OUT-OF-HOSPITAL BENEFITS DAY-TO-DAY BENEFITS IN-HOSPITAL BENEFITS. Standard. Page 12

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1 Standard

2 If you are single or married with children and wanting peace of mind that your family s general medical needs are covered, without having to break the bank then this product is perfect for you. Overall annual limit (OAL) - Unlimited MONTHLY CONTRIBUTIONS OUT-OF-HOSPITAL BENEFITS Out-of-hospital claims excluding Network GP consultations will be paid from current available savings first. Once savings are depleted, claims will be paid from the day-to-day benefit. Main member IN-HOSPITAL BENEFITS Adult dependant These benefits include major medical events. Child dependant R2 683 R2 321 R784 Your fourth and subsequent children will be covered free of charge. DAY-TO-DAY BENEFITS Main member Adult dependant Savings R1 212 R1 056 R360 Child dependant The day-to-day benefit covers out-of-hospital general radiology, pathology, paramedical services (such as audiology, physiotherapy, occupational therapy and more) and specialist consultations, if referred by your family doctor. GP consultations Specialist consultations Pathology General radiology Specialised radiology Paramedical services (Allied medical professions) - speech therapy, occupational therapy, dietetics Prosthesis internal and external Internal nerve stimulators Cochlear implants Mental health hospitalisation Take home medication (TTO) Physical rehabilitation Alternatives to hospitalisation Oncology Organ transplants Renal dialysis Unlimited, at 100% of the Bonitas Rate Network Specialists: Unlimited, covered in full Non-network Specialists: Unlimited, covered at 100% of the Bonitas Rate Unlimited, at 100% of the Bonitas Rate Unlimited, at 100% of the Bonitas Rate Unlimited, subject to pre-authorisation Unlimited, at 100% of the Bonitas Rate R per family, per year ICPS is the **DSP for hip and knee replacements a R5 000 co-payment is payable when not using the DSP. R per family, per year R per family, per year R per family, per year R400 per beneficiary, per admission R per family, per year R per family, per year R per family, per year Unlimited, subject to treatment protocols Unlimited, subject to treatment protocols Main member only R4 020 Main member + 1 dependant R6 140 Main member + 2 dependants R6 590 Main member + 3 dependants R7 110 Main member + 4 or more dependants R7 600 GP consultations In-network Out-of-network (Sub-limit to In-network) Main member only R3 580 R1 160 Main member + 1 dependant R5 260 R1 790 Main member + 2 dependants R5 790 R1 950 Main member + 3 dependants R6 100 R2 050 Main member + 4 or more dependants R6 630 R2 210 *Specialist consultations Acute medication General radiology Pharmacy Advice Therapy (PAT) Pathology Paid from available savings, then covered from day-to-day benefits Paid from available savings, then covered from day-to-day benefits Paid from available savings, then covered from day-to-day benefits Paid from available savings Paid from available savings, then covered from day-to-day benefits Standard Page 12

3 Mental health consultations Paramedical services R per family, per year (sub-limit to mental health hospitalisation, in and out of hospital consultations) Paid from available savings, then covered from day-to-day benefits Oral hygiene 2 x annual scale and polish treatments per beneficiary (once in 6 months) Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age Specialised radiology R per family, per year (subject to pre-authorisation) Benefit for fluoride is limited to beneficiaries between ages 5 & 16 years Standard General medical appliances Stoma care products Hearing aids R6 900 per family, per year General medical appliances limit may be exceeded by R5 600 per year R per family, per two year cycle (10% co-payment) Foot orthotics R3 900 per beneficiary, per year (10% co-payment) Appliances - wheelchairs, CPAP machines, etc. HIV/Aids Optometry Vision examination (Iso-Leso members) Vision examination (Non Iso-Leso members) Single vision lenses (glass/plastic) Bifocal lenses (glass/plastic) Multifocal lenses (glass/plastic) Frames Contact lens materials Basic dentistry Consultations X-rays: Intra-oral X-rays: Extra-oral Included in general medical appliances limit R per beneficiary, per year (if registered on Aid for Aids program) R5 270 per family, per two year cycle R490 per beneficiary, per two year cycle R350 per beneficiary, per two year cycle R160 per beneficiary, per lens, per two year cycle R350 per beneficiary, per lens, per two year cycle R700 per beneficiary, per lens, per two year cycle R800 per beneficiary, per two year cycle R1 750 per beneficiary, per two year cycle Covered at the Bonitas Dental Tariff (BDT) 2 x annual check-ups per beneficiary (once in 6 months) Benefit is subject to managed care protocols 1 x per beneficiary, per three year cycle Fillings Root canal therapy and extractions Plastic dentures and associated laboratory costs Specialised dentistry Partial metal frame dentures and associated laboratory costs Crown and bridge and associated laboratory costs Implants and associated laboratory costs Orthodontics and associated laboratory costs Benefit for fillings are granted once per tooth in 365 days Benefit for re-treatment of a tooth is subject to managed care protocols A treatment plan and x-rays may be required for multiple fillings Benefit is subject to managed care protocols 1 x set of plastic dentures (an upper and a lower) per beneficiary, per four year cycle Covered at the Bonitas Dental Tariff (BDT) 1 x partial frame (an upper or a lower) per beneficiary, per five year cycle Benefit is subject to managed care protocols Subject to a DENIS Designated Service Provider Network Pre-authorisation is required 1 x crown per family, per year Benefits for crowns will be granted once per tooth, per five year cycle A treatment plan and x-rays may be requested No benefit Pre-authorisation is required Benefit is subject to managed care protocols Orthodontic treatment is granted once per beneficiary, per lifetime Additional benefit may be considered where specialised dental treatment is required Page 13

