http://www.resomed.co.za/ | Resolution Health is an open medical scheme offering six different medical cover options tailored to suite the needs of their members during each stage of life. Whatever your health care requirements, from basic hospital cover to more comprehensive medical care, Resolution Health will provide you with the healthcare you need, when you need it most. Members also have access to a unique wellness and loyalty programme, Zurreal4life, which encourages members to make healthy living a lifestyle.
- 1.MEMBERSHIP HANDBOOK Classic, Millennium and Supreme
2. 2 3. Welcome to the Resolution Health family. As one of South
Africas 10 largest open medical schemes, we look forward to
providing you with holistic healthcare products and solutions to
suit your every need. Our six benefit options offer an exceptional
range of healthcare cover packages which are tailor-made to meet
the unique and varied healthcare expectations of the full consumer
spectrum. Our cover ranges from elementary and hospital cover to
more comprehensive benefit structures and is suitable for the whole
family. The Resolution Health product offering will ensure that you
have access to the benefits you need, when you need them. Our
holistic approach to your overall health and wellbeing is
complemented by our exceptional Zurreal4life wellness and loyalty
programmes.These programmes ensure that you have access to your
desired level of wellness opportunities. From the entry-level
Zurreal4life loyalty programme which is available to all members
FREE of charge, to the Zurreal4life Gold intermediate and the
extended programme, Zurreal4life Platinum, you can have the
lifestyle you desire. Resolution Health places the healthcare needs
of its members first, and it is with this mind-set that we
restructured our 2013 product basket. Each of Resolution Healths
six new healthcare options was specifically designed to ensure that
you are on the correct option that caters to your unique healthcare
needs. The design will ensure that you have appropriate medical
scheme cover and are protected from inappropriate cross-
subsidisation. This is complemented by our holistic health
management approach, which is aimed at maintaining your health.
This is done through our innovative Preventative Guardian Benefit
and the ground-breaking disease management programme, Patient
Driven Care (PDC). Add to this our advanced technology and
customer-centric approach, and you and your family can rest assured
that your health will be in the best possible hands. We look
forward to caring for you and your loved ones through our
exceptional products and outstanding service during 2013 and
beyond. Yours in health Mark Arnold Principal Officer Dear member 3
4. This handbook has been designed to provide you with important
information about your benefits and it is essential that you
familiarise yourself with its contents. Your Needs and your
healthcare Option 5 Which is your Ideal Resolution Health Option? 5
Membership Details 6 Termination of Membership 8 Monthly Membership
Contributions 8 Claims Procedure 9 Benefits 9 Emergency Services 9
Prescribed Minimum Benefits (PMB) 10 Dental Benefits 10 Optical
Benefits 11 Maternity Programme 11 Health Assist 11 Chronic
Medication: Chronic Disease List (CDL) and Resolution Health
Additional Chronic Conditions 12 Pharmacy Preferred Provider
Network 12 Oncology Benefits 13 HIV 13 Exclusions (services or
events not covered by the Scheme) 13 Hospitalisation 14 Procedure
Co-payments 15 Prosthesis Sub-limits 16 Other Insured Benefits 17
External Medical Appliance Sub-limits 17 Childhood Immunisations 18
Contributions 19 Late Joiner Penalties 19 Definitions 20 *Register
for e-statements now online to receive your statements via e-mail *
This Member Guide does not replace the Schemes Rules. The
registered Rules are legally binding and will always take
precedence. Contents 4 5. Resolution Health has simplified the
process of choosing your ideal healthcare cover by providing easy
to understand benefits. Each of our six options provides cover that
is specifically designed to meet the needs of individuals, families
and employers both through benefit design and affordability. When
choosing Resolution Health as your healthcare partner, our benefit
rich options translate into true value for money. Supreme Option
The Supreme Option provides comprehensive in-hospital benefits and
generous day-to-day benefits which are designed for those in need
of extensive cover. It is ideal for individuals and families who
want complete peace of mind. Hospitalisation at any hospital
Specialist fees paid at 220% of the Scheme Rate at preferred
providers for in and out of hospital services Access to a maternity
programme Casualty benefit for emergencies Excellent day-to-day
benefits Unlimited GP benefits Generous specialist visits Radiology
and pathology Oncology programme at network provider Basic and
advanced dentistry and oral surgery Optometry benefit Extended list
of chronic medication at preferred providers Auxiliary services
Physiotherapy, psychology and speech therapy benefit Access to
Preventative Care Programme Oral contraception benefit FREEaccess
to Zurreal4life, an elementary loyalty and lifestyle programme
Millennium Option The Millennium Option combines the flexibility of
a medical savings plan, with an above threshold benefit when your
day- to-day expenses are particularly high. This option allows for
unused savings to be carried over annually to the next year and
includes comprehensive in-hospital and chronic cover.
Hospitalisation at any hospital Specialist fees paid at 150% of
Scheme Rate at preferred providers in and out of hospital Access to
a maternity programme Basic radiology and pathology Advanced
radiology Oncology programme at network provider Basic and advanced
dentistry Optometry benefit Chronic medication at preferred
providers Extra chronic disease benefits Acute medicine benefits as
well as schedule 0 - 2 medicine benefits (over the counter
medicine) Auxiliary services Savings account for day-to-day
expenses Access to Preventative Care Programme Oral contraception
benefit FREEaccess to Zurreal4life, an elementary loyalty and
lifestyle programme Classic Option The Classic Option is
traditional in design, and provides balanced in-hospital and
day-to-day benefits at affordable premiums. The Classic Option is
ideal for individuals and families who put a premium on choice and
affordability. Hospitalisation at any hospital Specialist fees paid
at 150% of Scheme Rate at preferred providers in and out of
hospital Access to a maternity programme Basic radiology and
pathology Advanced radiology Oncology programme at network provider
Access to Preventative Care Programme Acute medicine benefit as
well as schedule 0 - 2 medicine benefits (over the counter
medicine) Chronic medication at designated pharmacies Oral
contraception benefit Day-to-day limits and sub-limits applicable
FREE access to Zurreal4life, an elementary loyalty and lifestyle
programme Your needs and your healthcare option Which is your ideal
Resolution Health option? 5 6. Change of personal details
Toensurecontinuedcommunicationandpromptclaimsmanagement, we require
the following information: E-mail address Cell phone number for sms
notifications Claims refund banking details Contribution banking
details You can update your details by logging onto our website at
www. resomed.co.za to download the necessary forms. The Scheme will
not be held responsible if a members rights are prejudiced or
forfeited, should we not have your updated details. Please note
that e-statements will be sent to all members with email addresses.
