ANNEXURE B2 NETWORK CHOICE BENEFIT OPTION. Effective date: 1 January 2014 TABLE OF CONTENTS

Transcription

1 PART 1 ANNEXURE B2 NETWORK CHOICE BENEFIT OPTION Effective date: 1 January 2014 TABLE OF CONTENTS 1. DEFINITIONS GENERAL PROVISIONS CAPITATION AGREEMENT PP S THOSE LISTED IN CLAUSE (EXCLUDING OPTOMETRY PPN NETWORK AND MEDICATION FOR PMB CONDITIONS- PHARMACY NETWORK) PP/DSP CDE,PPN NETWORK AND PHARMACY NETWORK PMB S PRE-AUTHORISATION REFERRALS TO SPECIALISTS ANNEXURE C NECESSARY TREATMENT QUALITY OF LIFE MANAGMENT :- GENERAL BENEFITS DRUG UTILISATION REVIEWS SUPPLY OF MEDICINES GENERIC DRUGS SUBJECT TO MMAP CLAUSE REFERENCES 12 PART BENEFITS AND LIMITS IN HOSPITAL SERVICES (SUBJECT TO PRE-AUTHORISATION) OUT OF HOSPITAL SERVICES OTHER BENEFITS PAGE 1 OF 24

2 PART 1 1. DEFINITIONS 1.1 Any word or term to which a meaning has been assigned elsewhere in these Rules shall bear the same meaning when used in this Annexure, unless the context indicates otherwise or the word is otherwise defined in this Annexure. 1.2 In this Annexure, unless the context otherwise indicates, the following terms shall have the following meanings: Chronic Medicine shall mean a medicine which is subject to authorisation in accordance with the Fund s protocol and which at the discretion of the Board, is considered to be life sustaining Dispensing Fee means a dispensing fee equal to 36% of the Single Exit Price of a medicine but up to a maximum of R59,40 (including VAT), and for the purposes of these Rules such fee shall be for all the services described by the term dispense as defined in the Regulations to the Medicines and Related Substances Act 101 of 1965 contained in GNR 1102 of 11 November an interchangeable multisource pharmaceutical product (commonly known as a generic ) is a product that has exactly the same active ingredient/s and salt/s combination strength of the active ingredient/s and dosage form (for example tablets versus capsules) as other pharmaceutical products that can be obtained from manufacturers or suppliers; MMAP means the maximum price that the Fund will reimburse for an interchangeable multi-source pharmaceutical product, which maximum price will be determined according to the then current reference price model maintained by Medikredit Integrated Healthcare Solutions (Pty) Limited with the name Maximum Medical Aid Price; Pharmacy Network means those networks of pharmacies indentified as DSP s for this benefit option which can be viewed on the Fund s web site; Preferred Provider or PP shall mean the relevant service provider from the list below (or the providers of the relevant health service designated by them), designated by the Board and allowed to provide the following services to Beneficiaries under this Benefit Option:- 1 This definition may change at short notice in the future due to GNR 9337 of 23 July 2010 PAGE 2 OF 24

3 Medical service PP Diagnosis and treatment by a general practitioner Medicross Contracted Network or an individually contracted GP Basic dentistry Medicross Contracted Network or an individually contracted dentist Optometry PPN Network (Preferred Provider Negotiators (Pty) Limited) Hospitalisation Netcare group of hospitals Ambulance and evacuation service Netcare 911 Medication for PMB Conditions Pharmacy Network Specific PMB conditions have DSP arrangements for the supply For the avoidance of doubt the PP s listed above (or the providers of the relevant health service designated by them) are designated service providers or DSP s, as mentioned in Chapter 3 of the General Regulations to the Act, in respect of PMB Conditions. Further, the phrase individually contracted GP or individually contracted dentist as mentioned above means an individual GP or dentist with whom the Fund has entered into a contract to charge at certain rates for this benefit option, a list of whom is available from the Fund on request or can be viewed on PAGE 3 OF 24

