COMPARISON BROCHURE 2015

Transcription

1 COMPARISON BROCHURE 2015

2 Private hospitals HOSPITALISATION SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Including: Surgical operations & procedures Theatre fees Labour and recovery wards Ward accommodation Intensive care and high care units X-rays and pathology Physiotherapy Ultrasound scans (other than for pregnancy) Blood transfusions Medicine dispensed and used in hospital Unlimited. Subject to Unlimited. Subject to Unlimited. Subject to Unlimited, only at DSP network hospitals. R3 500 co-payment applicable for non-dsp hospitals. Procedure co-payments may also be applicable. Protocols and optionspecific exclusion list Unlimited. Subject to and option-specific exclusion list Unlimited, subject to PMBs and only at DSP Network Hospitals. R3 500 co-payment applicable for non-dsp hospitals. Procedure co-payments may also be applicable. Protocols and optionspecific exclusion list 100% of 100% of 100% of 100% of 100% of 100% of Subject to hospital formulary Subject to hospital formulary Subject to hospital formulary Subject to hospital formulary Subject to hospital formulary Subject to hospital formulary Medicine received on discharge from hospital (TTO) Maximum of 7 days supply Maximum of 7 days supply Maximum of 7 days supply Maximum of 7 days supply Maximum of 7 days supply Maximum of 7 days supply General Practitioners, including consultations and procedures Clinical medical specialist fees, including consultations and procedures Provincial hospitals Diagnosis and treatment in respect of the Prescribed Minimum Benefits (PMB) package (as per Government Regulations). Contracted Providers up to 100% of Contracted Up to 220% of Scheme for Contracted Providers. Non-Contracted Providers up to 100% of Unlimited. Subject to. Contracted Providers up to 100% of Contracted Up to 150% of Scheme for Contracted Providers. Non-Contracted Providers up to 100% of Unlimited. Subject to. Contracted Providers up to 100% of Contracted Up to 150% of Scheme for Contracted Providers. Non-Contracted Providers up to 100% of Unlimited. Subject to. Contracted Providers up to 100% of Contracted at 100% of. Contracted Providers up to 100% of Contracted Unlimited. Subject to. Contracted Providers up to 100% of Contracted at 100% of. Contracted Providers up to 100% of Contracted Unlimited. Subject to at 100% of. DSP Providers at 100% of Contracted at 100% of. DSP Providers at 100% of Contracted Unlimited. Subject to Note: Pre-authorisation ( ) should ideally be obtained 14 days prior to an elective admission to allow time for any outstanding information to be submitted for review. In the case of a true emergency admission (requiring immediate treatment), pre-authorisation must be obtained within 48 hours or on the first working day after admission. The authorisation will be subject to case management protocols and formularies. All authorisations subject to Scheme Rules, Protocols and Policies. Laparoscopic and similar endoscopic procedures are excluded from benefits, unless pre-authorised under Scheme protocols. Laparoscopic co-payment is applicable on admission to hospital. 1

3 ANNUAL SUB-LIMITS (PRIVATE HOSPITALS) SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Casualty / emergency visits Clinician and facility fees only, clinician paid at 100% of Limited to R1 430 for emergency visits per family per Maternity Confinements Normal delivery Length of stay: 3 days & 2 Caesarean Section (clinically indicated only) Length of stay: 4 days & 3 Subject to MSA and ATB Subject to MSA Limited to R1 430 for emergency visits per family per Length of stay: 3 days & 2 Length of stay: 4 days & 3 Length of stay: 3 days & 2 Length of stay: 4 days & 3 Length of stay: 3 days & 2 Length of stay: 4 days & 3 Pre-authorisation Length of stay: 3 days & 2 Length of stay: 4 days & 3 Elective Caesarean Section Included Neonatal Intensive Care Protocols Protocols Protocols Protocols Protocols Antenatal care Maternity programme (registration ) Included Included Included Included Included Included Baby care Products at a Preferred Provider R825 R730 R675 R540 9 Consultations (Midwife, GP or Specialist) Included (any Provider) Subject to MSA and ATB (any Provider) 6 Specialist visits included 3 Specialist visits included Protocols and PMBs Pre-authorisation Length of stay: 3 days & 2 Length of stay: 4 days & 3 Protocols GPs or Midwives only. Specialists require authorisation 2D scans 2 Scans included 2 Scans included 4 Scans included 2 Scans included 2 Scans included 2 Scans included Antenatal classes Subject to MSA and ATB R1 270 Postnatal midwife visits Subject to MSA and ATB 4 Visits Other Psychiatric disorders Limited to Network Providers and subject to PMB and. Non PMB limited to R per family per Cochlear implants and all related thereto (once per lifetime per beneficiary) R per family per Organ transplants Unlimited, subject to PMB and Internal prostheses Trauma counselling (Assault, rape, hijacking and armed robbery) Limited to R per family per. Subject to Prosthesis Sub-Limits and 3 Psychologist visits per beneficiary per. (R590 per visit). Subject to Limited to Network Providers and subject to PMB and. Non PMB limited to R per family per R per family per Unlimited, subject to PMB and Limited to R per family per. Subject to Prosthesis Sub-Limits and Limited to Network Providers and subject to PMB and. Non PMB limited to R per family per R per family per Unlimited, subject to PMB and Limited to R per family per. Subject to Prosthesis Sub-Limits and Limited to Network Provider and subject to PMB and Limited to Network Provider and subject to PMB and R per family per. Subject to PMB and Limited to R per family per. No benefit other than PMB for joint replacements and spinal procedures. Subject to Prosthesis Sub-Limits and Limited to PMB at a Provincial Hospital in accordance with Public Sector Protocols, waiting lists and Regulation 8(3) of the Act Limited to R per family per. No benefit other than PMB for joint replacements and spinal procedures. Subject to Prosthesis Sub-Limits and Limited to Network Provider and subject to PMB and Limited to PMB at a Provincial Hospital in accordance with Public Sector Protocols, waiting lists and Regulation 8(3) of the Act Limited to R per family per. Subject to Prosthesis Sub-Limits, and PMB 2