Dependants A dependant is defined as a person who is immediate
family and/or who is financially dependant on the principal member.
This person should not be in receipt of remuneration of more than
the maximum social pension per month and/or belong to another
medical scheme. The dependants of a member who are registered with
the Scheme at the time of the members death, may retain their
membership with the Scheme without any new restrictions,
limitations or waiting periods. Dependants who become orphaned
(according to the definition in the Schemes Rules) as a result of a
members death, will remain a member until they become a member of
the Scheme in their own right, or are accepted onto any other
registered medical scheme, provided the monthly contribution is
paid. To add a dependant, go to www.resomed.co.za and download a
Registration of Additional Dependant form. Please email fully
completed forms to [email protected] or fax them to 086 513 1438.
Registration of dependants/spouse Members may apply for the
registration of their dependants on application for membership, or
any time thereafter as they become dependants of the main member.
Should a member wish to apply for membership of additional
dependant(s) over the age of 21 years, proof of full-time student
status from a registered institution must be submitted confirming
that the dependant is financially dependant on the main member. The
following proof should accompany the Registration of Dependant
application form which can be downloaded from www. resomed.co.za:
Proof of full-time student status from a registered institution.
Should a member wish to apply for membership of additional
dependant(s) over the age of 21 years, an affidavit must be
submitted confirming that the dependant is financially dependant on
the main member. Handicapped children: physician report to confirm
disability. 1. Membership details 6 Introducing Zurreal, the unique
stakeholder programme with dedicated services, rewards and product
solutions that delight and allow you to Embrace Life Zurreal is not
part of the Resolution Health Medical Scheme. All Zurreal offerings
are separate products sold (where relevant) and administered by
Agility Channel (Pty) Ltd, Registration number 2004/003709/07. 7.
Note: The Scheme allows a dependant who studies full-time to remain
on the Scheme as a child dependant until the age of 25 years.
Kindly submit with the application form proof of dependancy i.e. a
student certificate. Kindly submit proof of this/student
certificate to [email protected] on an annual basis to maintain
their status. If proof is not received, the child dependant will be
defaulted to an adult dependant status. Newborns/adoptions The
arrival of a new baby is always an exciting event. You can rely on
the comfort of Resolution Health to cover medical expenses if the
newborn or newly adopted baby is registered within 30 days of birth
or adoption. Contributions for the newly registered dependant are
due from the first day of the month following the birth or
adoption. Benefits will be calculated from the day of birth or
adoption provided the necessary documentation is received, together
with the application for registration within the required period of
30 days. Kindly fax a copy of the birth certificate/registration to
086 513 1438 or send an e-mail to [email protected]. Note: If a
newborn baby or newly adopted dependant is not registered within 30
days of birth or adoption, benefits will only be available from the
date of registration and not retrospectively from the date of birth
or adoption. Deregistration of dependants In order to ensure
efficient service, it is important to keep our member information
up to date. Kindly let us know within one calendar month of any
event that may change the status of a dependant, which may make
their membership invalid. When such dependant no longer qualifies
for membership, they will be deregistered and will no longer be
entitled to any benefits. Go to www.resomed.co.za to download a
Deregistration of Dependants form. Please email a fully completed
form back to [email protected] or fax to 086 513 1438.
Eligibility Membership is open to all individuals and groups and is
subject to the Rules of the Scheme. Membership Cards Two membership
cards per family will be issued and a single card per individual
member. Should you need additional cards, please send a request to
[email protected]. The card allows you to obtain services
from medical service providers. Should you need additional cards
for your dependants, please request these from client services on
0861 796 6400 or cardrequests@resomed. co.za or download the
necessary form from www.resomed.co.za Note: It is illegal to use a
membership card that does not belong to you. The unauthorised use
of a membership card is considered a fraudulent claim on the
Schemes membership privileges and will result in such membership
being cancelled immediately. 7 8. Membership may be terminated for
the following reasons: Abuse of privileges, false claims,
misrepresentation and non-disclosure of factual information The
Scheme will terminate the membership, or exclude a member or
dependant(s) from benefits, for any abuse of the benefits and
privileges of the Scheme by presenting false claims or material
misrepresentation or non-disclosure of information. Death
Membership is terminated on receipt of a death certificate.
Employer resignation from the Scheme Members who are members of
Resolution Health in terms of their conditions of employment, and
whose employer elects to resign from the Scheme, and does not join
another Scheme as an employer group, will not be members from that
date, unless they elect to continue membership in their private
capacity. The Scheme requires one calendar month notice period
prior to termination. Failure to pay amounts due to the Scheme
Members who fail to pay all due amounts to the Scheme will have
their membership terminated in terms of the Rules of the Scheme.
Resignation from employment Members who belong to Resolution Health
in terms of their conditions of employment, may not resign from the
Scheme without written consent from their employer. On resignation,
membership and benefits end as of the date of resignation, unless
members elect to continue membership in their private capacity.
Subject to the Schemes Rules. Voluntary termination Members who do
not belong to Resolution Health in terms of their conditions of
employment, may terminate their membership by giving one month
written notice. Employers that wish to end their association with
the Scheme may do so by giving one calendar month written notice.
