31	35	4,175	3,315	1,174
36	40	4,752	3,771	1,174
41	45	5,286	4,174	1,174
46	50	5,758	4,531	1,192
51	55	6,341	4,967	1,192
56	60	6,828	5,344	1,192
61	65	7,336	5,736	1,192
66+		7,859	6,116	1,192

Groups
Age Band		Main	Adult	Child
0	25	3,026	2,306	1,005
26	30	3,325	2,542	1.005
31	35	3,581	2,743	1,005
36	40	4,033	3,108	1,005
41	45	4,512	3,458	1,005
46	50	4,851	3,737	1,016
51	55	5,291	4,073	1,016
56	60	5,848	4,498	1,016
61	65	6,205	4,759	1,016
66+		6,213	4,769	1,016

OVERALL ANNUAL BENEFIT (OVERALL ANNUAL LIMIT)			Unlimited Benefit
Category A: Hospitalisation Benefit		% the NAMAF Tariff	Pre-authorisation: 100% of the tariff will be paid out. Without Pre-authorisation: No benefit will be paid except in the case of emergency hospital admissions and after-hours emergencies, weekends and public holidays.
Additional Hospital Benefit Cover: GPs and Specialists In-Hospital services are paid up to a maximum of 200% 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 3 days, then motivation)		Overall Annual Limit
	1.4 Blood Transfusions
	1.5. Radiology & Pathology (in-hospital) Additional Hospital Benefit Cover is excluded
	1.6. Physiotherapy & Biokinetics Additional Hospital Benefit Cover is excluded
	1.6.1. Physiotherapy & Biokinetics (in-hospital)
	1.6.2. Physiotherapy & Biokinetics (post-rehabilitation) Additional benefit once the patient is out of the hospital 12 sessions/ visits per Beneficiary (Benefit available within 3 months from hospital discharge) (Subject to prior approval)
	1.7 Medicine, fixed tariff procedures, hospital apparatus, and to take out medicine (7 days' supply only)
	1.8 Dialysis (Subject to Case Management and MHC guidelines)
	1.9 Organ Transplant (Subject to Case Management and MHC guidelines) Including medical expenses incurred by the donor if the recipient is a Fund member
	1.10. Internal Appliances & Materials (As per NMC protocol)	100% of the Cost
2.	General Practitioners and Specialists (In-Hospital Services) Additional Hospital Benefit Cover is included	200%	Overall Annual Limit
3.	Specialised Radiology Procedures (In & Out of Hospital) Additional hospital benefit cover is excluded A referral is only acceptable from a medical specialist (referral from GP acceptable in places where there is no medical specialist) (Subject to prior approval)	100%	Overall Annual Limit
	3.1 MRI & CT Scans		N$39 500 per Family
	3.2 Nuclear Medicine		Overall Annual Limit
4.	Maternity (Groups have cover from the date of joining. Individuals have a 9-month waiting period)	100%	Overall Annual Limit
	4.1. Confinement – full procedure		Overall Annual Limit
	4.2. Antenatal Consultation 12 consultations per Beneficiary (Pro-rated from the date of joining) Additional Hospital Benefit Cover is excluded		Part of the Maternity Benefit
	4.3. Ante / Postnatal Classes & Education Six sessions per Beneficiary (Pro-rated from the date of joining) Additional Hospital Benefit Cover is excluded
	4.4. Sonar Scans (Excluding 3D) 3 scans per Beneficiary per Pregnancy Additional Hospital Benefit Cover is excluded
	4.5. Tests for Chromosonal and Foetal Abnormalities Additional Hospital Benefit Cover is excluded
	4.6. Midwifery Service Additional Hospital Benefit Cover is excluded
5.	Insertion of Intrauterine Device w/ Hormone (All-inclusive) (Subject to prior approval)	100%	N$6 250 per Beneficiary Overall Annual Limit
6.	Oncology (Subject to Case Management and MHC guidelines)	100%	N$750 000 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 - A referral is only acceptable from a medical specialist
	6.3 Radiation Oncology (A referral is only acceptable from a medical specialist)
	6.4 Oncology Medication (chemotherapy, radiotherapy and hormone therapy)
	6.5 Hospitalisation and Related Procedures In-Hospital		Overall Annual Limit
7.	Refractive 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%	N$23 100 per Beneficiary once-off N$29 600 per Family Overall Annual Limit
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$14 500 per Family
	8.2 Hospitalisation		Overall Annual Limit
9.	Private Nursing/Frail Care/Hospice (Subject to Case Management)		N$38 700 per Family Overall Annual Limit
10.	Psychiatric Treatment – Hospitalisation (Subject to prior approval and MHC Guidelines)	100%	N$32 750 per Family Overall Annual Limit
11.	Alcoholism/Drug Addiction (Subject to prior approval and MHC guidelines)	100%	N$32 750 per Family Overall Annual Limit
12.	Specialised Dental Surgery – Hospitalisation (Subject to pre-authorisation)	100%	Overall Annual Limit
	12.1 Maxillo-Facial & Oral Surgery All-inclusive (trauma/non-elective) (Including dental extractions for children less then 10 years old and wisdom teeth extractions)		N$132 000 per Family
	12.2 Maxillo-Facial & Oral Surgery Hospitalisation Only (other/elective)		N$20 500 per Family
	12.3 Dental Implant – hospitalisation		N$20 500 per Family
	12.4 Maxillo-Facial & Oral Surgery - Internal prosthesis	100% of the 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 & Evacuation Services	100%	Overall Annual Limit
	14.1 Emergency Ambulance & Flights (Territory: SADC Countries) (Subject to prior approval)		Unlimited Benefit
	14.2 Ambulance/Inter-hospital Transfer (Subject to prior approval)		Overall Annual Limit
15.	Medical Referral Subject to accommodation and travelling reimbursement protocols (Subject to prior approval)		Overall Annual Limit
	15.1. Transport	80% of the Cost	N$10 150 per Family
	15.2 Accommodation Other than a Recognised Hospital/Medical Institution (Maximum of 2 days)	100% of the 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 the cost	N$10 000 000 per Incident