4 OTHER INSURED BENEFITS SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION External medical appliances Includes the following if prescribed by a registered healthcare practitioner and obtained from a supplier registered with the Board of Healthcare Funders (BHF): R per family per, subject to appliance sub-limits below: R per family per. Subject to PMBs, and appliance sub-limits below: R6 360 per family per. Subject to PMBs, and appliance sub-limits below: R3 500 per family per. Subject to PMBs, and appliance sub-limits below: R3 510 per family per. Subject to PMBs, and appliance sub-limits below: Artificial eyes (5-year cycle) R R R6 360 R3 500 R3 510 R1 680 Artificial larynx (5-year cycle) R R R6 360 R3 500 R3 510 R1 680 Artificial limbs (5-year cycle) R R R6 360 R3 500 R3 510 R1 680 Back supports (annual) R4 025 R3 815 R3 650 R3 500 R3 510 R1 680 CPAP Machine (3-year cycle, only at preferred providers) R8 700 R7 750 R6 360 R3 500 R3 510 R1 680 Crutches (annual) R660 R660 R660 R660 R660 R660 Disposable bladder and intestinal excretion bags (annual) R R R6 360 R3 500 R3 510 R1 680 Elastic stockings for control of varicose veins (annual) R660 R660 R660 R660 R660 R660 External breast prosthesis after mastectomy (annual) R1 335 R1 335 R925 R925 R925 R925 Glucometers (3-year cycle) R1 160 R900 R730 R660 R660 R660 Hearing aids (annual, 3-year lifespan / appliance) R R R6 360 R3 500 R3 510 R1 680 Home oxygen (only at preferred providers, annual) R R R6 360 R3 500 R R1 680 Leg, arm and neck supports (annual) R925 R845 R730 R660 R660 R660 Nebulisers / humidifiers (3-year cycle) R1 160 R845 R730 R660 R660 R660 Orthopaedic footwear (annual) R1 060 R900 R660 R660 R660 R660 Sleep apnoea monitors (infants < 1 year and only at R R R6 360 R3 500 R3 510 R1 680 pharmacy, 1 / beneficiary / life) Wheelchairs (3-year cycle) R6 740 R5 615 R4 495 R3 500 R3 510 R1 680 Oncology Oncologist Chemotherapy Radiotherapy Oncology-related blood tests HIV / AIDS Primary care including Voluntary Counselling and Testing and Treatment Hospitalisation if member is on the HIV Management Programme (registration ) Hospitalisation if member is not on the HIV Management Programme, subject to Reg 8 (3) Home nursing Unlimited, subject to and Preferred Provider Network, pre-authorisation HIV Management Programme Hospitalisation at Network Provider hospitals. Subject to and PMB Limited to Provincial Facility 12 Days per family per. 100% of Scheme Unlimited, subject to ICON Network and standard protocols. Pre-authorisation HIV Management Programme Hospitalisation at Network Provider hospitals. Subject to and PMB Limited to Provincial Facility 10 Days per family per. 100% of Scheme Unlimited, subject to ICON Network and standard protocols. Pre-authorisation HIV Management Programme Hospitalisation at Network Provider hospitals. Subject to and PMB Limited to Provincial Facility 5 Days per family per. 100% of Scheme Limited to R per family per. Subject to ICON Network and standard protocols. Preauthorisation HIV Management Programme Hospitalisation at Network Provider hospitals. Subject to and PMB Limited to Provincial Facility 5 Days per family per. 100% of Scheme Limited to R per family per. Subject to ICON Network and standard protocols. Preauthorisation HIV Management Programme Hospitalisation at Network Provider hospitals. Subject to and PMB Limited to Provincial Facility except in lieu of hospitalisation. Subject to pre-authorisation R1 680 per family per. Subject to PMBs, and appliance sub-limits below: Limited to R per beneficiary per. Subject to ICON Network and standard protocols. Pre-authorisation HIV Management Programme Hospitalisation at Network Provider hospitals. Subject to and PMB Limited to Provincial Facility except in lieu of hospitalisation. Subject to pre-authorisation 3