Membership contributions are due monthly in advance and are payable
no later than the 5th day of the month. Late payments will result
in suspended benefits or cancellation of membership. Where
contributions or any debt owing to the Scheme are not paid within 3
days, the Scheme has the right to suspend all benefits and give the
member or employer notice that membership may be cancelled should
all debts not be paid within 14 days of such notice. Benefits will
be reinstated when outstanding premiums are paid up to date,
provided that membership has not been cancelled. If payments are
not brought up to date, the member will not be entitled to any
benefits from the date of default of payment. Any benefit already
paid may be recovered by the Scheme. Note: No refunds or portion of
a members contribution will be paid where membership, or cover in
respect of dependants, terminates during the course of a month. In
terms of the Rules of the Scheme, the Scheme has the authority to
increase or decrease at any time the amount of contributions
payable by all members to ensure the financial stability of the
Scheme. 2. Termination of membership 3. Monthly membership
contributions 8 9. Should your medical service provider not submit
claims to us electronically, please submit a signed claim to
[email protected] or send this to: Resolution Health
Medical Scheme PO Box 1075 Fontainebleau 2032 Please include the
following essential details: Membership number. Name of the Option.
Members surname and details. Surname, initials and other details of
the patient. The practice number, group practice number and
individual provider registration number of the service provider;
and in case of a group practice, the practice number of the
practitioner who provided the service. Date when the service was
rendered. The nature and cost of services rendered, including the
supply of medicine to the member or registered dependant, with the
name, quantity and dosage of the medicine - include the net amount
payable by the member for the prescribed medicine. The relevant
diagnostic (ICD-10) code, relating to the service. If the ICD-10
code does not appear on the account it should be obtained from the
service provider prior to submission. If the member has already
paid the account, the original receipt must be submitted with the
claim. Claims must reach us by no later than the last day of the
fourth month, following the month in which the service was
rendered. Accounts for treatment of injuries or expenses recovered
from third parties, must be supported by a statement detailing the
circumstances in which the injury was sustained or the accident
occurred. Claims payments to service providers and members take
place twice a month. The Scheme will supply the member with a
detailed claims statement after every payment run. Should there be
any irregularities on the account, the Scheme will state the reason
for the error or why it is unacceptable. The member or service
provider then has the opportunity to return the corrected claim
within 60 days of such notice. Note: Certain service providers
charge fees above those which are covered as listed in the
membership guide. The Scheme will only pay providers at the rate
depicted in the Benefit Schedule, usually the Scheme Rate, unless
otherwise specified. The Benefit Schedule also identifies limits
and sub-limits for certain services and products. To avoid members
being held liable for any shortfall, it is essential they determine
what providers charge upfront prior to any services being
delivered. The Scheme may also exclude certain services from
benefits, as set out in Exclusions (section 5.12, page 13).
Resolution Health provides a range of benefits to suit both your
lifestyle and budget and which are competitive with similar
products within the market. Members may change benefit options
subject to the following: Changes may only be made annually
effective 1 January A written application to change your benefit
option must reach the Principal Officer by no later than 31
December for the next year All options cover the Prescribed Minimum
Benefits (PMBs), subject to Scheme Protocols. Members and their
dependants are entitled to the benefits of their option during a
financial year as per the Benefit Schedule listed in this handbook.
Once depleted, any additional interventions that qualify as PMB
will be funded according to Scheme protocols. Pre-authorisation and
proof of PMB status is required for automated payment. Members
should check the different option benefits, the list of approved
chronic conditions (section 5.8, page 12) and exclusions (section
5.12, page 13), to ensure they select the most appropriate option
to get the best possible benefits from their cover for the year.
When joining the Scheme during the year, all benefits except
hospitalisation and other risk benefits, that have Rand limits will
be pro-rated in proportion to the period of membership. This will
be calculated from the date of admission to the Scheme to the end
of the year. 5.1. Emergency services (0861 112 162) Resolution
Health in partnership with Europ Assistance offers access to
emergency assistance 24-hours a day to arrange emergency medical
assistance, anywhere in South Africa. In the event of an emergency,
should a member be unable to get to a hospital, appropriate
transportation, such as an ambulance is arranged. In addition to
emergency transportation, the Medical Evacuation product also
offers: Emergency telephonic medical advice Dispatch of ambulances
and flights Arrangements for compassionate visits by a family
member Arrangements for the escorted return of minors after an
accident Repatriation to appropriate facility in area of residence
after an accident Referrals to doctors and other medical facilities
The relaying of information to a family member/acquaintance
Telephonic trauma counselling 4. Claims procedure 5. Benefits 9 10.
5.2. Prescribed Minimum Benefits (PMB) The Prescribed Minimum
Benefits or PMBs is a list of diseases or conditions listed in the
Medical Schemes Act which schemes are required to pay for. Included
in this is the Chronic Disease List (CDL list) of chronic
conditions that also fall under the umbrella of PMBs. In certain
circumstances the Scheme may only provide cover for members and
their dependants in provincial hospitals or at the Schemes
appointed private Designated Service Provider (DSP) facilities. All
PMB conditions will be funded according to Scheme Rules and
Protocols at the appropriate level of care. The list of PMB
conditions and ICD codes is available from the Council for Medical
Schemes website: www.medicalschemes.com. The Scheme will only fund
claims for these PMB conditions on clinical confirmation of the ICD
code such additional information includes doctor motivations as
well as any supporting documents such as radiology and pathology
reports or any other the Scheme requires to confirm the ICD code on
accounts. The minimum level of medical cover is that provided in
the state or public sector. The Scheme has certain entitlements
which members have to observe to ensure cover for PMB benefits, as
specified in the benefit schedule. These may include: Designated
Service Provider (DSP) hospital networks, medical practitioners,
other professional providers, dialysis, oncology, pharmacy networks
etc. Clinical confirmation of a condition, as above Pharmaceutical
formularies, including reference and MMAP pricing Treatment
protocols, including level of care protocols Treatment algorithms
for CDL conditions and other DTPs Benefits will be restricted to
PMB cover in the following circumstances: Where a member or their
dependant(s), who could reasonably have obtained a service from a
preferred provider, chooses to use another provider of his/her
choice, the Schemes liability for the costs of obtaining such
services will be restricted. Members with waiting periods imposed
upon joining the Scheme may or may not have cover for PMB
conditions. Members should check this on their Terms of Acceptance
letter. Where a PMB condition requires further treatment but annual
benefits have been exhausted. Where benefits are limited to PMB.