4 1.2.7 Per Member Family means for each Member Family and the term Member Family has the meaning given to it in the Rules (being the Member and all his or her Dependants); PP Tariff shall mean, as a benefit to a member, the net or final amount payable by the Fund to the PP or the providers of the relevant health service designated by the relevant PP, provided that the Beneficiary complies with the requirements of clause 2 below. Accordingly, unless otherwise stated in this Annexure or the Rules (such as in clause 2) the term 100% of PP Tariff means that, Members shall not be liable for a co-payment in respect of that relevant health service rendered by the PP or its suppliers of the medical service.) PPN Network means Preferred Provider Negotiators (Pty) Limited; "Pre-authorisation" shall mean the PP's or the Fund s prior approval and authorisation, as is more fully described in clause 2; subject to MMAP as in the phrase 100% of Single Exit Price plus a Dispensing fee therefor, subject to MMAP means that should there be: no such interchangeable multisource pharmaceutical product (see clause above) then the benefit is 100% of Single Exit Price plus a Dispensing fee therefor; or such an interchangeable multisource pharmaceutical product (see clause above) then the benefit is 100% of Single Exit Price therefor, but limited as a maximum to the price specified in the MMAP therefor, plus a Dispensing Fee therefor. 2. GENERAL PROVISIONS Subject to the provisions detailed in the Regulations to the Medical Schemes Act, and to the provisions of Annexure C, the following provisions apply to the above mentioned benefit option, the benefits for which are listed in this annexure. 2.1 CAPITATION AGREEMENT It is recorded that the agreement which the Fund has with the PPN Network is a capitation agreement, as mentioned in regulation 15 to the General Regulations to the Act. 2.2 PP S THOSE LISTED IN CLAUSE (EXCLUDING OPTOMETRY PPN NETWORK, CDE - DIABETES AND MEDICATION FOR PMB CONDITIONS- PHARMACY NETWORK) The term PMB Condition means a prescribed minimum benefit condition as defined in section 7 of the General Regulations to the PAGE 4 OF 24

5 Act. This clause 2.2 does not apply to the PPN Network, CDE and to the Pharmacy Network (to which clause 2.3 below applies) Beneficiaries may only receive the relevant medical service at the PP s listed in clause or at the providers of the relevant health service designated by them. Save for a PMB Condition (to which clause applies), failure to comply with this rule will result in the Member concerned, and not the Fund, being personally liable for the full cost of that medical service In respect of PMB Conditions only: Save as stated in clause , should a Beneficiary not make use of a DSP as required hereunder, a co-payment equal to the difference between the Fund s agreed tariff with its DSP for that service and the cost charged by the non-dsp will apply Save as stated in clause , should a Beneficiary not make use of the Fund s formulary drug and opt to use another drug, a co-payment equal to the difference between the cost of the Fund s formulary drug and the cost of the non-formulary drug will apply Pre-authorisation of a PMB is required and compliance will influence the application of the relevant protocol The provision of all medical services and medication (including those relating to PMB s) must comply with the protocols prescribed by the managed health care organisations engaged in respect of this benefit option For diagnosis, treatment, care or medication involuntarily obtained by a Beneficiary from a medical provider other than in terms of the PP listed in clause (save for PPN Network, CDE and the Pharmacy Network to which clause 2.3 applies), the Fund will pay the benefits for such PMB Condition in full as mentioned in this Annexure B2, subject to (1) the terms of payment for PMB s mentioned elsewhere in this Annexure B2 and (2) appropriate interventions aimed at improving the efficiency and effectiveness of healthcare provision, including such techniques as requirements for Pre-authorisation, the application of treatment protocols and the use of formularies The term involuntarily obtained shall have the same meaning as the meaning or description given to the phrase a beneficiary shall be deemed to have involuntarily obtained a service from a provider other than a designated service provider in regulation 8(3) of the General Regulations to the Act In respect of service involuntarily obtained for a PMB from a provider other than a PP mentioned in clause 2.2.3, a Beneficiary shall be taken to a PP once he or she is in a stable PAGE 5 OF 24