5 OTHER INSURED BENEFITS SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Hospice, rehab and step down facility Specialised radiology CT, MRI, PET and Nuclear Medicine scans Video EEG for epilepsy surgery Dialysis 21 Days per family per. 100% of Scheme R per family per. Protocols. Co-payment of R1 700 per incident (in-and-out of hospital). Pre-authorisation. 100% of R per family per Unlimited at Network Provider. Protocols. Pre-authorisation 18 Days per family per. 100% of Scheme R per family per. Protocols. Co-payment of R1 700 per incident (in-and-out of hospital). Pre-authorisation. 100% of 15 Days per family per. 100% of Scheme R per family per. Protocols. Co-payment of R1 700 per incident (in-and-out of hospital). Pre-authorisation. 100% of Note: Other Insured Benefits are pro-rated for members who join or resign during the year. Authorisation must be obtained in advance from the Scheme for all hospitalisation and Other Insured Benefits. s shall be granted for: The replacement of existing External Medical Appliance items, without satisfactory proof that the existing item is obsolete Costs of maintenance, spares or accessories Hospice, rehab and step down facility benefit includes accommodation and visits by a medical practitioner, except where inclusive global fees are applicable. 12 Days per family per. 100% of Scheme R8 480 per family per. Protocols. Co-payment of R1 700 per incident (in-and-out of hospital). Pre-authorisation. 100% of 10 Days per family per. 100% of Scheme R6 740 per family per. Protocols. Co-payment of R1 700 per incident (in-and-out of hospital). Pre-authorisation. 100% of Covered at Network Provider. Protocols and PMB. Preauthorisation Covered at Network Provider. Protocols and PMB. Preauthorisation Covered at Network Provider. Protocols and PMB. Preauthorisation Covered at Network Provider. Protocols and PMB. Preauthorisation Covered at Network Provider. Subject to and PMB. Pre-authorisation Covered at Network Provider. Subject to and PMB. Pre-authorisation Emergency evacuation and ambulance services 100% of 100% of 100% of 100% of 100% of 100% of Limited to Europ Assistance ( ) INTERNATIONAL TRAVEL COVER Included Included Included Included Included CHRONIC MEDICATION BENEFIT SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Chronic diseases 25 CDL conditions + HIV, BPH and HRT Included. Subject to Supreme Chronic Formulary. Reference and GRP pricing apply Included. Subject to Millennium Chronic Formulary. Reference and GRP pricing apply Included. Subject to Classic Chronic Formulary. Reference and GRP pricing apply Included. Subject to Progressive Flex Chronic Formulary. Reference and GRP pricing apply Included. Subject to Hospital Chronic Formulary. Reference and GRP pricing apply Included. Subject to registration by a Network Provider. Subject to Foundation Chronic Formulary. Reference and GRP pricing apply Additional chronic conditions Pro-rated for members who join during the year. M R4 930 M+ R9 850 Benefits subject to stated sub-limits and thereafter to PMB CDLs M R2 380 M+ R4 770 Benefits subject to stated sub-limits and thereafter to PMB CDLs M R1 855 M+ R3 710 Benefits subject to stated sub-limits and thereafter to PMB CDLs Note: Chronic medication, Should be obtained from a preferred provider. Is restricted to formularies, clinical entry criteria and disease management protocols where applicable. Requires a script from a person legally entitled to prescribe and the relevant ICD-10 diagnosis code. Must be registered by the doctor or pharmacy on

6 OUT-OF-HOSPITAL SERVICES SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Day-to-day limits Principal: R Adult : R9 540 Child: R1 330 As specified Covered from MSA As specified As specified As specified General practitioners Consultations outside Provider Networks may incur a co-payment Unlimited. Non-Contracted Providers up to 100% of. Contracted Providers up to 100% of Contracted. CDL PMB consultations covered separately. Subject to Disease Management Protocols. Pre-authorisation Subject to MSA and ATB. Non-Contracted Providers up to 100% of. Contracted Providers up to 100% of Contracted. CDL PMB consultations covered separately. Subject to Disease Management Protocols. Pre-authorisation Subject to MSA. Non- Contracted Providers up to 100% of. Contracted Providers up to 100% of Contracted or at cost (as per member selection). CDL PMB consultations covered separately. Subject to Disease Management Protocols. Pre-authorisation M 4 visits per M+1 7 visits per M+2+ 9 visits per. Contracted Providers up to 100% of Contracted. CDL PMB consultations covered separately. Subject to Disease Management Protocols. Pre-authorisation PMB cover. Non-Contracted Providers up to 100% of. Contracted Providers up to 100% of Contracted. Preauthorisation Unlimited at Foundation Network Provider with authorisation after 4 th visit per beneficiary. (limited to 2 out-ofnetwork visits per family). Contracted Providers up to 100% of Contracted Specialists Consultations (consultations outside networks may incur a co-payment) Room procedures (require pre-authorisation, limited to Scheme protocols). Contracted Providers at 100% of Contracted (up to 220% of Scheme ). Contracted Providers at 100% of Contracted (up to 150% of Scheme ). Contracted Providers at 100% of Contracted (up to 150% of ) or at cost (as per member selection). Contracted Providers up to at 100% of Contracted M 2 visits per M+1 3 visits per M+2+ 3 visits per Limited to PMB at Network Providers. Subject to preauthorisation Subject to PMB and referral by GP Provider. Subject to pre-authorisation and limited to Specialist Network Providers M 4 visits per M+1 5 visits per M+2+ 6 visits per Additional visits subject to PMB and pre-authorisation Subject to MSA and ATB. Additional visits subject to PMB and pre-authorisation Subject to MSA. Additional visits subject to PMBs and pre-authorisation Additional visits subject to PMBs and pre-authorisation 5

