This is an option on which your Medical Scheme offers primary care benefits that are obtainable from a network of providers (General Practitioners (GPs), Dentists, and Optometrists). Members must make use of the network providers to qualify for primary care benefits. Benefits are also subject to clinical protocols and formularies.
Who is CareCross?
CareCross is a managed care organisation appointed by your Medical Scheme to provide primary healthcare through their provider network.
The CareCross provider network is made up of General Practitioners (GPs), Dentists, and Optometrists who are conveniently located across South Africa. These providers have been selected to render services to you and your family.
What are clinical protocols and formularies?
Protocols are a set of clinical guidelines, while formularies refer to lists of medicines and/or tests that apply to certain benefits on the network option. Unless otherwise specified, benefits on your option are generally unlimited as long as they are within the CareCross protocols and formularies and requested by your CareCross GP.
How do I access my benefits?
The first and most important step is to select a CareCross GP from whom you will obtain services.
Note that each member of the family is able to select a CareCross GP that suits them. This means that where family members live apart, each dependant is still able to visit a CareCross doctor near him/her.
Refer to the CareCross website, www.carecross.co.za or contact the CareCross Call Centre on 0860 103 491 for more information on a CareCross provider closest to you.
Please remember that consulting hours for individual CareCross General Practitioners may vary. Doctors in general are however open during office hours between 9am5pm on week days and until 12pm on Saturdays.
What are the benefits covered by CareCross GPs?
As many consultations as are medically necessary to get you healthy.
Selected minor trauma treatment, such as stitching of wounds.
Medication for acute ailments subject to the CareCross formulary.
Registration and treatment of your chronic condition.
Your GP should inform you of any services that are not part of the CareCross benefits.
You will be responsible for the payment of any services outside of the CareCross benefits.
Accounts for services rendered at your CareCross GP will be submitted by your CareCross GP to CareCross on your behalf.
What is acute medication and where do I get it?
Acute medication refers to medicines prescribed by GPs to treat common, acute illnesses such as influenza (flu). Acute medication is provided subject to a formulary.
Should you require acute medication, there are one of two ways in which you may receive the medication:
A CareCross dispensing GP will provide you with the medication from his consulting rooms or,
A non-dispensing CareCross GP will give you a prescription which can be filled at any Mediscor enabled pharmacy.
Please ask your non-dispensing GP to direct you to the nearest Mediscor enabled pharmacy.
Your GP should advise you if the medicine that you need is not on the CareCross acute medicine formulary (list).
You will be required to pay for medicines which are not on the acute formulary.
What happens if I need a GP after hours or if on holiday?
You may visit any available GP or the nearest hospital outpatient facility.
The benefit for after-hours visits is limited to 3 visits per family to a maximum of R1 000 per family per year.
You will be required to pay for these visits/treatments upfront.
You may however claim back the costs of these services by completing a reimbursement form obtainable from CareCross (also available on the CareCross website).
The form and the detailed accounts must be submitted to CareCross for review.
Once validated, CareCross will refund you the appropriate costs within 30 days from date of receipt of your claim. Please note that your claim must reach CareCross Health within 4 months from the date of treatment to qualify for benefits.
What are my dental benefits?
Dental benefits are only obtainable from a contracted CareCross dentist.
The CareCross dental benefits are for basic dentistry only and are subject to clinical protocols.
Benefits are limited to primary extractions, fillings, scaling and polishing, emergency pain relief.
Root canal treatment, crowns and other advanced dentistry arenot covered.
Please contact CareCross to confirm your benefits.
What cover do I have for optometry?
CareCross will only provide cover at a CareCross contracted optometrist.
The benefit covers an optical test, a basic frame from a selected range of frames, with white standard mono- or bifocal lenses; or contact lenses to the value or R400. If you choose a frame outside of the selected range of frames, CareCross will pay R150 towards this frame. You will have to pay the balance of the frame directly to the optometrist.
Kindly note that any additional services such as tinting etc. are not covered under this benefit. You will have to pay these services yourself.
The optical benefit is available per beneficiary, every 24 months.
What if I have a chronic condition?
Please consult your CareCross GP to confirm your diagnosis.
Once confirmed, the CareCross GP will complete a chronic application form to register you for chronic benefits.
This form will be forwarded to CareCross by your GP, for an evaluation.
You will be notified via SMS as soon as the chronic application has been processed.
Approval of chronic medicine benefits is subject to clinical protocols for the chronic conditions covered by CareCross and a chronic medicine formulary applies.
Chronic benefits are subject to the CareCross list of chronic conditions and chronic medicine formularies.
Should you have any enquiries in this regard, please contact the CareCross Call Centre on 0860 103 491.
What if I need chronic medication?
You will be advised if your request for chronic medication has been approved.
If approved, you will be contacted by the CareCross chronic medicine provider to arrange access to your chronic medicines.
Approved chronic medicines are obtainable from selected pharmacies. The CareCross chronic medicine provider will assist you with selecting a pharmacy convenient for you.
Note that most chronic medicines may only be collected once per month.
It may also be necessary for you to visit your CareCross GP to renew your chronic script at least every 6 months.
What about blood tests (pathology)?
Basic blood tests according to an approved tariff list are only covered as requested by your CareCross GP.
Your CareCross GP has a list of these tests and will advise you whether or not the required tests are covered by CareCross.
Your CareCross GP may draw the specimen himself or he may send you with the completed yellow CareCross referral form to the closest pathology laboratory to have the tests done.
Important points to remember:
Always have your membership card with you.
Know the provider’s practice hours and try to stay within these practice hours.
Should you require blood tests and/or x-rays, the CareCross GP will request these tests on the yellow CareCross request form. Always check with your GP that all the tests called for are covered as he/she may need to call for authorisation for a test not on the list.
Ask your GP questions if you need more information or if you are unsure of the treatment.
You will be liable for the costs of services outside the CareCross Health list of defined benefits.
Contact the CareCross Call Centre on 0860 103 491 if you have any questions about your primary care benefits.
What if I need X-rays (radiology)?
The CareCross benefits cover a list of X-rays that may be performed by a radiologist.
Your CareCross GP will advise you whether or not the required X-ray is covered.
Your CareCross GP will complete a yellow CareCross referral form for the radiologist, indicating the type of X-ray to be performed.
Your GP will direct you to the closest Radiology practice to have the X-ray performed.