6 condition and the scheme will arrange the necessary availability of services and transfer. 2.3 PP/DSP CDE, PPN NETWORK AND PHARMACY NETWORK It is recorded that the agreement between the Centre for Diabetes and Endocrinology ( CDE ) and the Fund is a full capitation agreement and the risk and costs (as between CDE and the Fund only and subject to regulation 15E (a)) of any hospitalisation of Beneficiaries on that programme for certain conditions is borne by CDE in full In this benefit option (annexure B2), the Fund requires the use of the following Designated Service Providers and/or Preferred Providers 2 :- (a) in respect of diabetes, being the Centre for Diabetes and Endocrinology ( CDE ); (b) in respect of optometry, Preferred Provider Negotiators (Pty) Limited ( PPN Network ) other than as stated in clause 2.11 (b) of Part 2 below; and (c) in respect of medication for PMB Conditions the Pharmacy Network, in respect of which the following provisions of this clause 2.3 apply: In respect of the PPN Network: only the benefits (of the type) mentioned in clause 2.11 A and B of Part 2 below will be funded by the Fund at this DSP and Preferred Provider. Any additional costs incurred at the DSP/Preferred Provider by a Beneficiary shall be for the Beneficiary s account as a co-payment; and save as stated in clause 2.3.6, should a Beneficiary not make use of the DSP/Preferred Provider (the PPN Network or the providers of the relevant health service designated by it), a copayment by the Beneficiary equal to the difference between the tariff agreed with this DSP/Preferred Provider (as mentioned in clause 2.11 B of Part 2 below) and the cost charged by the non- Preferred Provider/DSP service provider will apply In respect of CDE:- Save as stated in clause 2.3.6, if a Beneficiary obtains treatment, care, equipment or medication for diabetes at a provider other than CDE or its network of approved providers, the Member concerned shall be liable for a co-payment in respect thereof equal to the 2 The terminology under the Act is that DSP s are used in respect of PMB, s (regulation 8), while the term Preferred Provider refers to the other medical conditions concerned PAGE 6 OF 24

7 difference between the cost charged by the non-preferred Provider/DSP service provider and any amounts refunded by CDE to the Member or the Fund as the case may be In respect of the Pharmacy Network:- Save as stated in clause 2.3.6, if a Beneficiary obtains medication for PMB Conditions at a provider other than the Pharmacy Network or its network of approved providers, the Member concerned shall be liable for a co-payment or penalty equal to 20% of the Single Exit Price of the medicine/s obtained by the Beneficiary For diagnosis, treatment, equipment, care or medication involuntarily obtained by a Beneficiary for a PMB from a medical provider other than a Designated Service Provider as mentioned in clause above, the Fund will pay the benefits for such PMB Condition in full subject to (1) the terms of payment for PMB s mentioned elsewhere in this Annexure B2 and (2) appropriate interventions aimed at improving the efficiency and effectiveness of healthcare provision, including such techniques as requirements for Pre-authorisation, the application of treatment protocols and the use of formularies The term involuntarily obtained shall have the same meaning as the meaning or description given to the phrase a beneficiary shall be deemed to have involuntarily obtained a service from a provider other than a designated service provider in regulation 8(3) of the General Regulations to the Act Unless otherwise stated, all co-payments must be paid directly to the supplier concerned Except in the case of an Emergency Medical Condition, Pre- Authorisation shall be obtained by a Member prior to the Member or his Dependants involuntarily obtaining a service or medication as mentioned in clause 2.3.6, to enable the Fund to confirm that the circumstances contemplated in clause are applicable. 2.4 PMB s Subject to clauses 2.1, 2.2, and 2.3, all Prescribed Minimum Benefits are fully covered according to law Where diagnostic tests and examinations are performed but do not result in confirmation of a diagnosis for a PMB Condition, except for an Emergency Medical Condition, such diagnostic tests or examinations are not considered to be a PMB Benefits for PMB conditions will be assessed according to the definitions and criteria mentioned in clauses 1, 2 and 2A of the Explanatory Notes to Annexure A of the General Regulations to the Medical Schemes Act. PAGE 7 OF 24