7 OUT-OF-HOSPITAL SERVICES SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Dentistry Conservative dentistry limits Covered as stated below. Protocols Protocols, MSA, ATB and sub-limits of: M R5 300 M+1 R7 310 M+2+ R8 690 Protocols and MSA Protocols and annual limits of: M R2 800 M+ R4 500 Subject to Preferred Provider Network and annual limits of: M R1 680 M+ R2 800 Consultations 2 Annual check-ups and 2 emergency consultations per beneficiary per. 2 Annual check-ups and 2 emergency consultations per beneficiary per. Subject to MSA 2 Annual check-ups and 2 emergency consultations per beneficiary per. 2 Annual check-ups and 2 emergency consultations per beneficiary per. X-rays Intra-oral: 8 per beneficiary per Extra-oral: 1 per beneficiary per Intra-oral: 8 per beneficiary per Extra-oral: 1 per beneficiary per Subject to MSA Intra-oral: 8 per beneficiary per Extra-oral: 1 per beneficiary per Intra-oral: 8 per beneficiary per Extra-oral: 1 per beneficiary per Fillings A treatment plan and X-rays will be requested for treatment plans of more than 5 fillings. Benefits for fillings are available where such fillings are clinically indicated and will be granted once per tooth in a 1 year benefit cycle. There are no benefits for Amalgam (silver) fillings to be replaced with composite fillings (white filling material). Covered at 100% A treatment plan and X-rays will be requested for treatment plans of more than 5 fillings. Benefits for fillings are available where such fillings are clinically indicated and will be granted once per tooth in a 1 year benefit cycle. There are no benefits for Amalgam (silver) fillings to be replaced with composite fillings (white filling material). Covered at 100% Subject to MSA A treatment plan and X-rays will be requested for treatment plans of more than 5 fillings. Benefits for fillings are available where such fillings are clinically indicated and will be granted once per tooth in a 1 year benefit cycle. There are no benefits for Amalgam (silver) fillings to be replaced with composite fillings (white filling material). Covered at 100% of providers. A treatment plan and X-rays will be requested for treatment plans of more than 5 fillings. Benefits for fillings are available where such fillings are clinically indicated and will be granted once per tooth in a 1 year benefit cycle. There are no benefits for Amalgam (silver) fillings to be replaced with composite fillings (white filling material). Covered at 100% of Oral hygiene 2 Annual scale and polish treatments per beneficiary. for oral hygiene instructions or adult fluoride 2 Annual scale and polish treatments per beneficiary. for oral hygiene instructions or adult fluoride Subject to MSA. for oral hygiene instructions or adult fluoride 2 Annual scale and polish treatments per beneficiary. for oral hygiene instructions or adult fluoride 1 Annual scale and polish treatment per beneficiary. for oral hygiene instructions or adult fluoride Preventative Fissure sealants programme. Benefit for 1 fissure sealant per molar tooth in a 3 year cycle. Limited to individuals younger than 16 years Fissure sealants programme. Benefit for 1 fissure sealant per molar tooth in a 3 year cycle. Limited to individuals younger than 16 years Subject to MSA Fissure sealants programme. Benefit for 1 fissure sealant per molar tooth in a 3 year cycle. Limited to individuals younger than 16 years Protocols and Network Providers. 1 Fluoride treatment per beneficiary younger than 12 years Extractions Subject to MSA More than 4 requires pre-authorisation. Covered at 100% of Root canal therapy Subject to MSA Emergency root canal only. Acrylic dentures 1 Set of acrylic dentures (upper and lower) per beneficiary per 4 year cycle 1 Set of acrylic dentures (upper and lower) per beneficiary per 4 year cycle Subject to MSA 1 Set of acrylic dentures (upper and lower) per beneficiary per 4 year cycle Protocols and Network Providers. 1 set of acrylic dentures (upper and lower) per beneficiary per 4 year cycle 6