CATEGORY B: DAY-TO-DAY BENEFIT		COVER	Sub-limits are pro-rated from the 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		N$15 000	N$19 250	N$21 250	N$21 500	N$21 750	N$22 000
	17.1 Consultations/Visits (out-of-hospital, including casualties)	100%	Payable from General Practitioners and Specialists Benefit
	17.2 Procedures/Services (out-of-hospital, 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 is Applicable (Additional Benefit once limit is exceeded)
18.	Medicine & Injections		N$30 490	N$47 600	N$51 500	N$52 250	N$53 160	N$53 820
	18.1. Acute Paid at the maximum Namibia Medicine Price List on generics	80%	N$8 350	N$12 750	N$15 550	N$16 000	N$16 350	N$16 600
		80%	N$8 350 per Beneficiary
	18.2. Chronic Paid at the maximum Namibia Medicine Price List on generics		N$20 250	N$32 800	N$33 750	N$33 900	N$34 300	N$34 550
	18.2.1. Members aged 65 and below	80%	No Limit per Beneficiary
	18.2.2. Members aged 66 and above	100%	Payable from Medicine & Injections
	18.3. Essential Vaccination/Immunisation (As per WHO guidelines) Paid at the maximum Namibia Medicine Price List on generics	100%	Payable from Medicine & Injections
	Benefit Booster is Applicable (Additional benefit once limit is exceeded)
	18.4. Self-medication Paid at the maximum Namibia Medicine Price List on generics	100%	N$1 890	N$2 050	N$2 200	N$2 350	N$2 510	N$2 670
		100%	N$225 per claim per Beneficiary per day
19.	Primary Health Care Services		N$1 250	N$1 500	N$1 700	N$1 900	N$2 100	N$2 300
19.	Primary Health Care Services		N$1 250 per Beneficiary
	19.1. Consultations & Procedures	100%	Payable from Primary Health Care Services
	19.2. Medicine & Injections Paid at the maximum Namibia Medicine Price List on generics	100%	Payable from Acute Medication
	Benefit Booster is Applicable (Additional Benefit once limit is exceeded)
20.	Dentistry
	20.1 Conservative and Specialised Dentistry (Including Dental Therapy)	100%	N$15 750	N$19 000	N$20 750	N$21 250	N$21 750	N$22 250
		100%	N$15 750 per Beneficiary
	20.2 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
	20.2.1 In-Hospital	100%	N$14 500 per Beneficiary N$23 900 per Family N$3 800 per dental implant component
	20.2.2 In-Practice	150%	N$26 500 per Beneficiary N$40 000 per Family N$3 800 per dental implant component
	Benefit Booster is applicable (Additional benefit once limit is exceeded)
	20.3 Orthodontics (Subject to prior approval and MHC guidelines)	100%	N$23 000 per Beneficiary once-off
	20.4 Maxillo-Facial and Oral Surgery (Elective) Consultation and Procedure (Subject to pre-authorisation)		The available benefits are for either In-hospital or In-practice
	20.4.1 In-Hospital	100 %	N$6 250	N$7 250	N$7 800	N$8 300	N$8 800	N$9 350
	20.4.1 In-Hospital	100 %	Limited to N$6 250 per Beneficiary
	20.4.2 In-Practice	100 %	N$9 600	N$11 150	N$11 950	N$12 700	N$13 500	N$14 000
	20.4.2 In-Practice	100 %	Limited to N$9 600 per Beneficiary
21.	Optical Benefits (Every 2 years (Including frame) (2023-2024)		N$4 900	N$9 800	N$10 100	N$10 400	N$10 700	N$11 000
21.			N$4 900 per Beneficiary
	21.1. Optical tests	100%	Payable from Optical Benefits
	21.2. Spectacles & Lenses	100%	Payable from Optical Benefits
	21.3. Frame	100% of Cost	N$1 870 per Beneficiary
	21.4. Readers Spectacles	100% of Cost	N$105 per Beneficiary
22.	Auxiliary Services		N$15 300	N$24 500	N$26 500	N$27 750	N$28 250	N$28 750
22.	Auxiliary Services		N$15 300 per Beneficiary
	22.2. Audiology/Speech Therapy	100%	Payable from Auxiliary Services
	22.1. Art Therapy	100%	Payable from Auxiliary Services