8 2.5 PRE-AUTHORISATION In all cases where prior approval and authorisation by the PP or the Fund, as the case may be, ( Pre-authorisation ) is required, the payment of any claim relating thereto will always be subject to sufficient benefits being available to a Member at the time of payment and further that his membership has not been terminated or suspended for any reason. Benefits that are subject to Preauthorisation are set out in this Annexure and in Annexure C If no such Pre-authorisation is obtained, the Board shall impose a penalty of 20% of the accounts concerned with a maximum of R2 500 in respect of benefits (PMB s and others) but subject to clause This penalty may be deducted from payments due to the Member In the case of emergency treatment, Pre-authorisation is not required, but Members are expected to contact the Fund within 48 hours or on the 1st working day following admission to verify that payment will be made. Failure to do so within such time limits could result in the consequences mentioned in clause Notwithstanding any provision to the contrary, a Member must obtain Pre-authorisation for the intended admission to hospital and treatment at least 48 hours prior to being admitted to hospital, unless the admission to hospital is considered an emergency in which case Members are expected to comply with clause Failure to obtain the Pre-authorisation, or to verify the payment as aforesaid, within such time limits could result in the consequences mentioned in clause With the exception of expected confinements, the Pre-authorisation obtained from the Fund shall be valid for a period of 90 (ninety) days after the date of authorisation. 2.6 REFERRALS TO SPECIALISTS All referrals to a specialist medical practitioner must be made by the PP practitioners listed in clause above. 2.7 ANNEXURE C All the benefits set out in this Annexure B2 are subject to the Exclusions and Limitations set out in Annexure C. 2.8 NECESSARY TREATMENT The Board must be satisfied, on the application of the attending medical practitioner, that the treatment will be necessary for the control of the condition. PAGE 8 OF 24

9 2.9 QUALITY OF LIFE MANAGEMENT :- GENERAL BENEFITS Benefits for PMB Conditions and conditions listed in the Chronic Disease List (CDL, being the list of diseases under the heading chronic conditions in the PMBs reflected in annexure A to the General Regulations); % of the Cost, for consultations, visits, diagnostic procedures, examinations and tests, treatment and medical and surgical procedures provided by the required medical practitioner mentioned in the table in clause and subject to protocols laid down by the Fund; % of the Single Exit Price plus the dispensing fee charged by the DSP, subject to MMAP and use of the DSP (Pharmacy Network), of Chronic Medicines which is prescribed by the required medical practitioner mentioned below and which is listed in the Fund s applicable Condition Medicine List (CML) for PMB conditions; The benefits set out in clauses and apply to conditions listed in the following table and are subject further to the provisions of clauses to inclusive. Condition Addison s Disease Treating practitioner GP, Physician, Paediatrician Asthma GP, Physician, Pulmonologist, Paediatrician, Physiotherapist, subject to clinical protocols Bipolar Mood Disorder Psychiatrist, Clinical Psychologist, Social Worker Bronchiectasis Cardiac Failure Cardiomyopathy Disease Chronic Obstructive Pulmonary Disease Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus GP, Physician, Pulmonologist, Physiotherapist GP, Physician, Cardiologist, Dietician GP, Physician, Cardiologist, Dietician GP, Physician, Pulmonologist, Physiotherapist GP, Physician GP, Physician, Cardiologist, Dietician Gastroenterologist, General Surgeon, Dietician, GP, Physician GP, Physician, Paediatrician, Endocrinologist PAGE 9 OF 24