8 OUT-OF-HOSPITAL SERVICES SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Advanced dentistry Sub-limits R per family per. Pre-authorisation Subject to MSA, ATB and sub-limits of: M R5 300 M+1 R7 310 M+2+ R8 690 Pre-authorisation Subject to MSA. Pre-authorisation R4 770 per family per. Pre-authorisation As stated below. Pre-authorisation As stated below. Preauthorisation Crowns Bridges Included Included Implants Included Partial metal dentures 1 Per jaw per beneficiary every 3 years Subject to MSA Periodontics Orthodontics Fixed braces Benefits on preauthorisation will be applied to cases assessed as treatment mandatory, as per orthodontic indices. 1 Per lifetime for beneficiaries younger than 38 years. Orthognathic surgery and repairs or replacements, including retainers, are not covered 1 Per lifetime for beneficiaries under the age of 18 years. Repairs or replacements, including retainers, not included 1 Per lifetime for beneficiaries under the age of 18 years. Subject to MSA Surgery, dental hospitalisation, anaesthetics and associated costs Only for impacted wisdom teeth and extensive dental/ multiple procedures in children under 5 years of age. Multiple hospital admissions are not covered. Co-payment of will apply to all in-hospital dental admissions per protocol. Pre-authorisation is for certain Maxillo- Facial procedures that are covered in hospital, subject to Only for impacted wisdom teeth and extensive dental/ multiple procedures in children under 5 years of age. Multiple hospital admissions are not covered. Co-payment of will apply to all in-hospital dental admissions. Scheme Protocols apply Dental Account subject to MSA. Only for impacted wisdom teeth and extensive dental / multiple procedures in children under 5 years of age. Multiple hospital admissions are not covered. Co-payment of will apply to all in-hospital dental admissions. Scheme Protocols apply Only for impacted wisdom teeth and extensive dental/ multiple procedures in children under 5 years of age. Multiple hospital admissions are not covered. Co-payment of will apply to all in-hospital dental admissions. Scheme Protocols apply Limited to R3 930 per family per for impacted wisdom teeth and associated costs. Multiple hospital admissions are not covered. Co-payment of will apply to all inhospital dental admissions. apply Subject to PMBs only. Pre-authorisation. Multiple hospital admissions are not covered. apply 7

9 OUT-OF-HOSPITAL SERVICES SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Optometry Limited to Network Provider and 24 month benefit cycle Consultations / examination 1 consultation per beneficiary 1 consultation per beneficiary 1 consultation per beneficiary Spectacles R1 890 benefit for 1 pair of single vision spectacles. Inclusive of a frame and consultation per beneficiary R1 030 benefit for 1 pair of single vision spectacles. Inclusive of a frame and consultation per beneficiary R940 benefit for 1 pair of single vision spectacles. Inclusive of a frame and consultation per beneficiary Or Or Or R2 280 benefit for 1 pair of flat top bifocal spectacles. Inclusive of a frame and consultation per beneficiary Or Subject to MSA, ATB and sub-limit of R2 380 per beneficiary Subject to MSA R1 570 benefit for 1 pair of flat top bifocal spectacles inclusive of a frame and consultation per beneficiary Or R1 430 benefit for 1 pair of flat top bifocal spectacles inclusive of a frame and consultation per beneficiary R2 860 benefit for 1 pair of multifocal spectacles. Inclusive of a frame and consultation per beneficiary R1 820 benefit for 1 pair of multifocal spectacles. Inclusive of a frame and consultation per beneficiary Or Or Contact lenses R2 130 per beneficiary R1 030 per beneficiary Note: Non-emergency dental treatment performed in a hospital operating theatre or day clinic under general anaesthetic shall be subject to prior pre-authorisation by the Scheme in order to qualify for benefits. This includes theatre fees, anaesthetist fees, ward fees and associated costs, but excludes the dental practitioner and procedure costs that shall be subject to the conservative or advanced dentistry limits. Out of hospital benefits are subject to the formularies and case / disease management protocols. PMB management also included in overall benefit. All specialised dentistry must be pre-authorised at For more details on your dental benefits, optical benefits and exclusions please visit PREVENTATIVE CARE SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Preventative care limit Excludes consultation R3 370 per family per. applies R2 240 per family per. applies R2 240 per family per. applies R2 240 per family per. applies As specified Blood pressure Blood sugar Cholesterol Body Mass Index R106 per beneficiary over the age of 18 years. Only at pharmacy R106 per beneficiary over the age of 18 years. Only at pharmacy R106 per beneficiary over the age of 18 years. Only at pharmacy R106 per beneficiary over the age of 18 years. Only at pharmacy Included in the Foundation Network Provider consultation HIV test 8