Note: Where specific benefits are limited to PMB conditions,members
may be liable for a co-payment if services are obtained from a non-
DSP facility. 5.3. Dental benefits General Dental benefits can be
obtained from any provider, but will be funded according to the
Scheme specific rates. Preferred providers are contracted to charge
and deliver services according to the Scheme specific rates. It is
therefore advisable to use preferred providers to ensure no
co-payments. Co- payments may be applicable if members choose to
use a non- preferred provider or services not covered in their
specific benefit option. The Scheme benefits and protocols, as well
as the list of the preferred providers and dental rates, are
available on our website on www. resomed.co.za. Please familiarise
yourself with the defined benefit before visiting your dentist.
Advanced dentistry always needs to be authorised. General surgery
exclusions (in dental chair and in-hospital) include: Bone
augmentations Sinus lifts Bone and tissue regeneration
Gingivectomies Surgical procedures associated with dental
implantology Oral hygiene instructions Professionally applied
topical fluoride in adults Nutritional and tobacco counselling Root
canal treatment on third molars (wisdom teeth) and primary teeth
Ozone therapy Soft base to new dentures Apisectomies in-hospital
The surgical procedures listed above are not covered by the Scheme.
The member will be liable for the full account. 10 11. Anxious
Patients Hospitalisation and general anaesthesia is not covered
where patients require anxiety control only. Many people are
anxious about dental treatment and mild sedation is sometimes
required. Benefits are payable for sedation methods such as
laughing gas or sedative medications. No pre-authorisation is
required for laughing gas or sedative medications. Conscious
sedation (iv sedation) for surgical procedures require
pre-authorisation and are subject to Scheme Protocols. General
anaesthesia and hospitalisation Hospitalisation for dentistry is
not automatically covered and is subject to pre-authorisation.
Hospitalisation for the removal of impacted teeth in adults is
available on all options. General anaesthetic benefits are
available for very young children (younger than 5 years of age) for
extensive dental treatment (multiple extractions and fillings),
subject to admission protocols. Hospitalisation protocols: Where an
underlying medical condition creates a substantially increased risk
of treatment in the dentists rooms and justifies admission, an
authorisation may be granted. A medical report from a medical
practitioner confirming the medical condition will be required.
Multiple hospital admissions are not covered. An x-ray or clinical
report may be requested to process a hospital pre-authorisation.
Hospitalisation for impacted teeth will only be authorised for
pathology or severe pain based on Scheme Protocols and evidence.
Soft tissue impactions will not be covered. Hospitalisation is not
covered where anxiety of dental treatment is the reason for the
admission. 5.4. Optical benefits Optical benefits are subject to a
24-month benefit cycle and can be obtained from any provider, but
will be funded according to the Scheme specific optical rates and
tariff structures to ensure no co- payments or rejected claims.
Preferred providers are contracted to charge and deliver services
according to the Scheme specific rates and it is therefore
advisable to use preferred providers to facilitate ease of access
and ensure no co-payments. Co-payments may be applicable if members
choose to use a non-preferred provider or enhancements which fall
outside the option specific entitlements. The Scheme benefits and
protocols as well as the list of the preferred providers and
optical rates are available on our website on www.resomed.co.za.
Please familiarise yourself with the defined benefit before
visiting your optometrist. 5.5. Maternity programme All expectant
members have access to the maternity programme. To register call
0861 111 778 after a blood test has confirmed the pregnancy. The
member is entitled to two 2D ultrasound scans. After the 32nd week,
the member must call pre-authorisation to activate access to the
baby care products voucher on the applicable option.This can be
redeemed from any preferred provider pharmacy. The baby care
benefit is valid for 1 year from date of activation. 5.6. Health
Assist (Nurse helpline 0861 112 162) Professional medical advice
24-hours a day is offered and includes: Emergency medical advice
Appropriate first aid advice in case of emergency Assessing
day-to-day symptoms Important health knowledge and counselling Drug
database Poison information HIV/AIDS and cancer Addiction Trauma
counselling 11 12. 5.8.Chronic medication: the Chronic Disease List
(CDL) and Resolution Health Additional Chronic Conditions How to
register for Chronic Medication: Your doctor or pharmacy must phone
Swift Online on 0800 132 345 with ICD-10 codes and relevant test
results. Swift Online hours: Monday to Friday 08:00 - 18:30,
Saturday 09:00-13:00. 5.9. Pharmacy Preferred Provider Network The
list of Resolution Health Medical Scheme recommended pharmacies is
available on the Scheme website on www.resomed.co.za or on
www.medikredit.co.za. Any additional cost at one of these
recommended pharmacies may be due to: Reference pricing or Maximum
Medical Aid Price (MMAP) pricing Chronic Disease List (CDL)
Conditions (All Options) Millennium Option Additional Chronic
Conditions Supreme Option Additional Chronic Conditions Addisons
Disease Osteoarthritis ADHD Asthma Gastro-Oesophageal Reflux
Disease (GORD) Angina Pectoris Bipolar Affective Mood Disorders
Gout Ankylosing Spondylitis Bronchiectasis Major Depression
Medication Benign Prostatic Hypertrophy Cardiac Dysrhythmia
(Arrhythmia) Cerebrovascular Accident (Stroke) Cardiac Failure
Cushings Syndrome Cardiomyopathy Delusional Disorder Chronic
Obstructive Pulmonary Disorders (COPD) Female Menopause Chronic
Renal Failure/Disease Gastro-Oesophageal Reflux Disease (GORD)
Crohns Disease Gout Diabetes Insipidus Hyperthyroidism Diabetes
Mellitus Type 1 & 2 Idiopathic Thrombocytopenic Purpura
Epilepsy Interstitial Fibrosis of the Lung Glaucoma Major
Depression Haemophilia Menieres Syndrome Hyperlipidaemia Motor
Neuron Disease Hypertension Myasthenia Gravis Hypothyroidism
Osteoporosis Ischaemic Heart Disease (Coronary Artery Disease)
Ostheoarthritis Multiple Sclerosis Peripheral Vascular Disease
Parkinsons Disease Pituitary Adenoma Rheumatoid Arthritis Psoriasis
Schizophrenia Scleroderma Systemic Lupus Erythematosis Urinary
Incontinence Ulcerative Colitis Pagets Disease 12 13. 5.10.Oncology
benefits The Oncology benefit covers chemotherapy, radiotherapy,
oncologist fees and blood tests within benefit limits, protocols
and guidelines. Other investigative work-up is allocated to
out-of-hospital benefits and thereafter PMB according to Scheme
Protocols. Benefits for all options are based on the ICON Network
protocols and pre-authorisation is required. A Preferred Provider
Network is in place for all options and Scheme Protocols apply.