10 Condition Treating practitioner Diabetes Mellitus type 1 GP, Physician, Ophthalmologist, Paediatrician, Dietician, Podiatrist, Endocrinologist Diabetes Mellitus type 2 GP, Physician, Ophthalmologist, Paediatrician, Dietician, Podiatrist, Endocrinologist Dysrhythmia Epilepsy Glaucoma Haemophilia A & B HIV/AIDS Hyperlipidaemia Hypertension Hypothyroidism Oncology Physician, Cardiologist, Paediatrician, GP GP, Physician, Neurologist, Occupational Therapist, Speech Therapist, Paediatrician GP, Physician, Ophthalmologist GP, Physician, Paediatrician, Haematologist GP, Physician, Paediatrician GP, Physician, Cardiologist, Paediatrician, Dietician GP, Physician, Cardiologist, Dietician GP, Physician, Paediatrician Refer to oncology benefit (clause 1.7 below), as determined by individual case Multiple Sclerosis GP, Physician, Neurologist, Ophthalmologist, Urologist, Physiotherapist, Occupational Therapist Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus GP, Neurologist, Physician GP, Physician, Paediatrician, Rheumatologist Psychiatrist, Clinical Psychologist, Social Worker GP, Physician, Dermatologist, Paediatrician Erythematosus Ulcerative Colitis Gastroenterologist, General Surgeon, Dietician, GP, Physician Benefits for out of hospital DTP Conditions: % of the Cost, for consultations, visits, diagnostic procedures, examinations and tests, treatment and medical and surgical procedures mentioned in the Diagnostic and Treatment Pairs and performed out of hospital, subject to protocols and formularies prescribed by the Fund PAGE 10 OF 24

11 % of the Cost, plus Dispensing Fee therefor, of medication provided that such medication (a) is listed in the funds applicable formulary (b) is subject to MMAP and (c) is dispensed by the DSP. General provisions applicable to clause and are: The Board must be satisfied, on the application of the attending medical practitioner, that the treatment will be necessary for the management of the condition The Fund requires that the initial diagnosis of conditions listed in clause must be made by the treating practitioner mentioned in that clause under the heading treating practitioner and then in terms of the Fund s relevant protocol Members are encouraged to register all PMB Conditions, which are treated out of hospital, with the Fund. Such registration is for validation purposes and such registration shall be in accordance with the Fund s procedures. Failure to do so will not exclude a member from benefits, but it does expose members to the risk of delays and of not receiving the correct payment. The medical practitioner concerned may be required to provide information as part of that validation procedure The Board has the right to introduce from time to time a Managed Health Care programme (a programme whereby a condition or illness is managed by a Participating Health Care Provider and/or Managed Health Care Organisation appointed by the Fund). Copies of these contracts are available on request. Designated Service Providers ( DSP ) may be appointed in terms of such programmes. For the purposes of this clause only, Preauthorisation shall not be regarded as such a programme, as the provisions of clause 2.5 apply to Pre-authorisation [clause deleted] DSP s and PMB s In this benefit option (annexure B2), the Fund requires the use of a DSP or Preferred Provider in respect of optometry, diabetes and medication for PMB Conditions as mentioned in clause and 2.2 (the provisions of which clauses apply to this clause 2.9) In this clause, the term involuntarily obtaining shall have the same meaning as the meaning or description (mutatis mutandis) given to the phrase a beneficiary shall be deemed to have involuntarily obtained a service from a provider other than a designated service provider in regulation 8(3) of the General Regulations to the Act. Except in the case of an Emergency Medical Condition (but see clause 2.5.3), Pre-Authorisation shall be obtained by a Member prior to the Member or his Dependants involuntarily obtaining a service or medication, to enable the Fund to confirm that the PAGE 11 OF 24