4 On pre-authorisation cases will be clinically assessed by using an orthodontic needs analysis. Benefit allocation is subject to the outcome of the needs analysis and funding can be granted up to 80% of BDT Benefit for Orthodontic treatment will be granted where function is impaired Benefit will not be granted where Orthodontic treatment is required for cosmetic reasons Only one family member may commence Orthodontic treatment in a calendar year Benefit for fixed comprehensive treatment is limited to individuals between ages 9 & 18 years Pre-authorisation is required Benefit is subject to managed care protocols Benefit is limited to conservative, nonsurgical therapy only and will only be applied to members who are registered on the Periodontal Program * Subject to the specialist network. **Designated Service Provider CHRONIC BENEFITS These offer cover for conditions that require medicine on an ongoing basis. The Standard option offers cover for all of the following 44 chronic conditions. Cover is limited to R8 250 per beneficiary and R per family, per year on the Comprehensive Formulary. This is subject to pre-authorisation. A 40% co-payment will be required if you decide to use a non-dsp to obtain your medication. Pharmacy Direct is the **DSP for chronic medication. Once this amount is depleted, you will still be covered for the 27 Prescribed Minimum Benefits, highlighted below, subject to the use of in-formulary medicine. Periodontics 1. Acne 16. Crohn s Disease 31. Hypertension 2. Addison s Disease 17. Depression 32. Hypothyroidism 3. Allergic Rhinitis 18. Dermatitis 33. Multiple Sclerosis 4. Ankylosing Spondylitis 19. Diabetes Insipidus 34. Narcolepsy Maxillo-facial surgery and oral pathology Surgery in the dental chair Hospitalisation (general anaesthetic) Benefit is subject to managed care protocols Pre-authorisation is required A co-payment of R2 000 per hospital admission applies Admission protocols apply General anaesthetic benefits are available for children under the age of 5 years for extensive dental treatment General anaesthetic benefits are available for the removal of impacted teeth. Benefit is subject to managed care protocols Benefit is subject to managed care protocols Pre-authorisation is required Benefit is subject to managed care protocols Benefit is limited to extensive dental treatment Please refer to the last section herein for exclusions and for Scheme rules & exclusions 5. Asthma 20. Diabetes Type Obsessive Compulsive Disorder 6. Attention Deficit Disorder (5-18 Year Olds) 21. Diabetes Type Panic Disorder 7. Barrett s Oesophagus 22. Dysrhythmias 37. Parkinson s Disease 8. Behcet s Disease 23. Eczema 38. Post-Traumatic Stress Syndrome 9. Bipolar Mood Disorder 24. Epilepsy 39. Rheumatoid Arthritis 10. Bronchiectasis 25. Gastro-Oesophageal Reflux Disorder 40. Schizophrenia Standard Laughing gas in dental rooms 11. Cardiac Failure 26. Glaucoma 41. Systemic Lupus Erythematosus IV conscious sedation in rooms Scheme exclusions 12. Cardiomyopathy 27. Gout 42. Tourette s Syndrome 13. Chronic Obstructive Pulmonary Disease 28. Haemophilia 43. Ulcerative Colitis 14. Chronic Renal Disease 29. Hyperlipidaemia 44. Zollinger-Ellison Syndrome 15. Coronary Artery Disease 30. HIV/Aids Page 14

5 Standard SUPPLEMENTARY BENEFITS At Bonitas we believe in giving you more. These additional benefits provide cover in or out-of-hospital and payable from OAL. Maternity care Per event Infant paediatric benefit Childhood illness benefit Preventative care 12 x ante-natal consultations 2 x 2D scans 4 x post-natal consultations with a midwife R1 100 for ante-natal classes 1 x amniocentesis 2 x consultations per beneficiary under 1 year of age 2 x consultations per beneficiary between ages 1 and 2 years 2 x GP consultations per beneficiary between ages 2 and 12 years Subject to DSP Women's health 1 x mammogram - female members between ages 50 & 74 years, per two year cycle 1 x pap smear - female members between ages 21 & 65 years, per three year cycle General health 1 x annual HIV test per beneficiary, per year 1 x annual Flu vaccine per beneficiary, per year Cardiac health 1 x full Lipogram - members 20+ years of age, per five year cycle Elderly health 1 x lifetime Pneumococcal vaccine - members 65+years of age 1 x annual Faecal Occult blood test - members between ages 50 & 75 years Wellness screening benefit 1 x assessment per beneficiary, per year at a **DSP Limited to: Wellness extender Blood pressure test Glucose test Cholesterol test Body mass index Waist to hip ratio assessment R1 400 per family per year Subject to registration and completion of health risk assessment per beneficiary Beneficiary may then choose from the following: GP consultation Biokineticist consultation Dietician consultation Physiotherapy consultation Wearable devices (subject to approval) Smoking cessation program (subject to approval) Page 15

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7 All about our processes and partners The YourHealth Portal Maternity Prescribed Minimum Benefits Managed Care Medicine Management Pharmacy Advised Therapy (PAT) Chronic Medicine Pharmacy Direct Hospital Management Networks GP Network Specialist Referrals Specialist Network The Standard Select and BonFit Hospital Network Dental Benefits Optical Benefits Diabetic Program Hip and Knee Replacement Program HIV/Aids Management Emergency Medical Services Exclusion List Termination of Bonitas Membership The YourHealth Portal The YourHealth Portal is an exciting online educational web and mobile health portal that gives you as a beneficiary access to an abundance of resources in order to help you make better health choices and to be well informed. The portal includes e-tutorials and educational articles, tools and quizzes, and so much more, all housed in an easy to use online space. Easily accessible through the secure member zone, you will have access to the following: E-tutorials - covering topics such as asthma, backache, healthy eating, depression, diabetes, hypertension, smoking cessation, stress, weight loss and work place health. Weekly stepby-step s with practical advice, motivating case studies and a short questionnaire to help you to assess your understanding Wellness programs including fitness and nutrition programs - personalised interactive diet and fitness programs with week-by-week dietary and exercise guidelines, based on a profilesetting questionnaire. Your performance is tracked and displayed Pregnancy program - regular electronic communication to assist moms and dads during this journey through life A to Z database of diseases and conditions Condition Centres (provide disease related information and articles on a number of important chronic conditions) Databases of symptoms, medication, first aid and wellness Self-assessment tools What do I need to register? Membership number ID number address A username and Password How to register on Member Zone to access the YourHealth Portal Visit the Bonitas website at Go to the top right hand corner of the page and click on Login/Registration This will take you to the Account Login Page where you can either sign in or create a new account If you are already registered to log into the secure area where you can view personal information: Fill in your username and password and click on Sign in to access your account Click on YourHealth Portal Page 56