Pre-authorisation requires submission of a treatment plan by the
oncologist to [email protected]. Note: MMAP and reference
pricing is applicable. 5.11. HIV Resolution Health provides for
out-patient care including consultations, blood tests, counselling
and medication. Registration is required to access this benefit.
Call 0861 111 778 or register via email at [email protected]
Note: Hospitalisation for HIV positive members is only funded in a
provincial facility if you are not registered and compliant on the
programme. Thus any admission to a private hospital under these
circumstances will only be funded at provincial rates and members
will be financially liable to the private hospital for any
shortfall. To avoid this, it is important that HIV positive members
register with the programme. 5.12. Exclusions (services or events
not covered bythe Scheme) Resolution Health exclusions 2013 Subject
to the PMBs in either a public care system or at the facilities of
one of the Schemes Designated Service Providers, as contemplated in
Regulation 8 of the Regulations promulgated in terms of the Act, or
provided for in a benefit option. The Schemes liability is limited
to the cost of medical services as defined in the Act and provided
for in the rules of the Scheme and, further subject to the
provisions of rule 1.2 of Annexure B, expenses in connection with
any of the following shall not be paid by the Scheme:
1.Compensation for pain and suffering, loss of income, funeral
expenses or claims for damages. 2.Expenses incurred for
recuperative or convalescent holidays. 3.Services not considered
appropriate in terms of Managed Healthcare Principles, or that are
not lifesaving, life sustaining or life supporting. The Scheme
reserves the right to determine such instances in general or for
specific instances at any time, at its discretion. The following
conditions, procedures, treatments and apparatus will specifically
be excluded: 3.1. Any breast reduction or augmentation or breast
reconstruction unless related to diagnosed malignancy in the
affected breast (subject to Scheme Protocols). Prophylactic
mastectomy only considered for BRCA mutations. Reconstruction
following prophylactic mastectomy will not be funded 3.2.
Gynaecomastia 3.3. Hyperhidrosis 3.4. Eximer laser and radial
keratotomy 3.5. Phakic implants 3.6. Bariatric surgery and other
treatments, services or charges for or related to obesity 3.7.
Keloid and scar revision and any other cosmetic procedures and
treatments 3.8. Dynamic spinal devices 3.9. CT or virtual
colonoscopy 3.10. Change of sex operations and procedures 3.11.
Growth hormone 3.12. Sleep and hypnosis therapy 3.13. Elective
Caesarean section (except Supreme Option) 3.14. Cancer treatment
outside network protocols 3.15. Medicines not registered with or
used outside their Medicines Control Council registration or
proprietary preparations 3.16. Medication outside the formulary
3.17. Pre-hospital admissions 3.18. Nasal reconstruction 3.19.
Bat-ears 3.20. Removal of skin blemishes 3.21. Liposuction 3.22.
Face-lift and eyelid procedures 4. Exercise programmes. 5.
Kilometre charges and travelling expenses with the exception of
ambulance services. 6. Examinations and tests for the purpose of
application for insurance policies; school camp; visa; employment;
emigration or immigration; admission to schools or universities;
medical court reports; as well as fitness examinations and tests.
7. Charges for appointments not kept. 8. Accommodation in
convalescent, old age homes, frail care or similar institutions. 9.
Costs associated with vocational guidance, child guidance, marriage
guidance, school therapy or attendance at remedial education
schools or clinics. 10. Purchase of: 10.1. Applicators, toiletries,
sunglasses and/or lenses for sunglasses and beauty preparations
10.2. Patented foods and nutritional supplements including baby
foods 10.3. Remedies for the treatment of infertility 10.4. Tonics,
slimming preparations, appetite suppressants and drugs/medicines as
advertised to the public for the specific treatment of obesity.
Further all cost escalations and/or increases for any services
accessioned by or in relation to obesity 13 14. 10.5. Sunscreen and
sun tanning lotions 10.6. Soaps and shampoos (medicinal or
otherwise) 10.7. Household and biochemical remedies which are not
promoted by the medical profession with evidence to support benefit
(Scheme Protocols and assessment will apply) 10.8. Cosmetic
products (medicinal or otherwise) 10.9. Anti habit-forming products
10.10. Vitamins and multi-vitamins unless prescribed by a person
legally entitled to prescribe by the Scheme 10.11. Remedies for
bodybuilding purposes 10.12. Aphrodisiacs 10.13. Household
bandages, cotton wool, dressings and similar aids 11. Infertility,
sterility, artificial insemination of a person as defined in the
Human Tissue Act, (Act 65 of 1983), as well as vaso-vasostomies
(reversal of sterilisation procedures), subject to PMBs. 12.
Diagnostic tests and examinations performed that do not result in
confirmation of the diagnosis of a PMBs condition unless such
condition qualifies as a bona-fide emergency medical condition.
Diagnostic tests will only be funded up to and inclusive of the
minimum tests required to exclude a PMB condition. 13.Repair of
hearing aid and medical apparatus. 14.Experimental, unproven or
unregistered treatment or practices. 15.Donor costs in respect of
an organ transplant will not be covered by the Scheme unless the
recipient is a member of the Scheme for a PMB related transplant.