12 circumstances contemplated in the aforesaid regulation 8(3) are applicable It is recorded that the benefits mentioned in clauses and 2.9.2, have been developed according to accepted medical protocols. However, the Board may, in its sole and absolute discretion, grant further benefits in respect of the above medical conditions if the Board is satisfied, on the application of the Member supported by a certificate or appropriate report from the attending medical practitioner, that the treatment will be necessary for the treatment and control of the condition Where diagnostic tests and examinations are performed but do not result in confirmation of a diagnosis of a PMB Condition, except for an Emergency Medical Condition, such diagnostic tests or examinations are not considered to be a PMB DRUG UTILISATION REVIEWS The Fund reserves the right to conduct a drug utilisation review on the use of Chronic Medicine by a provider of service who has been approved by the Board, and if necessary to require the Member to register with the Fund s disease management programme or the Fund s relevant Managed Health Care programmes If any changes to the medication prescribed are required, these will only be made with the approval of the prescribing medical practitioner (unless otherwise legislated) SUPPLY OF MEDICINES Unless otherwise decided by the Board, the supply of medication shall not exceed more than one month s use or, in the case of more medication being needed due to continued absence from the country on international travel only, three months use. The onus shall be on the Member to prove that the quantity of medicine ordered does not represent more than one or three months supply as the case may be, subject to limits and formulary GENERIC DRUGS Benefits paid according to the MMAP list are subject to Regulation 15 I (c) of the General Regulations to the extent that it is applicable SUBJECT TO MMAP Notwithstanding any provision to the contrary, medication for acute, PMB Conditions, oncology, wellness, immunisation and OTC medication is subject to MMAP CLAUSE REFERENCES Unless otherwise stated, references to clause numbers are to clauses in this Annexure. PAGE 12 OF 24

13 ANNEXURE B2 NETWORK CHOICE PART 2 BENEFITS AND LIMITS 1. In Hospital Services (Subject to Pre-Authorisation and utilisation of a Netcare Facility) 1. In Hospital Services (Subject to Pre-Authorisation) Accommodation in: General wards Intensive and High Care Units Day clinics Limits per Member Family per Year Benefits 100% of Scheme Tariff 1.1 Rehabilitation treatment of any drug addiction or alcoholism limited to one rehabilitation admission per Beneficiary per Year and if such treatment falls under clause 182T of the PMB list in the Act, then such treatment shall be limited to hospital based management up to three weeks per year. Psychiatric admissions PMB at 100% of Cost 1.2 (subject to Pre-authorisation and Members are encouraged to register on the Emotional Wellness Programme) PAGE 13 OF 24

14 1. In Hospital Services (Subject to Pre-Authorisation) Confinements: Limits per Member Family per Year Benefits 1.3 Normal Vaginal Delivery 3 days 100% of Scheme Tariff Caesarean Section (if medically necessary) 4 days 1.4 Surgical Prostheses implanted under general anaesthetic (Preauthorisation required) 100% of Cost limited to R per Member Family per year, subject to clauses 2.2 to 2.4 in Part 1 above. Medicine and materials: 1.5 Prescribed, dispensed and used while in hospital 100% of Single Exit Price, plus Dispensing Fee. subject to MMAP. Supplied by the hospital for use after discharge 7 days supply per hospital admission 1.6 HIV/AIDS associated diseases PMB cover at 100% of Cost 1.7 Chemotherapy and Radiotherapy, Organ Transplants, Renal Dialysis Subject to Preauthorisation, case management, and registration on the relevant managed healthcare programme DSP Providers only; PMB rules apply (see clauses 2.2 to 2.4 on pages 3 to 5 above) Subject to protocols PAGE 14 OF 24

15 1. In Hospital Services (Subject to Pre-Authorisation) Limits per Member Family per Year Benefits 1.8 Medical and surgical procedures, operations and services 100% of CBT 100% of CBT 1.9 Advanced Radiology in Hospital subject to the provisions of clause 2.5 in the table below Combined limit with clause 2.5 below R per Member Family per annum combined limit with clause Basic Radiology in Hospital 100% of CBT 1.11 Pathology in Hospital 100% of CBT 1.12 Supplementary healthcare in hospital 100% of CBT, but physiotherapy is limited to R8 700 per Member Family per year, subject to clauses 2.2 to 2.4 in Part 1 above 1.13 Blood Transfusion 100% of cost 1.14 Home Nursing (subject to Preauthorisation and in lieu of hospitalisation) Case Management, up to 21 days 100% of CBT 1.15 Approved step-down facilities and physical rehabilitation Case Management, for a maximum of % of Scheme Tariff PAGE 15 OF 24