8 If you are not registered to log into the secure area where you can view personal information: Click on Register Click on Members Fill in your membership number and click Validate Code Confirm or choose from the list of members/dependants to indicate your status and name and click Select Enter your chosen Username and validate with your address Create a password and confirm your password Read through the terms and conditions and then click Create Account to complete the process Click on YourHealth Portal Maternity At Bonitas we strive to create the best experience for you and your loved ones during your pregnancy by providing you and your unborn child with the necessary health information and support. The Scheme will supply every pregnant member with a mother and baby gift pack when registered on the maternity program. How do I register? Register by either logging on to the Bonitas website or contacting the call centre. Go to in order to login onto the member zone. Call between 8:30am and 4:00pm Monday to Friday to register for your mother and baby gift pack. This number is not available on public holidays or weekends What information do I need when I apply for the mother and baby gift pack? Membership number Name and surname Contact details Delivery address Alternative delivery address Date of expected delivery Please note: In order to ensure that you receive your mother and baby gift pack, the courier company will be in contact with you to arrange a suitable date and time for delivery. Prescribed Minimum Benefits (PMB) By law, all medical aids are required to fund the diagnosis, treatment and care of any emergency medical condition and a list of 270 groups of conditions known as Diagnosis and Treatment Pairs, which includes 27 common chronic conditions known as Prescribed Minimum Benefit conditions. Which PMB conditions are covered by Bonitas? Emergency medical conditions An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not provided, the emergency could result in damage to bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death. Diagnosis and Treatment Pairs (270 medical conditions) The Regulations of the Medical Schemes Act provide a long list of conditions identified as Prescribed Minimum Benefit conditions. The list is in the form of Diagnosis and Treatment Pairs (DTPs). A DTP links a specific diagnosis to a treatment and indicates how these PMB conditions should be treated. Please note: It is not always possible to diagnose a condition before admitting a patient for treatment. However, if doctors suspect that the patient suffers from a condition that is a PMB condition, the medical fund will need to approve treatment in order for it to be paid correctly. Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time. The 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories: Brain and nervous systems Eye Ear, nose, mouth and throat Respiratory system Heart and blood vessels Page 57

9 Gastrointestinal Liver, pancreas and spleen Musculoskeletal Skin and breast Endocrine, metabolic and nutritional Urinary and male genital system Female reproductive system Pregnancy and childbirth Haematological, infectious and miscellaneous systemic conditions Mental illness Chronic conditions The following 27 conditions must be covered: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy Chronic Obstructive Pulmonary Disorder Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus Type 1 Diabetes Mellitus Type 2 Dysrhythmias Epilepsy Glaucoma Hemophilia HIV/Aids Hyperlipidemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis Did you know? PMB diagnoses may not legally have Scheme Specific Exclusions applied to them. For example, if you contract septicaemia after cosmetic surgery, Bonitas has to provide healthcare cover for the treatment of the septicaemia because it is a PMB condition. The cost of the cosmetic surgery would however, remain uncovered, as this is on the Exclusion List. Do I need to apply for Prescribed Minimum Benefits? Although the process is mostly automated and these conditions are identified through the ICD-10 (diagnosis) codes reflected on your claims, you can apply for Prescribed Minimum Benefits by calling the call centre or by logging into How will PMB s be covered? As per legislation, you will be provided with at least the minimum treatment needed for you PMB condition. Your Fund will pay costs in full for PMB treatment only received from our DSP s. This will be paid from your available benefit limits first, then your treatment will be covered from risk. For example, radiology services will be paid from your Radiology annual sub-limit. Once your benefit limits are reached, further services clinically appropriate for your PMB condition will continue to be paid from a risk pool. If further treatment is needed for your condition, your treating doctor will need to submit clinical motivation for assessment and approval. How can I avoid rejected PMB claims? Check that your doctor (or any other medical service provider) has placed the correct ICD-10 code on your invoice. ICD-10 codes provide accurate information on your diagnosis and help the Scheme to decide what benefits you are entitled to and how these benefits should be paid. ICD-10 codes must also be provided on medicine prescriptions and referral notes to other healthcare providers (e.g. pathologists and radiologists) who are not able to make a diagnosis, therefore they require the diagnosis information from your referring doctor in order for their claims to be paid correctly by the Scheme. Did you know? Medical Schemes are obliged by law to treat information about members conditions as confidential. Page 58