16.Interest and legal costs on outstanding accounts. Note that the
availability of a treatment/procedure or diagnostic test in a state
facility does not automatically imply PMB access and Scheme
Protocols always apply. 5.13. Hospitalisation You are able to
obtain authorisation 24-hours a day. All hospital admissions are
subject to pre-authorisation,Scheme Rules and managed care
policies, protocols and formularies. Authorisation must be obtained
at least 72-hours in advance from the Scheme for all non-emergency
hospital admissions and procedures. In the case of true emergency
admissions, authorisation must be obtained within 48-hours or on
the first working day after admission. Laparoscopic and similar
endoscopic procedures are excluded from benefits, unless
pre-authorised otherwise under Scheme Protocols. All PMB diagnoses
require proof of status and Scheme Protocols apply. Co-payments: -
Members need to pay the following amounts upfront to the hospital
when they are admitted for the procedures. - Co-payments do not
apply if these procedures are performed out-of-hospital or when it
is a PMB condition. When two related co-payments are applicable,
only the larger will apply. - Specialised radiology co-payment
applies irrespective of hospitalisation and other co-payments. 14
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lifestyle benefits you could ever want Zurreal4life are not part of
the Resolution Health Medical Scheme. All Zurreal offerings are
separate products sold (where relevant) and administered by Agility
Channel (Pty) Ltd, Registration number 2004/003709/07. 15.
Procedure Co-payments 15 Procedure Classic/Millennium Supreme
Arthroscopy R3 000 R2 000 Circumcision R2 000 - Colonoscopy,
sigmoidoscopy, proctoscopy R2 000 - Conservative back treatment R3
000 R3 000 Excision nailbed R1 500 - Nasal surgery (including
endoscopy) R4 500 - Gastroscopy R2 000 - Hysterectomy R3 000 -
Hysteroscopy R2 250 R2 250 Joint replacements R5 720 R5 720
Laparoscopic procedures R3 000 R3 000 Myringotomy R1 750 - Reflux
surgery R8 600 R8 600 Skin lesions R1 500 - Specialised radiology
R1 500 R1 500 Spinal surgery R6 250 R6 250 Cystoscopy R2 000 -
Hernia repair R3 000 - Rotator cuff surgery R5 720 R5 720
Tonsillectomy and adenoidectomy R1 750 R1 750 Urinary Incontinence
repair R3 000 R3 000 Dental admissions R2 000 R2 000 Gynaecological
laparoscopy, endometrial ablation R3 000 R3 000 Tympanoplasty R1
500 R1 500 Varicose veins R3 000 R3 000 Procedure specific
co-payments still apply if alternative to endoscopic or
laparoscopic surgery is stated in protocol Excluded unless PMB
proven (protocols apply) NOTE: Pre-authorisation is available 24/7
and therefore a maximum of 48 hours will be allowed for legitimate
emergencies only and proof of emergency status may be required.14
Days are recommended for booked cases. Authorisation does not imply
recognition of PMB status until proof of such status has been
received by the Scheme. This may include clinical motivation with
supporting documentation such as laboratory reports, imaging etc. *
Not available as elective procedure and only PMB status will apply.
Note that Scheme Protocols apply to all procedures to ensure
equitable access to care. Procedure Co-payments 16. Prosthesis
Classic Millennium Supreme Knee R31 000 R38 000 R38 000 Hip R28 500
R34 500 R34 500 Shoulder Elbow Ankle R44 000 R44 000 R44 000
External fixator R45 000 R50 000 R50 000 Spinal Fusion Cervical
Lumbar, dorsal Cervical Lumbar, dorsal Cervical Lumbar, dorsal 1
level R17 750 R20 000 R17 750 R22 250 R17 750 R22 250 2 levels R27
500 R32 000 R27 500 R34 000 R27 500 R34 000 3 levels R38 000 R40
000 R38 000 R40 250 R38 000 R40 250 4 or more levels R45 000 R45
000 R50 000 R50 000 R50 000 R50 000 Coronary stents 1 stent R19 000
R19 000 R19 000 2 stents R31 000 R31 000 R31 000 Total R45 000 R50
000 R50 000 Pelvic floor R6 250 R6 250 R6 250 Hernia mesh R6 250 R6
250 R6 250 Intraocular lens R2 500 R2 900 R2 900 5.14. Prosthesis
sub-limits 16 17. 5.15.Other insured benefits Authorisation must be
obtained in advance from the Scheme for all hospitalisation and
other insured benefits. No benefits shall be granted for (1) the
replacement of existing external medical appliances without
satisfactory proof that the existing item is obsolete or (2) costs
of maintenance, spares or accessories. Hospice care, rehabilitation
and step-down facilities include accommodation and visits by a
medical practitioner (except where inclusive global fees are
applicable). Please note that certain insured benefits may be
pro-rated for members that join during the course of the year.
5.16. External medical appliances sub-limits NOTE: - Sub-limits for
other prostheses determined per case. - Benefits will be pro-rated
in proportion to the period of membership. External Medical
Appliances Frequency cycle Classic Millennium Supreme R6 000 per
family subject to PMB R9 000 per family subject to PMB R12 000 per
family Artificial eyes 5-year cycle R6 000 R9 000 R12 000
Artificial larynx 5-year cycle R6 000 R9 000 R12 000 Artificial
limbs 5-year cycle R6 000 R9 00 R12000 CPAP machine 3-year cycle R6
000 R9 000 R7 750 Leg, arm and neck supports Annual R 650 R 750 R
825 Back support Annual R3 250 R3 400 R3 590 Crutches Annual R 590
R 590 R 590 Disposable bladder and intestinal excretion bags Annual
R6000 R9 000 R12 000 Elastic stockings for varicose veins Annual R
590 R 590 R 590 External breast prosthesis after mas- tectomy
Annual R 825 R 1 190 R1 190 Glucometers 3-year cycle R 650 R 800 R1
050 Hearing aids (3-year lifespan) Annual R 6000 R9 000 R12 000
Home oxygen Annual R 6000 R9 000 R12 000 Nebulisers/humidifiers
3-year cycle R 650 R 750 R1 050 Orthopaedic footwear Annual R 590 R
560 R 900 Sleep apnoea monitors (infants < 1 year) 1/beneficiary
per life R6 000 R9 000 R12 000 Wheelchairs 3-year cycle R4 000 R5
000 R 6000 Sleep apnoea monitors (infants < 1 year)
1/beneficiary per life R 6000 R9 000 R12 000 Wheelchairs 3-year
cycle R 4000 R5 000 R6 000 17 18. 5.17. Childhood immunisations The
following schedule is recommended by the National Department of
Health up to the age of 18 months: (Only applicable on certain
options and limited. Please refer to Preventative Care Benefits) 8.