16 1. In Hospital Services (Subject to Pre-Authorisation) facilities, (subject to Preauthorisation) Limits per Member Family per Year (ninety) days per hospital event in any benefit Year Benefits 2. Out of Hospital Services 2. Out of Hospital Services Limits per Beneficiary per Year Benefits 2.1 Consultations, visits, examinations, treatments and diagnostic procedures by a general practitioner or a specialist (subject to referral from a general practitioner) For GP s who are part of the Medicross Contracted Network and who have agreed to the negotiated PP Tariff and GP s who are individually contracted to the Fund for this purpose (see clause above), GP consultations are limited to 10 visits per Beneficiary per Year. 100% of PP Tariff being R330,00 for a consultation and the agreed facility fee combined Specialists (only on referral from PP GP) limited to R6 870 per Member Family (determined at 100% of CBT) 100% of CBT ( PAGE 16 OF 24

17 2. Out of Hospital Services Limits per Beneficiary per Year Benefits 2.2 Basic Dentistry : Check-ups, fillings, extractions subject to the provisions of clause B5.1 and B5.2 of Annexure C - Limitations Unlimited through PP, subject to protocols 100% of 2013 PP Tariff plus 6%, but subject to the code for the medical service being on the list of approved codes on the Fund s website Specialised Dentistry: 2.3 Including dentures, crowns & bridges etc Implants excluded Limited to R2 690 per Beneficiary per Year 100% of CBT 2.4 Pathology 100% of CBT Tariff when performed by a registered Pathologist on referral by a PP or Specialist up to a limit of R4 810 per Beneficiary per Year, subject to a list of approved codes on the Fund s website PAGE 17 OF 24

18 2. Out of Hospital Services Limits per Beneficiary per Year Benefits R per Member Family per Year including the following (all of the following are subject to Pre-authorisation): CT Scans, or MRI, or PET scans, 2.5 Advanced Radiology This is a combined in/out of hospital limit and the benefits in clause 1.9. of the table above accumulate towards this limit. 3 Ante natal foetal scans per pregnancy 2D scans only. 80% CBT 100% of CBT PAGE 18 OF 24

19 2. Out of Hospital Services Limits per Beneficiary per Year Benefits 2.6 Basic radiology (black and white X-rays) 100% of CBT Tariff, when performed by a registered Radiologist provided referred by a PP or Specialist - up to a limit of R3 030 per Beneficiary per Year. This includes Mammogram one per female Beneficiary of 40+ years old Subject to a list of approved codes on the Fund s website Infertility - as per PMB As per PMB 100% of PP Tariff; being 100% of the actual cost incurred for this PMB, subject to clauses 2.2 to 2.4 in Part 1 above. 2.8 HIV/AIDS consultations, investigations and treatment. Subject to registration on the HIV/AIDS managed health care programme For PMB COVER - 100% of PP Tariff; being 100% of the actual cost incurred for this PMB, subject to clauses 2.2 to 2.4 in Part 1 above. 2.9 Chronic Medicine (CDL conditions only) Items on the Fund s formulary PAGE 19 OF % of the Single Exit Price plus a Dispensing Fee therefor, subject to MMAP and DSP

20 2. Out of Hospital Services Limits per Beneficiary per Year Benefits 2.10 Acute Medication Items on the Fund s basic formulary Items on the Fund s extended formulary 100% of the Single Exit Price plus a Dispensing Fee therefor, subject to MMAP and limits 80% of the Single Exit Price plus a Dispensing Fee therefor, subject to MMAP and limits (This is a 24 month benefit cycle for benefits below). a) One consultation with an optometrist contracted to PPN Network; and either b) Spectacles 2.11A Optical & Optometric tests if provided by PPN Network as a DSP Spectacles consisting of a PPN Frame to the value of R150 or R550 off any alternative frame and/or lens enhancements and one pair of lenses consisting of either one pair of Clear Aquity Single Vision or Clear Aquity Bifocal lenses or Clear Aquity Multifocal lenses 100% of PP Tariff, subject to clauses 2.2 to 2.4 in Part 1 above OR c) Contact lenses up to R800 PAGE 20 OF 24

