HMO BENEFITS FOR RETAIL HEALTH PLANS
| Benefits | Pleasant Plus | Pleasant Bliss | Pleasant Luxury |
| Outpatient Limit | Up to a limit of N250,000 | Up to a limit of N350,000 | Up to a limit of N500,000 |
| Registration | Covered | Covered | Covered |
| General consultations / follow up | Covered | Covered | Covered |
| Specialist consultation | Twice in a month | Twice in a month | Covered |
| Prescribed drugs and medicines (recommended for covered services) | Covered | Covered | Covered |
| Lab investigations | Covered | Covered | Covered |
| Plain & contrast X-rays | Covered | Covered | Covered |
| Nutritionist/Dietician consultation | Covered | Covered | Covered |
| Radiological investigations (X-ray) | Covered | Covered | Covered |
| Accident & emergencies: resuscitative or life-saving initial treatment (up to plan limit) | Covered | Covered | Covered |
| Advanced & Complex Investigations (CT Scan, MRI) | Once per annum | One per annum | Twice per annum |
| Drug refills for chronic conditions** | Limit of N120,000 per annum | Limit of N144,000 per annum | Limit of N180,000 per annum |
| ENT Services | Covered | Covered | Covered |
| Inpatient | Up to a limit of N800,000 | Up to a limit of N1,000,000 | Up to a limit of N1,500,000 |
| Admission (including feeding) | Semi-Private ward 25 days per annum | Semi-Private ward 25 days per annum | Semi-Private ward 25 days per annum |
| Instensive Care | 24hours | 48hours | 72 hours |
| Prescribed drugs and medicines (recommended for covered services) | Covered | Covered | Covered |
| Lab investigations | Covered | Covered | Covered |
| Plain & contrast X-rays | Covered | Covered | Covered |
| Physiotherapy | 15 sessions per annum | 20 sessions per annum | 25 sessions per annum |
| Advanced & Complex Investigations (CT Scan,MRI) | Once per annum | Once per annum | Twice per annum |
| Surgeries and day care procedures (minor, intermediate and major) including Cancer Care: Oncology Tests, Drugs, Surgical Therapy*** | Within annual surgery limit of N500,000 per annum | Within annual surgery limit of N750,000 per annum | Within annual surgery limit of N1,000,000 per annum |
| Immunization | |||
| Routine immunization for 0-5 years – NPI (OPV, DPT, measles, pentavalent vaccine, BCG, vitamin A, hepatitis B) | Covered | Covered | Covered |
| Additional Immunization 0-5 (yellow fever, pneumococcal & meningitis) | Covered | Covered | Covered |
| Immunization 6years and above (hepatitis b, yellow fever & meningitis) | Covered | Covered | Covered |
| EYE & DENTAL | |||
| Optical care (consultation and testing) | Covered | Covered | |
| Optical: frames and contact lenses* | N25,000 once in two years | N35,000 once in two years | N50,000 once in two years |
| Optical surgery/Treatment * | Limit of N80,000 per annum | Limit of N100,000 per annum | N150,000 once in two years |
| Dental care (scaling and polishing, pain management, fillings, extractions, preventive care)* | Limit of N80,000 per annum | Limit of N100,000 per annum | Limit of N150,000 per annum |
| PERI-NATAL | |||
| Ante-natal care & delivery services. *** | N250,000 | N400,000 | N600,000 |
| Neonatal care (ear piercing & circumcision) *** | Covered | Covered | Covered |
| Family planning services (counselling, IUCDs, Injectable & oral contraception) | Covered | Includes Norplant | Includes Norplant |
| OTHER SERVICES | |||
| Ambulance services (hospital to hospital within city) | Covered | Covered | Covered |
| HIV/AID care & treatment (free specialist centers) | Covered | Covered | Covered |
| Kidney Dialysis*** | One week | Two weeks | Three Weeks |
| Health checks (up to Outpatient Limit) | Limited to: (physical examination, BP, urinalysis, blood sugar, full blood count, blood group and genotype, HIV screening, chest x-ray, BMI, cholesterol, Hepatitis B & C screening) | Limited to: (physical examination, BP, urinalysis, blood sugar, full blood count, blood group and genotype, HIV screening, chest x-ray, BMI, Hepatitis B & C screening cholesterol, pap’s smear, PSA & mammography) | Limited to: (physical examination, BP, urinalysis, blood sugar, full blood count, blood group and genotype, HIV screening, chest x-ray, BMI, Hepatitis B & C screening cholesterol, pap’s smear, PSA & mammography) |
| Mental health services (consultation and counselling up to 8 weeks)* | Covered | Covered | Covered |
| Provider Access | Tier 2 Hospitals | Tier 2 & NNPC Medical Services | Tier 2 & NNPC Medical |
| Annual Benefit Limit | N1,750,000 per enrollee | N2,200,000 per enrollee | N3,000,000 per enrollee |
| Access fee per person per annum | N235,000.00 | N354,000.00 | N486,000.00 |
| Discount for 4 & above family enrollees | |||
| Group Discount from 10 and above |
** 3 months moratorium applies
*** 1 year moratorium applies
ELIGIBILITY
- Individual between 0 – 60years
EXCLUSIONS
The following are excluded from all plans:
- Overseas treatment
- Transplant surgery.
- Plastic/cosmetic surgeries.
- Family planning services not listed in the covered services
- Home care and domiciliary services.
- Joint replacements and prosthetic limbs.
- Congenital abnormalities.
- Self-inflicted injuries
- Speech disorders
- Speech and hearing aid
- Consultations with unrecognized consultants, hospitals, family doctors, therapists, dental practitioners or complementary medicines practitioners.
- Other medical services not listed in the covered services
Note
The following benefits will not be covered or provided in the first 3 months of the commencement to the scheme:
- Optical care
- Dental care
- Management of chronic diseases
The following benefits will not be covered or provided in the first year of the commencement to the scheme:
- Surgeries
- Cancer Care
- Psychiatric Care
- Kidney dialysis
- Ante-natal care & delivery services
- Neonatal care