	22.3. Biokinetics	100%	N$7 560 per Beneficiary
	22.4. Chiropractor		Payable from Auxiliary Services
	22.4.1. Consultation & Procedure	100%
	22.4.2. Medicine	80%
	22.5. Clinical Psychology/Psychological Counsellor	100%	N$7 560 per Beneficiary
	22.6. Clinical Technology	100%	Payable from Auxiliary Services
	22.7. Dietician	100%
	22.8. Hearing Aid Acoustician	100%
	22.9. Homeopathy/Naturopathy/Phytotherapy
	22.9.1. Consultation & Procedure	100%
	22.9.2. Medicine	80%	Payable from Acute Medicine and Injections
	22.10. Occupational Therapy	100%	Payable from Auxiliary Services
	22.11. Orthotist/Prosthetist	100%	Payable from Auxiliary Services
	22.12. Physiotherapy	100%	N$7 560 per Beneficiary
	22.13. Podiatry/Chiropody	100%	Payable from Auxiliary Services
	22.14. Social Worker	100%	N$7 560 per Beneficiary
	Benefit Booster Applicable (Additional benefit once limit is exceeded)
23.	Wheelchair (Subject to prior approval) Inclusive of repair & maintenance	100% of Cost	N$17 750 per Beneficiary every 4 years (2020-2023)
24.	Artificial Limbs (Subject to prior approval)	100% of Cost	N$36 750 per Beneficiary every 2 years (2022-2023)
25.	Artificial Eyes (Subject to prior approval)	100% of Cost	N$17 250 per Beneficiary every 4 years (2020-2023)
26.	Hearing Aid Apparatus (Subject to prior approval) Inclusive of repair & maintenance	100% of Cost	N$35 000 per Family every 3 years for both ears (N$17 500 per ear) (2023-2025)
27.	Appliances (External) (Subject to MHC guidelines)	80% of the Cost	N$5 150 per Family
28.	Medical Devices for Diabetes Management (Subject to prior approval and MHC guidelines)
	28.1. Insulin Pumps	80% of the Cost	N$40 000 per Beneficiary every 4 years (2023– 2026)
	28.2. Other Devices (Glucose Monitoring System / Glucose Reader)		N$20 000 per Beneficiary
	28.3. Diabetes-related Consumables	80% of the Cost	N$36 000 per Beneficiary
29.	Specified Illness Conditions As per the National Guidelines (Sub-limits are pro-rated from the date of joining)		N$36 100	N$72 200	N$72 200	N$72 200	N$72 200	N$72 200
	29.1. HIV/AIDS (As per the National Guidelines for antiretroviral therapy)		N$36 100 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	N$480
	29.1.3. Consultation (after the first full HIV consultation/assessment) 6 consultations per Beneficiary	N$440
	29.1.4. HIV Counselling	100%	N$1 300 per Beneficiary
	29.1.5. Pathology Tests	100%	N$7 800 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)	100%
	29.3. Post-Exposure Prophylaxis (PEP)	100%
	29.4. Pre-Exposure Prophylaxis (PrEP)	100%
30.	Benefit Booster Applicable if medicine & injections, dentist, GPs & Specialists, primary health care & auxiliary services benefits are depleted		N$3 400 per Beneficiary N$6 270 per Family
	30.1. Medicine & Injections (Acute & Chronic) Excluding self-medication	70%	Payable from Benefit Booster
	30.2. Dentistry (Excluding orthodontics)	70%
	30.3. General Practitioners & Specialists (Consultations/visits & procedures/services out-of-hospital, including casualties)	80%
	30.4. Primary Health Care	80%
	30.5. Auxiliary Services	70%

Download Sapphire 2023 Detailed Benefits

Sapphire - Our Benefits - Options & Benefits | NMC

Key Benefits

Ambulance and Evacuation Services

International Medical Travel Insurance

Day-to-Day Benefits

Contributions

Announcements

Sapphire - Our Benefits - Options & Benefits | NMC

Key Benefits

Ambulance and Evacuation Services

International Medical Travel Insurance

Day-to-Day Benefits

Contributions

Announcements ×

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