21 2. Out of Hospital Services Limits per Beneficiary per Year Benefits (This is a 24 month benefit cycle). b) One consultation with an optometrist not contracted to PPN Network: R250 and either b) Spectacles 2.11B Optical & Optometric tests if not provided by PPN Network as a DSP Spectacles consisting of R550 towards the cost of a frame and/or lens enhancements and one pair of lenses consisting of either one pair of clear single vision spectacle lenses limited to R140 per lens or one pair of clear flat top bifocal lenses limited to R310 per lens or one pair of clear flat top multifocal lenses limited to R570 per lens; 100% of PP Tariff, subject to clauses 2.2 to 2.4 in Part 1 above OR e) Contact lenses up to R Supplementary Health Occupational Therapy and Physiotherapy On referral from PP GP 100% of CBT Tariff limited to R1 870 per Beneficiary per Year PAGE 21 OF 24

22 2. Out of Hospital Services Limits per Beneficiary per Year Benefits 2.13 OTC Medicine R760 per Beneficiary per Year 80% of the Single Exit Price plus a Dispensing Fee therefor, subject to MMAP 2.14 External Appliances As per clause B3 of Annexure C 100% of Cost, limited to R4 500 per Beneficiary per Year, subject to clauses 2.2 to 2.4 in Part 1 above Baby Apnoea monitor: R1 600 Breast pumps: R Casualty or Out-of-area Non- Network visits ( out of area refers to outside the area where the Beneficiary is contracted to the PP, and Non-Network means a service provider who is not part of the PP s network) One visit per Beneficiary or two per Member Family per Year AND one casualty visit (facility fee, consumed medication and materials) limited to R1 120, but a 20% co-payment will always apply for all such claims; to be paid by the member and claimed from the Fund for reimbursement Immunisation (other than clause 2.17) Diphtheria, Tetanus, Whooping Cough (Pertussis), Poliomyelitis, Mumps, Measles, Rubella, Chicken pox, Hepatitis A, Hepatitis B, Tuberculosis, Haemophilus Influenza, Meningitis Yellow Fever, Pneumococcal, Rotavirus, Typhoid and H1N1 Influenza A (Swine Flu) R1 170 per Beneficiary per Year PAGE 22 OF % of the Single Exit Price plus a Dispensing Fee therefor, but subject to MMAP

23 2. Out of Hospital Services Limits per Beneficiary per Year Benefits 2.17 Cervical Cancer Vaccine 100% of the Single Exit Price plus a Dispensing Fee therefor, but subject to MMAP. The vaccine will be paid for females between the ages of 9 and 16. Maximum three doses of the vaccine will be paid provided the child is not older than 16 years Depression 100% Psychotherapy (no benefit for medication) Other Benefits 3. Other Benefits 3.1 Ambulances and evacuation services Netcare 911 Unlimited, subject to Preauthorisation by Netcare 911 for nonemergencies and post authorisation within 48 hours of emergencies 100% of PP Tariff of approved provider PAGE 23 OF 24

24 3. Other Benefits CAMAF HEALTH RISK ASSESSMENT The Fund has engaged the services of Virgin Life Care to provide the benefits under the programme listed below to Adult Beneficiaries only at no cost to them (but subject to the terms and condition of the programme which are available on the Fund s website This programme is known as the CAMAF Lifestyle Programme. The benefits under this wellness programme are:- a) Health assessments at Clicks, Dischem, Pick n Pay clinics or selected biokineticists; b) Health reports to participants; c) Telephonic access to biokineticists and dieticians for assistance; and d) Reporting and health monitoring, with goal setting to improve health. Subject to conditions of the programme -o0o- PAGE 24 OF 24