10 What do I do if my PMB claim is rejected? In the event of your PMB claim being rejected, you can contact the Bonitas call centre to query the rejection. Once diagnosed, please keep all your supporting documents on file as the consultant may ask for this information when advising on your claim. Managed Care What is managed care? The term managed care describes a range of techniques that aim to reduce instances of high cost treatment and hospitalisation that are caused by a medical condition, sometimes due to complications or deterioration, which could have been avoided or improved through quality care and support. By looking at both the type of treatment you are receiving from your doctor and the cost thereof, we aim to improve the quality of care while managing your benefits more effectively. Each Managed Care program has specific criteria and protocols which are followed. The aim of these programs is to ensure that you get good quality medical care while managing your benefits carefully, thereby also minimising the clinical and financial risk to the Scheme. In some cases, we have agreements with doctors, hospitals and healthcare professionals to provide you with a range of services at a reduced cost. With your consent, we work closely with your doctors to help your benefits stretch further and make sure that you are supported more than adequately. Our Managed Care programs put you on the path to wellness by supporting you through your treatment. They cover everything from chronic medicine, to the long-term treatment of a condition like diabetes and emergency hospitalisation. Which Managed Care programs do Bonitas offer? We offer a variety of programs that coordinate care for everything from back ailments to oncology. Chronic Medicine Management This program ensures that you are covered for the treatment of a list of chronic diseases and provides you with quick and easy methods to update your medicine. It also ensure you aren t paying too much for your medicine by working together with the pharmaceutical industry to regulate medicine prices, to keep track of new products and generics and negotiate dispensing fees. Hospital Benefit Management This program will help you to pre-authorise your hospital stay and support you through the process to make sure that you know what to expect when you re admitted and discharged. It will ensure that your benefits are managed effectively. Oncology Benefit Management This program offers you emotional support through social workers and clinical staff and manages your oncology benefits, on your behalf, by liaising with your treating doctor regarding your treatment plan and, where possible, matching it to your available benefits. Bonitas has partnered with The Independent Clinical Oncology Network (ICON) of dedicated specialist oncologists who subscribe to the ICON culture of patient-centric and ethical cancer care. The network represent 80% of the private practising oncologists with a national geographic footprint. The partnership with Bonitas focuses on the enhancement of every aspect of quality of care including patient-centeredness, clinical outcomes and affordability of care. Disease Management through Integrated Care This program supports you through your prescribed treatment to ensure you are getting the best care and doing what you can to get better. A team of health coaches help you to identify the areas you need to improve on, offer you advice on your condition and work together with your treating doctor to give you the best support possible. The Bonitas Back Rehabilitation Program If you are diagnosed with certain back and neck conditions, you will be provided with advice on the most appropriate care, as well as have access to physiotherapists and doctors, where clinically appropriate, that will help you to manage and improve your condition. Contact details: Chronic Medicine Management Call: chronicmeds@bonitas.co.za Hospital Authorisations Call: hospital@bonitas.co.za Page 59

11 Oncology Management Call: Medicine Management Pharmacy Advised Therapy (PAT) What is PAT? You don t always have to go to a doctor to get medicine. Your pharmacist can recommend and dispense certain medicines without a doctor s prescription. When is it useful? If you have a mild sore throat, cold, a mild cough or anything similar, ask your pharmacist to dispense appropriate medicine and to clearly write PAT on your claim. Why do it? The cost of this claim is deducted from your normal day-to-day benefit or savings accounts. You don t have to pay for this out of your pocket and you save on the cost of a consultation with your doctor (subject to benefit limit). Chronic medicine Chronic medicine is medication used on an ongoing basis to treat certain chronic health conditions. Did you know? Common chronic conditions include heart disease, diabetes, hypertension, arthritis, asthma and osteoporosis. How do I apply for the chronic medicine benefit? You, your doctor or pharmacist may apply for chronic registration. You will need to have the following information on hand: Your membership number The beneficiary s date of birth The ICD 10 code The doctor s practice number The medicine details Some chronic medication may require additional clinical information. Apply via telephone Call and follow the voice prompts. Once you select the appropriate option your call will be routed through to a consultant who will guide you through the process. Apply online Go to and log in as a member. Go to Clinical Information and click on Online Chronic Application. Follow the prompts on the system and once all information has been captured click on View Summary. You can print this screen for your records. Click on Submit and a reference number will be provided for follow up on the progress of the application. What happens after I register on the program? Once registered and your application has been approved, you will receive a Medicine Access Card listing the medicines to be paid from your Chronic Medicine benefit. If the medicine authorised differs from the medicine requested, a letter of explanation will be attached to your access card and a copy will be sent to the prescribing doctor. ou will need a repeat script from your doctor for the medicines listed on the card. Please note: The access card is not a prescription and cannot be used to have medicines dispensed. Your doctor determines the number of repeats and will advise you how often he needs to see you to monitor your condition. Whenever you need to have your medicine dispensed, produce a valid doctor s prescription together with the access card. The duration of authorisation varies from medicine to medicine. Some medicines may be authorised ongoing, whilst others may only be authorised for a limited period. Page 60

12 Types of formularies There are two types of formularies: Restrictive Formulary Restrictive formularies provides access to a restrictive range of medicines to treat your chronic condition. You will not have a co-payment for medicines on this formulary if they are authorised and obtained from the Designated Service Provider. Comprehensive Formulary Provides access to a wider range of medicines to treat your chronic conditions. If you choose to use a medicine that is not on the formulary allowed by your option, you may have to pay a co-payment upfront. Your co-payment may be substantial if the cost of your medicine is higher than listed on the Medicine Pricing List. A co-payment may also apply if you are required to use a Designated Service Provider and choose not to. Both formularies include alternative products that will not require a co-payment to be made, so if you do not wish to incur any co-payments, discuss alternative therapies with your treating doctor and ensure that you obtain your medicine through a Designated Service Provider. Disease Authorisation When you apply for chronic medicine, you are approved for treatment of your chronic condition and not a specific medicine only. This means that when you need to change or add a new medicine for your condition, you can do this quickly and easily at your pharmacy with your new prescription without having to contact us. Each condition is allocated a basket of medicine for its treatment. The quantity of each medicine in the basket is limited to the most commonly prescribed monthly dose. You do need to contact us on if: You have a medicine that is not in your condition s basket If you are diagnosed with a new condition You require higher quantities than those in the basket You do not need to update us with your new medicine if: Your medicine is in the basket You change to another medicine in the basket You need a quantity or dosage of a medicine that is listed in the basket. Please note: Pre-approved medicine in the basket will still be subject to the Medicine Pricing List and formulary co-payments. Pharmacy Direct Pharmacy Direct is the Designated Service Provider (DSP) for chronic medication. Medicine is delivered to your home, place of work or to the nearest Post Office, depending on your choice. A large number of our patients are based in rural areas where there are no other pharmaceutical services available. Pharmacy Direct has the capability to deliver medication to members and dependants residing at different addresses. Patients are advised by SMS, telephone or of delivery. Members are required to register with Pharmacy Direct in addition to applying for chronic medication. Contact details: Practice number: Fax: /1/2/3 Queries: Aid for AIDS: care@pharmacydirect.co.za Website: How do I register with Pharmacy Direct? Ensure you ve applied for chronic medicine. Visit to download the application form, complete all relevant sections and fax it to /1/2 or it through to care@pharmacydirect.co.za. Alternatively, you can call Pharmacy Direct on to register an online application. Please fax a copy of the original repeat prescription for all medication required to /1 or to care@pharmacydirect.co.za. If you do not have the prescription, please contact your doctor. Please note: An electronic copy of all documentation is acceptable. However, you are required to send your original prescription for schedule 5 and 6 medicine to Pharmacy Direct. Page 61