Definitions Age of child Vaccine recommended At birth OPV(0) Oral
Polio Vaccine BCG Bacilles Calmette Vaccine 6 weeks OPV(1) Oral
Polio Vaccine DTP/Hib(1) Diptheria, Tetanus, Pertussis &
Haemophilus influenza type b Vaccine Heb B(1) Hepatitis Vaccine
PCV(1) Pneumococcal Conjugated Vaccine 10 weeks OPV(2) Oral Polio
Vaccine RV (1) Rotavirus Vaccine DTP/Hib(2) Diptheria, Tetanus,
Pertussis & Haemophilus influenza type b Vaccine Heb B(2)
Hepatitis Vaccine PCV(2) Pneumococcal Conjugated Vaccine 14 weeks
OPV(3) Oral Polio Vaccine RV (2) Rotavirus Vaccine DTP/Hib(3)
Diptheria, Tetanus, Pertussis & Haemophilus influenza type b
Vaccine Heb B(3) Hepatitis Vaccine PCV(3) Pneumococcal Conjugated
Vaccine 9 months Measles Vaccine(1) 18 months OPV(4) Oral Polio
Vaccine DTP Diptheria, Tetanus, Pertussis Measles Vaccine (2) 18
19. 6. Contributions 19 Monthly contribution for MILLENNIUM OPTION
Savings: Risk: Total contribution: Principal: R 504 R 2014 R 2518
Adult Dependant : R 413 R 1652 R 2065 Child Dependant: R 121 R 483
R 604 2013 CONTRIBUTIONS Benefit Option Principal: Adult Dependant:
Child Dependant: Classic R 1,626 R 1,383 R 651 Supreme R 2,712 R
2,637 R 694 7. Late Joiner Penalties Additional premiums for
persons joining medical schemes late in life will be added to the
applicable premium rates, and are a standard practice in the
industry. Premium penalties will be applied as follows in respect
of persons over the age of 35 years, who were without medical
scheme cover for the period indicated hereunder after the age of 30
years: 1 4 years 0.05 multiplied by the relevant contribution above
5 14 years 0.25 multiplied by the relevant contribution above 15 24
years 0.5 multiplied by the relevant contribution above 25+ years
0.75 multiplied by the relevant contribution above Rule 4.19
Credible coverage - any period during which a late joiner was:
4.19.1 Member or a dependant of a medical scheme 4.19.2 Member or a
dependant of any entity doing the business of a medical scheme
which, at the time of membership of such entity, was exempt from
the provisions of the Act 4.19.3 Uniformed employee of the South
African Defence Force, or a department of such employer, who
received medical benefits from the South African National Defence
Force, or 4.19.4 Member or a dependant of the Permanent Force
Continuation Fund, but excluding any period of coverage as a
dependant under the age of 21 years 20. ATB Above Threshold Benefit
(Millennium Option). Savings amounts are allocated as part
contribution collection and balance accumulated from previous year.
The contribution savings amount is available for the duration of
the benefit year and pro-rated on joining and resignation. BHF
Board of Healthcare Funders CAT/CT Computerised Axial Tomography
CDL (Chronic Disease List) Diagnoses, medical management and
medication to the extent that this is provided for by way of a
therapeutic algorithm rhythm for specified condition, published by
the Minister by notice in the Gazette. Dental benefits Can be
obtained from any provider, provided they charge according to the
Scheme specific dental grids. This will ensure no co-payments.
Contracted providers are contracted to charge and deliver services
ac- cording to the Scheme specific grids and it is therefore
advisable to use contracted providers to facilitate ease of access
and ensure no co-payments or levies. The latter may be applicable
if the member chooses not to adhere to Scheme specific grids or
elects to use a non- contracted provider. A list of contracted
providers as well as the dental grids can be found on
www.resomed.co.za. DSP Designated Service Provider Exclusion The
Schemes list of condition and procedure exclusions GP General
Practitioner HIV Human Immunodeficiency Virus ICON Independent
Clinical Oncology Network MMAP (Maximum Medical Aid Price) The
price a Scheme funds as a representative price for identical active
medication ingredients. This is published by MediKredit and can be
viewed at www.medikredit.co.za. All medication above the MMAP is
subject to a co-payment. MRI Magnetic Resonance Imaging MSA Medical
Savings Account Network Provider A healthcare provider or group of
providers selected by the Scheme as designated or preferred
provider/s for diagnosis, treatment and care. Optical benefits Can
be obtained from any provider, provided they charge according to
the Scheme specific optical grids. This will ensure no co-payments.