10 PREVENTATIVE CARE SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Mammogram (screening) 1 Examination per female beneficiary per over the age of 35 years 1 Examination per female beneficiary per over the age of 35 years 1 Examination per female beneficiary per over the age of 40 years 1 Examination per female beneficiary per over the age of 40 years Pap smears PSA testing over the age of 45 years over the age of 45 years over the age of 45 years over the age of 45 years over the age of 45 years Vaccinations Flu 1 Dose flu vaccination per beneficiary per 1 Dose flu vaccination per beneficiary per 1 Dose flu vaccination per beneficiary per 1 Dose flu vaccination per beneficiary per At discretion of Foundation Network Provider Childhood immunisations Childhood immunisations as recommended by the Department of Health up to 18 months R1 685 benefit for childhood immunisations as recommended by the Department of Health up to 18 months R1 685 benefit for childhood immunisations as recommended by the Department of Health up to 18 months R1 685 benefit for childhood immunisations as recommended by the Department of Health up to 18 months At discretion of Foundation Network Provider HPV vaccine (cervical cancer prevention) 1 course (3 doses per registered schedule) per female beneficiary per life between 9 and 46 years 1 course (3 doses per registered schedule) per female beneficiary per life between 9 and 25 years Nurse helpline (including Rape Crises Centre) Advice and information regarding any emergency medical condition. Call Advice and information regarding any emergency medical condition. Call Advice and information regarding any emergency medical condition. Call Advice and information regarding any emergency medical condition. Call Advice and information regarding any emergency medical condition. Call Advice and information regarding any emergency medical condition. Call Oral contraception R1 344 per female beneficiary per (R112 per month) R1 344 per female beneficiary per (R112 per month) R1 344 per female beneficiary per (R112 per month) R1 344 per female beneficiary per (R112 per month) Note: Pro-rated for members who join or resign during the year. ADDITIONAL OUT-OF-HOSPITAL BENEFITS SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Annual limits M R6 670 M+1 R M+2+ R Alternative Healthcare Services Biokineticists Chiropodists Chiropractors Dieticians Homeopaths Naturopaths Occupational Therapists Osteopaths Podiatrists Social workers Acupuncture M R2 860 M+1 R4 240 M+2+ R % of Subject to annual limit Subject to MSA and ATB Subject to MSA Flexi Benefit: M R2 020 per M+ R2 560 per Subject to MSA and ATB Subject to MSA Subject to Flexi Benefit Limited to Network Provider benefits 9

11 ADDITIONAL OUT-OF-HOSPITAL BENEFITS SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Radiology and pathology Excluding specialised radiology PhySIOTHERAPy PsyCHOLOGy and psychiatric treatment Speech therapy and audiology Acute medication Subject to relevant plan formulary Reference and GRP pricing may apply Benefit protocols apply Use preferred provider pharmacies Note: Pro-rated for proportional annual membership. M R2 860 M+1 R3 510 M+2+ R % of. Subject to annual limit R1 250 per family, 100% of. Subject to annual limit R1 430 per family, 100% of. Subject to annual limit R1 430 per family, 100% of. Subject to annual limit M R6 700 M+1 R M+2+ R With a sub-limit on Schedule 0-2 drugs of: M R2 020 M+1 R3 480 M+2+ R3 800 Subject to annual limit Subject to MSA and ATB Subject to MSA Limited to PMBs Limited to PMBs. Subject to Network Provider Formulary list Subject to MSA and ATB Subject to MSA Limited to PMBs Subject to Flexi Benefit Subject to MSA and ATB Subject to MSA Limited to PMB at DSP Providers Subject to MSA and ATB Subject to MSA Subject to MSA, ATB and sub-limits of: M R5 300 M+1 R7 310 M+2 R8 690 With a sub-limit on Schedule 0-2 drugs of: M R1 570 M+1 R2 190 M+2 R2 580 Subject to MSA Limited to: M R2 020 M+ R2 560 With a sub-limit on Schedule 0-2 drugs of: M R560 M+ R785 Limited to PMB at DSP Providers Limited to Network Providers. and Formularies apply. For Non-Dispensing Providers, script limit of R85 per event (limited to 4 events per beneficiary) 10

12 2015 CONTRIBUTIONS SUPREME PROGRESSIVE FLEX HOSPITAL Principal Member R3 442 R1 713 R1 233 Adult dependant R3 305 R1 584 R1 049 Child dependant R878 R529 R460 Monthly Risk Contribution Monthly Saving Contribution MILLENNIUM OPTION Total Monthly Contribution Medical Savings Account Self Payment Gap (SPG) Threshold ATB Principal R2 545 R637 R3 182 R7 641 R2 875 R R4 934 Adult Dependant R2 162 R540 R2 702 R6 481 R2 173 R8 654 R4 208 Child Dependant R610 R152 R762 R1 826* R523** R2 349** R689** CLASSIC OPTION Risk Saving Total Medical Savings Account Principal R1 982 R350 R2 332 R4 200 Adult Dependant R1 744 R308 R2 052 R3 696 Child Dependant R748 R132 R880 R1 584* MONTHLY CONTRIBUTIONS: FOUNDATION OPTION Principal Adult Dependant Child Dependant R0 - R4 400 R715 R715 R215 R R6 750 R854 R854 R294 R R9 300 R1 082 R1 082 R345 R R1 635 R1 635 R561 * First three children only ** Per child 11