13 How do I order medication? Please fax a copy of the original repeat prescription for all medication required to /1/2 or to care@pharmacydirect.co.za. If you do not have a valid, repeat prescription, please contact your doctor. Please note: By law, medication can only be dispensed once a pharmacy is in possession of a valid prescription. It remains the responsibility of the patient to obtain his/her prescription from the prescribing doctor and to forward this to Pharmacy Direct and to Chronic Medicine Management for chronic authorisation. An electronic copy of documentation is acceptable. However, by law you are required to send your original prescription for any schedule 5 and 6 medicine to be obtained from Pharmacy Direct. How soon can I expect delivery of my medication? Please note: Before medication can be sent, to new or existing Pharmacy Direct users, Pharmacy Direct would engage in certain interventions to ensure good pharmacy practice. Case Dispatch Time Note Delivery Time First time delivery of urgent/lifethreatening medication First time delivery of other chronic medication Delivery of medication where a new, valid prescription has been received hours until dispatch 3-5 working days until dispatch 3-5 working days until dispatch, or as per automated existing dispense dates Dependant on whether chronic authorisation is already in place Dependant on whether chronic authorisation is already in place Dependant on whether chronic authorisation is already in place hours, depending on location hours, depending on location hours, depending on location Medication is automatically dispensed on a 28-day cycle. Pharmacy Direct uses an advanced scheduling and planning system to deliver medication to patients on a monthly basis. Did you know? By law, prescriptions are only valid for six months. Therefore, patients don t need to re-order medication each month, but rather, update their prescription every six months. Pharmacy Direct contact details: Fax: /1/2/3 Queries: care@pharmacydirect.co.za Website: Hospital Management Pre-authorisation for hospital admission All hospital stays must be pre-authorised (including emergencies). It is best to do this at least two days before you go to hospital. No account will be paid unless pre-authorisation is obtained. In cases of emergency, preauthorisation can be obtained 48 hours after the emergency. On the Standard Select and BonFit options, a 30% co-payment will apply to all non-network and non-authorised hospital admissions, except in the case of an emergency. How do I apply for pre-authorisation? You can apply for pre-authorisation in one of these ways: Online Log in to and click on the pre-authorisation button. Follow the prompts. all the relevant information to hospital@bonitas.co.za. Telephone Call between 8:30am and 4:00pm Monday to Friday to pre-authorise your hospital stay. This number is not available on public holidays or weekends. Page 62

14 What information do I need when I apply for pre-authorisation? Membership number Beneficiary name and date of birth Date of admission and the proposed date for the operation Name of the doctor and their telephone and practice numbers Name of the hospital with their telephone and practice numbers All the relevant procedure codes All the relevant associated medical diagnosis codes Are there any other treatments/procedures that I need pre-authorisation for? You will also need pre-authorisation for the following: Renal clinic admissions for dialysis Procedures in doctor s rooms instead of hospitalisation Physical rehabilitation care in rehabilitation facilities Drug and alcohol rehabilitation care in specific facilities Hospice admissions Oxygen therapy at home All specialised radiology What happens in the case of an emergency treatment/admission to hospital over a weekend, public holiday or at night? In this case, you must contact the pre-authorisation call centre on the first working day after the incident. Failure to obtain pre-authorisation for a planned event or authorisation on the first working day after an emergency event will mean that you are liable for the full account according to the rules of the Scheme. Will I receive any communication about my pre-authorisation? You will receive a letter confirming your pre-authorisation by or post. This letter contains a number of disclaimers printed at the end. Please make sure you take note of these disclaimers as they reflect the Scheme rules. If you are unclear, please discuss the disclaimers with your treating doctor. You will also need to keep note of: The unique pre-authorisation number The initial approved length of stay The status of all the codes What happens if I have to stay in hospital for longer than the initial approved length of stay? Ensure that your doctor, the hospital case manager or a family member s hospitalupdates@bonitas.co.za to inform the case management department of the extended length of stay. If there is a clinical reason for the stay, your Fund will approve the extra days. If not, you will be liable for the costs of the non-approved days and treatment. Do co-payments still apply on procedures performed in-hospital? Any procedure that is stipulated in the Scheme rules as attracting a co-payment will still attract a co-payment whilst in-hospital. Your diagnosis or treatment plan will not change this. Why are some requests for pre-authorisation declined? Some of the pre-authorisation requests may be declined if: The planned procedure is not covered by your benefit option as specified in the Scheme rules. The planned procedure is not in line with the acceptable treatment standards for a particular medical condition. The appropriate clinical information has not been received. The membership is inactive or similar issues with membership status. Case Management While you are in hospital, case managers ensure that appropriate care is provided at all times and that appropriate discharge planning takes place where clinically indicated and where benefits are available. This takes place according to the Scheme rules, clinical protocols and funding guidelines. When extended length of stay or level of care is requested, the case manager will request supporting information to be able to make an informed clinical decision. If there is any doubt at all, a medical advisor will assist and motivation might be requested from your treating provider, if needed. All changes in initial approvals are communicated to the hospital and treating provider. With long-term cases, your family members may also be involved. Page 63