13 co-payments PROCEDURE SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Arthroscopy Circumcision Colonoscopy, sigmoidoscopy, proctoscopy R3 370 No co-payment No co-payment R3 370 R3 370 R3 370 R3 370 Procedures only funded for prior proven PMB conditions, and strictly subject to Scheme rules and protocols. Co-payments will remain applicable for hospitalisation Conservative back / spinal R3 370 R3 370 R3 370 R3 370 R3 370 if benefits are appropriate treatment for out of hospital access, Cystoscopy Dental admissions Excision nailbed Gastroscopy No co-payment No co-payment No co-payment R1 690 R1 690 R1 690 R1 690 and where an alternative procedure that does not incur the co-payment is available. Applicable copayments as for Classic option. Endometrial ablation R3 370 R3 370 R3 370 R3 370 R3 370 Hernia repair No co-payment R3 370 R3 370 R3 370 R3 370 Hysterectomy No co-payment R3 370 R3 370 R3 370 R3 370 Hysteroscopy R2 530 R2 530 R2 530 R2 530 R2 530 Joint replacements R6 430 R6 430 R R6 430* R6 430* Laparoscopic procedures R3 370 R3 370 R R3 370 R3 370 Myringotomy No co-payment R1 970 R530 R1 970 R1 970 Nasal surgery (including No co-payment R5 060 R5 060 R5 060 R5 060 endoscopy) Reflux surgery No co-payment R9 660 R9 660 R9 660 R9 660 Rotator cuff surgery No co-payment R6 430 R6 430 R6 430 R6 430 Skin lesions No co-payment R1 690 R1 690 R1 690 R1 690 Spinal surgery R7 030 R7 030 R R7 030* R7 030* Tonsillectomy and R1 970 R1 970 R530 R1 970 R1 970 adenoidectomy Tympanoplasty R1 690 R1 690 R530 R1 690 R1 690 Urinary incontinence repair R3 370 R3 370 R3 370 R3 370 R3 370 Varicose veins R3 370 R3 370 R3 370 R3 370 R3 370 *Subject to PMBs only. Note: rules, policies and protocols. These co-payments are per incident or event. Procedure specific co-payments still apply, even for PMBs, if alternative to endoscopic or laparoscopic surgery is available. Co-payments for circumcision, nailbed excision, hysterectomy, myringotomy, tonsillectomy, adenoidectomy and tympanoplasty per Classic option irrespective of PMB status. Benefits restricted to DSP providers at DSP network hospitals. Additional R3 500 co-payment applicable for non-dsp hospitals. All Scheme rules and protocols remain applicable. All Scheme exclusions, including the additional exclusions for the Foundation option, remain applicable. 12

14 Prosthesis sub-limits PROCEDURE SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION Overall plan limit R R56,180 R R R R Knee R R R R R R Hip R R R R R R Shoulder / Elbow /Ankle R R R R49,450 R R External fixator R R R R R R Spinal Fusion Cervical Lumbar, Cervical Lumbar, Cervical Lumbar, Cervical Lumbar, Cervical Lumbar, Cervical Lumbar, dorsal dorsal dorsal dorsal dorsal dorsal 1 level R R R R R R R R R R R R levels R R R R R R R R R R R R levels R R R R R R R R R R R R or more levels R R R R R R R R R R R R Coronory Stents 1 stent R R R R R R stents R R R R R R Total R R R R R R Pelvic floor R7 000 R7 000 R7 000 R7 000 R7 000 R7 000 Hernia mesh R7 000 R7 000 R7 000 R7 000 R7 000 R7 000 Intraocular lens (each) R3 250 R3 250 R2 800 R2 800 R2 100 R

15 Chronic medication: Chronic diseases and additional chronic conditions CHRONIC DISEASES (ALL OPTIONS) CLASSIC OPTION ADDITIONAL CHRONIC CONDITIONS MILLENNIUM OPTION ADDITIONAL CHRONIC CONDITIONS SUPREME OPTION ADDITIONAL CHRONIC CONDITIONS Addison s Disease Asthma Benign Prostatic Hypertrophy Bipolar Affective Mood Disorders Bronchiectasis Cardiac Dysrhythmia (Arrhythmia) Cardiac Failure Cardiomyopathy Chronic Obstructive Pulmonary Disorders (COPD) Chronic Renal Failure / Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus Type 1 & 2 Epilepsy Glaucoma Haemophilia HIV Hormone Replacement Therapy Hyperlipidaemia Hypertension Hypothyroidism Ischaemic Heart Disease (Coronary Artery Disease) Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosis Ulcerative Colitis ADHD Allergic Rhinitis Eczema ADHD Allergic Rhinitis Arthritis Eczema Gastro-Oesophageal Reflux Disease (GORD) Gout Major Depression ADHD Allergic Rhinitis Angina Pectoris Ankylosing Spondylitis Arthritis Cerebrovascular Accident (Stroke) Cushing s Syndrome Delusional Disorder Eczema Gastro-Oesophageal Reflux Disease (GORD) Gout Hyperthyroidism Idiopathic Thrombocytopenic Purpura Interstitial Fibrosis of the Lung Major Depression Meniere s Syndrome Motor Neuron Disease Myasthenia Gravis Osteoporosis Paget s Disease Peripheral Vascular Disease Pituitary Adenoma Psoriasis Scleroderma Urinary Incontinence 14

16 DEFINITIONS Above Threshold Benefit (ATB) - The benefits available to Millennium members once the MSA savings amount has been depleted and the Self Payment Gap (SPG) amount has been paid from the members own pocket Acute condition - Illness that requires short-term treatment Annual sub-limit - A set amount allocated to a benefit Casualty Benefit - A benefit available on certain options which can be used to cover visits to the casualty ward CDL (Chronic Disease List) - A list of 25 conditions which all medical schemes must cover and form part of PMBs Chronic conditions - Illness that requires ongoing treatment Clinical motivation - A motivation from your doctor explaining why a certain medicine or procedure is such as test results and x-rays CML (Chronic Medicines List) - A list of medicines to treat the 25 CDL conditions for each option or plan Confinement - Having a baby Contributions - Your medical scheme fees that you pay every month Dependant - Family members who share your medical scheme Emergency services - The ambulance service (Europ Assistance) that we use in case of a medical emergency Flexi Benefit - An amount set aside for Progressive Flex members to cover certain treatments ICD 10 code - A unique treatment code used by doctors or facilities when submitting a claim to the Scheme ICON - Independent Clinical Oncology Network Immunisation - Injections given to prevent illnesses Late joiner penalties - An additional fee payable on top of your monthly contribution when you join a medical scheme late in life and have not been a member of a medical scheme before or for more than a year Medical Savings Account (MSA) - An allocated amount of your contributions on the Millennium and Classic options that is set aside for you to manage and use on health services as you require. The amount rollsover every year, earns interest and is transferred if you change medical schemes. Co-payment - An amount listed for certain treatments or procedures which are not covered by the medical scheme and which you will have to cover from your own pocket MMAP (Maximum Medical Aid Price) - The maximum amount Resolution Health will pay for a medicine as advertised by Medikredit on Network Provider - Service providers working together and forming a group or network. Members on some options must use these network providers. Non-disclosure - Not telling us something about your health condition Option - Either the Hospital, Foundation, Progressive Flex, Classic, Millennium or Supreme plan Over-the counter medicine (OTC) - Medication you can get at your pharmacy without a prescription Patient Driven Care TM (PDC TM ) - A unique approach to treating at-risk Resolution Health patients that gives them appropriate access to the amount of care they need to stay healthier for longer Practice Number - A unique identification number which your doctor or service provider has Pre-authorisation - Permission from Resolution Health before going for treatment, tests, etc. Preferred Providers - Doctors, pharmacies or hospitals who provide care to our members as per a contracted agreement. All members are advised to make use of preferred providers as far as possible Preferred Provider Network - A network of healthcare providers who provide care to our members as per a contracted agreement Prescribed Minimum Benefits (PMB) - A list of 271 conditions, including 27 chronic conditions that all medical schemes have to cover Preventative Care - Care that aims to stop you from getting sick or suffering an event like flu, stroke, heart attack or hospitalisation Principal Member - The main member of the Scheme who pays the monthly fees Pro-rated benefits - The portion of benefits you are entitled to based on how long you have been a member of the Scheme during any benefit year Prosthesis - An artificial device implanted into the body 15

17 PSA (Prostate-Specific Antigen) - A blood test for men which determines possible prostate cancer risk Resolution Health Chronic Conditions - An additional list of chronic conditions which Resolution Health funds from the Chronic Medication benefit Scheme exclusions - A list of things the Scheme does not cover or pay for - Guidelines that determine how we fund your care - The amount Resolution Health pays for a particular medicine or medical service Scheme Rules - The rules of the medical scheme, including all policies, protocols and medicine lists Service provider - Doctor or healthcare facility Self Payment Gap (SPG) - The amount the member needs to pay in between their MSA s available funds before they can access Above Threshold Benefits (ATB) on the Millennium option Statement - A document which details the benefits you have used and payments processed by the Scheme Termination - Ending of agreement Zurreal - A free wellness and loyalty programme available to all Resolution Health members and stakeholders that offers lifestyle benefits and aims to help individuals and families to live healthier, happier lives Zurreal Gold - An intermediate wellness and loyalty programme available to Resolution Health members which includes all the benefits of Zurreal with added extras such as a sporting rebate and Health Check Rewards Zurreal Platinum - The ultimate wellness and loyalty programme available to Resolution Health members which includes all the benefits of Zurreal and Zurreal Gold with added extras such as an Education Rebate, Gym Rebate and much more 16

18 Notes: 17

19 Notes: 18

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