15 Networks GP (General Practitioners) Network Bonitas offers the largest GP network in South Africa, providing you with access to over GPs countrywide. We ve negotiated special rates with these GPs to ensure that you won t have any co-payments and that your benefits last longer. Members on the Standard and Primary options are advised to use the Bonitas GP Network for all their GP visits. Members on the Standard Select option will be required to nominate their GP per beneficiary from our network on the application form or contact the call centre. How do I find a doctor on the Bonitas GP Network Call us on or use the Find a doctor tool on our website - or use the SMS locator facility. Specialist referrals Your GP should be the first person to advise you about your healthcare needs. Not only does your GP understand your illness, but he/she also knows which type of specialist is best for you to see. The GP will assist you in consulting with the right specialist should you need to, saving you both time and money. Please remind your GP to call the call centre to obtain an automated specialist referral authorisation number, via the IVR (Interactive Voice Response) system. On BonClassic, Standard, Standard Select, Primary and BonFit, female members may visit the gynaecologist once a year without referral. Members may also visit the ophthalmologist and oncologist without referral. Specialist Network At Bonitas, we constantly strive to give you access to affordable, quality healthcare. That s why we ve partnered with various healthcare professionals to create the Bonitas Specialist Network, which gives you access to over specialists nationally. If you are a member on the Standard, Standard Select, Primary, BonSave, BonClassic, BonFit and BonEssential Options, the Specialist Network will provide you with access to specialist services at a negotiated tariff for both in and out-of-hospital costs. The benefit of this initiative will result in your claim being paid in full without you being responsible for any shortfall. If you have a Prescribed Minimum Benefit condition and your day-to-day benefit limits have been exhausted, you can continue to consult with a specialist within the Bonitas Specialist Network without incurring any co-payments. Services for these conditions will be subject to the guidelines as contained within the Medical Schemes Act. How do I find a specialist on the Bonitas Specialist Network? Visit and use the provider locator tool. Alternatively, call us on or us at membermaint@bonitas.co.za. The Standard Select and BonFit Hospital Network The Standard Select and BonFit options offers members access to the best quality private hospitals on the extensive hospital network list. Visit and use the hospital locator tool. Alternatively, call us on or us at membermaint@bonitas.co.za. Dental Benefits DENIS is a fully accredited managed care organisation that manages your dental benefits. There is a pre-defined benefit per procedure, which is paid at the published Bonitas Dental Rate (see for the list of dental rates). Your dentist will also be able to provide information regarding your benefits, as DENIS supplies all dentists with a Chair side & Benefit Guide, which illustrate the dental benefit management methodology and benefits. Benefits for dentistry are paid on a fee for service basis. This means that for every procedure done by a dentist, there is a fee that is charged. These fees may differ from dentist to dentist. Your fund pays a benefit for each procedure, which may differ from the fee charged by your dentist. It is your right to negotiate this difference with your dentist. Dental benefits are paid at the Bonitas Dental Tariff (BDT) and are dependent on the plan you re on. Hospitalisation and certain specialised dentistry procedures and treatment must be preauthorised. Page 64

16 Please note: Procedures and treatment not pre-authorised will not attract a benefit, with the exception of crown and bridge procedures where a 20% penalty will apply if authorisation is applied for after the treatment has been done. A co-payment of R2 000 is applicable on all hospital admissions for dentistry on the Standard, Standard Select, BonSave, Primary, Bonfit and BonEssential options. Failure to pre-authorise orthodontic treatment will result in payment only from the date of authorisation for the remaining months of treatment, provided that the treatment is clinically indicated. Penalties do not apply to emergency hospital admissions. Co-payments for Orthodontics are levied on the Standard and Standard Select Option. A benefit for Crown & Bridgework on the Standard & BonClassic Options is subject to a DENIS Designated Service Provider Network. All conservative, out-of-hospital services on the BonCap Option are subject to a DENIS Designated Service Provider Network. Dental benefits are subject to managed care protocols and interventions, which may include the requirement of treatment plans and/or radiographs prior to benefit application. Dental Wellness Program As a Bonitas member, you are automatically a member of the Dental Wellness Program. You will receive various treatment-related information leaflets and oral screenings, advice and dental products will be provided at your company s wellness days. Visit for more information. How do I find a DENIS Network Provider? Visit and use the find a dentist tool. How do I submit claims to DENIS? Post the original copies of your dental claims to Private Bag X 1 Century City 7446, Cape Town or claims@denis.co.za Please ensure the following details are clearly visible: Your membership number The dentist s details and practice registration number The correct dependant name and code (see your membership card) The treatment date The relevant procedure codes The tooth numbers (if applicable) The relevant ICD-10 codes Which specialised dental benefits need to be pre-authorised? Crown and bridge procedures Orthodontics Implants Hospitalisation Intravenous Conscious Sedation Periodontics How do I get pre-authorisation for these specialised dental procedures? To pre-authorise dental procedures in hospital or under IV Conscious Sedation, please call Please have the following information on hand: Hospital practice number Anaesthetist practice number Treating clinician Hospital admission date Procedure code(s) with ICD10 code(s) and where relevant the applicable tooth numbers Main complaint as to why the procedure is needed If applicable, medical report of special medical conditions X-rays are needed if a 54 practice applies for the removal of impactions To pre-authorise the following specialised dental benefits, please use the relevant contact details: Crown and bridge procedures crowns@denis.co.za Orthodontics ortho@denis.co.za Implants ortho@denis.co.za Alternatively, you can fax the details to For more details on the pre-authorisation requirements for the above-mentioned specialised dental benefits, please visit Page 65

17 The Periodontal Program This benefit is only available to those members on the Standard, Standard Select, BonClassic and BonComprehensive Options. How do I apply to the Periodontal Program? Submit your CPITN score (supplied to you by your dental practitioner), together with your Periodontal treatment plan to perio@denis.co.za, or alternatively, fax it to Once authorisation has been obtained, cover for the treatment is subject to Scheme rules, exclusions and benefit protocols. What happens if my procedure is not pre-authorised? Procedures and treatment not pre-authorised will not attract a benefit and thus not be paid by the Scheme, with the exception of crown and bridge procedures where a 20% penalty will apply if authorisation is applied for after the treatment has been done. Failure to pre-authorise orthodontic treatment will result in payment only from the date of authorisation for the remaining months of treatment, provided that the treatment is clinically indicated. Penalties do not apply to emergency hospital admissions. Co-payments for Orthodontics are levied on the Standard and Standard Select options. Contact details: Call: Fax: bonitasenq@denis.co.za Claims: claims@denis.co.za Hospital authorisations: auths@denis.co.za Orthodontic and implant authorisations: ortho@denis.co.za Crown and bridge authorisations: crowns@denis.co.za Periodontal authorisations: perio@denis.co.za Optical Benefits Your optical benefits depend on the plan you have chosen. Our preferred provider for optical benefits is Iso-Leso. Their respected national network of optometric practices has a reputation for delivering high quality service and products to its patients and members of medical Schemes. They offer medical aid members substantial savings on clear single vision, bifocal and multifocal quality spectacle lenses. Their mission is to ensure the viability and stability of the optometric environment for all role players. The Iso-Leso philosophy is to encourage participation of all registered optometrists in the provision of optometric services. As the Iso-Leso provider base is diverse and includes private practitioners, group practices and optometric franchisees, we have a fair representation of the choices that Bonitas members face in seeking optometric care. In addition, Iso-Leso has embarked on improving the quality of professional services with the Practitioner Enhancement Program. This initiative is designed to accredit optometrists who invest in their professional standards of practice. This ultimately translates into a higher level of the quality of care for the Bonitas member. Your available savings may be used for Optical benefits. You can visit a non-network provider, however, your plan s optical benefit is limited to the Iso- Leso tariff. This means you may have to make a co-payment. How do I find an Iso-Leso Optical Provider? If you have any questions regarding your nearest Iso-Leso Provider, you can contact Iso-Leso at the following contact details. Contact details: Call: / 60 info@isoleso.co.za Page 66

18 Each beneficiary is entitled the following benefit over a 24-month cycle commencing on 1 January 2015: Either: One consultation and, if the required prescription is not less than 0,50DS or 0,50DC or the required reading addition is greater than 0,75DS One pair single vision lenses or; One pair flat top bifocal lenses or; One pair multifocal lenses or; A spectacle frame to the value of the specific benefit option Or: One consultation and contact lenses to the value of specific benefit option Please note: Services not covered by the matrix are for the members portion and should be paid directly to the practice, or can be refunded from available savings. Please note that claims older than 4 months from the date of service will not be accepted for payment. The practice is not entitled to collect the unpaid portion for the above products from the patient unless they are: Lens enhancements and add-ons (tints, ARC etc.) The difference on the frame value over the specific plan maximum benefit The difference on the contact lens value over the specific plan maximum benefit All tariffs are inclusive of VAT. Mobile Practice claims will only be paid if confirmation of registration as a mobile practice by HPCSA is supplied. Spectacle lens prescriptions must be included in both paper and electronic claims. Please contact your service provider for assistance in this regard. Payment for materials will be declined under the following circumstances: Where no script is indicated Where no ICD 10 codes are indicated Where the script is less than 0.50 D sphere or 0.50 D cylinder (with no sphere) in both eyes in the case of spectacles Invoices that do not comply with VAT legislation requirements Where the claim is older than 4 months from the date of service Diabetic Program Bonitas Medical Fund has partnered with the Centre for Diabetes and Endocrinology to provide excellent care to members with diabetes. The CDE is a holistic, multi-specialist Diabetes Centre in Houghton, Johannesburg. The Centre manages diabetes by using a team approach that includes diabetes specialists, diabetes educators, a dietician, podiatrists, a clinical psychologist, as well as exercise specialists if necessary. In addition, the Centre trains healthcare professionals in the principles and practice of good diabetes care and acts as the central office for a nationwide network of over 240 affiliated Centres for Diabetes. These accredited centres are contracted to provide all the benefits of the diabetes management program, which is a complete diabetes management package. The CDE has won numerous awards over the last 20 years for their excellence and they are acknowledged as world-class providers of diabetes care. Join now to optimise your diabetes health! The CDE program includes: consultations with a doctor who has received further training in diabetes management (a minimum of two per year) diabetes education to supplement your knowledge in diabetes and to enable you to selfmanage your diabetes more effectively annual consultations with a registered dietician access to the best and most appropriate medicines for diabetes a diabetes 24 hour emergency hotline a diabetes specialist (endocrinologist) supporting your treating doctor regarding your treatment as well as care support from a CDE case manager. Eye screening (ophthalmologist), and foot screening (podiatrist) services are also important components these are made available by Bonitas via their normal funding mechanisms. Your diabetes medication is important. The CDE, in conjunction with your treating doctor and a CDE endocrinologist, will ensure that your diabetes prescription is optimized for your diabetes treatment. Importantly, you will have your diabetes medication sent directly to you by the Bonitas preferred provider, Pharmacy Direct. This valuable service makes it convenient for you and ensures you always receive what you need for your diabetes care in a timeous manner. Page 67

19 If you wish to remain with the doctor who is currently treating your diabetes, ask him / her to contact the CDE central office in Houghton, Johannesburg. They will then provide information and the doctor will be trained and accredited as a preferred provider within the Centre for Diabetes network. How do I join the CDE? Members on all options who have diabetes can join the Centre for Diabetes and Endocrinology by: Calling them on to join the program. Asking your doctor to refer you to the nearest CDE Centre where you can register on the program. How much does it cost? There is no joining fee and no charge for your diabetes care services. If your Bonitas GP Network doctor is not a CDE accredited doctor, they are still able to participate. This means that you should be able to stay with your current Bonitas GP network doctor if you wish. The CDE will facilitate this if required. Contact details: Tel: (011) Fax: (011) members@cdediabetes.co.za Website: Hip and Knee Replacement Program ICPS (Improved Clinical Pathway Services) is a group of orthopaedic surgeons that specialise in performing hip and knee replacements according to standardised clinical care pathways. These care pathways have been developed in accordance with evidence based outcomes to ensure that the quality of the hip and/or knee replacement is of highest standard and to ensure the best health outcomes. ICPS uses a multidisciplinary team dedicated to assist with rapid and successful recovery and keeping the patient as comfortable as possible during the healing period. How to access and orthopaedic surgeon on the ICPS program Call the Bonitas call centre on where you will be given the details of an ICPS orthopaedic surgeon closest to you. Following your consultation with the ICPS orthopaedic surgeon and if the decision for surgery is made, an application for an authorisation number will be arranged on your behalf by the admin staff of the practice. This will allow you access to the ICPS program and ensure payment in full (subject to your prosthesis benefit) with no co-payment for the procedure. The ICPs surgeon will give you a booklet providing you with information on the ICPS program. The program is applicable to all members on the Bonitas Standard, Standard Select and BonClassic options. ICPS will assist with your hospital pre-authorisation should an operation be required. To alleviate the admin burden of submitting accounts, ICPS will submit one account to Bonitas for payment which will include: All hospital costs Surgeons and anaesthetist fees Prosthesis (subject to prosthesis benefit) Physiotherapist (pre-, intra-, and post-operative) Should you choose not to use an ICPS orthopaedic surgeon and are admitted for hip or knee surgery you will be liable for a R5 000 co-payment on admission to the hospital. If you are on the Standard Select option you are only allowed to use ICPS facilities. The program has been established to assist you in taking an active part in planning your care and recovery for hip or knee surgery as well as ensuring financial peace of mind. HIV/Aids Management South Africa s leader in HIV/Aids management and care, Aid for AIDS is a revolutionary, integrated approach to HIV/Aids management that has been delivering excellence since Our approach is to act as a care-coordinator between the funder, doctors, pathology labs, pharmacies and patients. Supported by a team of worldwide-respected clinicians in their field. Backed by a custom IT system that has become the gold standard in HIV/Aids disease management and we enable the optimal care of patients with an end-to-end solution. Page 68

20 Our program is designed to meet the needs of patients and equip them with the treatment and tools to lead normal, fulfilled lives. We empower funders to guard against the financial risk posed by unmanaged HIV/Aids in their employee or member populations. Shaped over years of clinical research and expertise, our methods are considered as the industry standard by healthcare professionals globally. It is very important to register on the program as soon as you know your status. Your plan has a benefit amount specifically for HIV/Aids-related medication. This benefit amount is used to pay for: Antiretroviral therapy (ART) Medication to protect you against illnesses such as TB and flu Regular monitoring tests Aid for AIDS offers a complete HIV/Aids disease management program to both members and beneficiaries: Medication to treat HIV (including drugs to prevent mother-to-child transmission and infection after sexual assault or needle-stick injury) at the most appropriate time Treatment to prevent opportunistic infections like certain serious pneumonias and TB Regular monitoring of disease progression and response to therapy Regular monitoring tests to detect possible side-effects of treatment Ongoing patient support via a team of trained and experienced counsellors Clinical guidelines and telephonic support for doctors Help in finding a registered counsellor for face-to-face emotional support Even if you do not need ART because it is still too early, it is important to register on the program in order to have access to all the other benefits that will assist in keeping you healthy. Strict confidentiality Every effort is made to keep members HIV status confidential. The staff members at our Aid for AIDS unit have all signed confidentiality agreements and work in a dedicated unit. They use separate telephone, fax, and private mailbag facilities. Patients need to use these facilities to maintain confidentiality. How do I register with Aid for AIDS? If you are HIV-positive, you must register with Aid for AIDS as soon as possible in order to make use of this benefit. Call and ask for an application form. All calls are strictly confidential. You may also pre-register yourself on the program where you will receive guidance on how to continue on the program to receive the benefit. You and your doctor must complete the application form and return it to Aid for AIDS by using the confidential, toll-free fax-line number on the form or via . What happens after I have registered? A highly qualified medical team will check your medical details and, if necessary, discuss cost-effective and appropriate treatment with your treating doctor. Once treatment has been agreed upon, you and your doctor will be sent a detailed treatment plan, which explains the approved medicine, as well as the regular tests that need to be done to ensure that the drugs are working correctly and safely. Contact details: Call: Fax: afa@afadm.co.za Website: Mobi-site: Please call me: Emergency Medical Services ER24 is the designated service provider for all emergency medical services for Bonitas members and their registered dependants. This benefit includes: Emergency medical response by road or air to the scene of the medical emergency Transfer to the closest appropriate medical facility by road or air Inter-hospital transfers (subject to authorisation) in accordance with Scheme rules Medical information and assistance hotline Trauma counseling and referral to appropriate healthcare professionals as required Member/dependant validation Medical information and assistance hotline where trained personnel provide trauma counseling, medical advice in emergencies and HIV counseling Page 69