Contracted providers are contracted to charge and deliver services
ac- cording to the Scheme specific grids and it is therefore
advisable to use contracted providers to facilitate ease of access
and ensure no co-payments of levies. The latter may be applicable
if the member chooses not to adhere to Scheme specific grids or
select to use a non- contracted provider. A list of contracted
providers as well as the opti- cal grids can be found on
www.resomed.co.za. OTC Over the counter medicine, i.e. schedule 0,
1 or 2 medication PMB (Prescribed Minimum Benefits) A list of 271
conditions that all medical schemes have to cover in terms of the
Medical SchemesAct.To view this list, visit the Council for Medical
Schemes website at www.medicalschemes.co.za. Private rate Usually a
maximum of 300% of the base Scheme Rate Pro-rated Benefits Benefit
entitlement calculated according to the duration of membership
during a benefit year PSA Prostate-Specific Antigen Scheme
Protocols A defined guideline applicable to certain conditions
/treatments/ procedures/diagnoses Scheme Rate The amount the Scheme
will fund for a specific tariff (this amount is calculated based on
historic fee structures in the Scheme adjust- ed annually bound by
CPI). All providers will be funded at Scheme Rates unless the
specific provider is contracted to deliver services at a contracted
fee. In the latter instance, the contract will govern the contract
of services and will also imply that no co-payments or admin-
istration fees other than those indicated in the benefit guide may
be levied. Scheme rate for specific procedures/benefit options can
be at viewed at www.resomed.co.za. Note that fees charged over and
above these are for the members account and CMS regulations will
apply. Fees can be viewed only after member login with member num-
ber and specific procedure and/or tariff code. In order to avoid
pos- sible co-payments and levies members are urged to utilise
contracted providers which are listed on www.resomed.co.za. SEP
Single Exit Price. The industry reference price for medication. SPG
Self payment Gap. The gap between accumulated savings and the
threshold amount. 20 8.Definitions 21. Note: Unlimited. Subject to
Scheme Protocols. 100% of Scheme Rate. 100% of Scheme Rate. 100% of
Scheme Rate. 100% of Scheme Rate. 100% of Scheme Rate. 100% of
Scheme Rate. 100% of Scheme Rate. 100% of Scheme Rate. 100% of
Scheme Rate. 100% of Scheme Rate. 100% of Scheme Rate. According to
hospital formulary. Maximum of days supply.7 f n p100% of Scheme
Rate or on-contracted roviders. 150% of Scheme Rate for ontracted
roviders.c p Unlimited. Private Hospitals Including: General
Hospital Fees: Surgical operations and procedures Theatre fees
Labour and recovery wards Ward accommodation Intensive care and
high-care units Visits and consultations by a GP X-rays and
pathology Physiotherapy Ultrasound scans (other than for pregnancy)
Blood transfusions In-Hospital Medicine: Medicine dispensed and
used in-hospital Medicine received on discharge from hospital
In-Hospital Medical Specialist Fees: Including consultations and
procedures by a Specialist Provincial Hospitals Diagnosis and
treatment in respect of the Prescribed Minimum Benets (PMB) package
(as per Government Regulations) Pre-authorisation is available 24/7
and therefore a maximum of 48 hours will be allowed for legitimate
emergencies only and proof of emergency status may be required.14
Days are recommended for booked cases. Pre-authorisation number:
0861 111 778. Authorisation does not imply recognition of PMB
status until proof of such status has been received by the Scheme.
This may include clinical motivation with supporting documentation
such as laboratory reports and imaging etc. All pre-authorisation
is subject to case management, protocols and formularies.
Laparoscopic and similar endoscopic procedures are excluded from
benets, unless pre-authorised under Scheme Protocols. Members need
to pay an amount upfront to the hospital when they are admitted
(not applicable if performed out-of Hospital). HOSPITALISATION
CLASSIC 21 22. Subject to out-of-hospital benet. Consultations
only. Length of stay: days nights.3 2and andLength of stay: days
nights.4 3 Subject to Scheme Protocols No Benet. Included. R600
baby product voucher -S9 3Consultations including max pecialist
visits. Subject to day-to-day limits. Included. Limited to etwork
roviders and subject to PMB andn p Scheme Protocols. Non PMB
limited to perR12 100 family per annum. In-hospital benet only.
R60000perfamilyperannum. UnlimitedsubjecttoPMBandSchemeProtocols.
Limitedto perfamilyperannum.R45000 p s lSubjectto rosthesis ub-
imits. SubjecttopsychologyandpsychiatricMSAandATBbenets.
R6000perfamilyper annum. SubjecttoPMBandScheme
Protocolsandappliancesub-limits. R6000 R6000 R6000 R6000 R650 R3250
R590 R6000 R590 R825 R650 R6000 R6000 R650 R590 R6000 R3125
Limitedto perbeneciaryperannum,subjecttoR150000 ICON
etworkandstandardprotocols,pre-authn orisation required. Casualty /
Emergency Visits (Clinician paid at 100% Scheme Rate) Maternity
Connements (Normal Delivery) Connements (Caesarean Section)
Neonatal Intensive Care Elective Caesarean Section Antenatal Care
Maternity Programme (registration required) Baby care products at a
preferred provider pharmacy Consultations (Midwife, GP, or
Specialist) (Subject to out-of-hospital services consultation
rates) 2 x 2D scans: Tari codes 5104, 3615 or 3617 only Other
Psychiatric Disorders Cochlear implants and all related thereto.
Organ Transplants Internal Prosthesis Trauma Counselling (Assault,
Rape, hijacking and Armed Robbery) NOTE: Pro-rated for members who
join during the year 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): Articial eyes Articial larynx Articial limbs CPAP
machine Leg, arm and neck supports Back support Crutches Disposable
bladder and intestinal excretion bags Elastic stockings for
varicose veins External breast prosthesis after mastectomy
Glucometers Hearing aids (3-year lifespan) Home oxygen Nebulisers /
humidiers Orthopaedic footwear Sleep apnoea monitors (infants <
1 year) Wheelchairs Oncology Oncologist Chemotherapy Radiotherapy
Oncology related blood tests ANNUAL SUB-LIMITS (PRIVATE HOSPITALS)
CLASSIC OTHER INSURED BENEFITS CLASSIC 22 23. OTHER INSURED
BENEFITS CLASSIC HIVManagement Programme.
HospitalisationsubjecttoSchemeProtocolsandPMB. Limitedto rovincial
acility.p f 5daysperfamilyperannum. 100%ofSchemeRate. 15days
perfamilyperannum. 100%of SchemeRate.
R10000perfamilyperannumsubjectto Scheme Protocol
.(In-and-outofhospital). Co-paymentofs R1500perincident.Pre-auth
required.orisation 100%ofSchemeRate CoveredatDSPandsubject
toPMBandScheme Protocols.Pre-auth required.orisation
100%ofSchemeRate. Included.SubjecttoClassicChronicFormulary.
ReferenceandMMAPpricingapplies. HIV Primary care including
Voluntary Counselling and Testing and Treatment Hospitalisation if
member is on the HIV Management Programme (registration required).
Hospitalisation if member is not on the HIV Management Programme,
subject to Reg 8 (3) Home Nursing Hospice, Rehabilitation and
Step-Down Facilities Specialised Radiology: (CT, MRI, PET and
Nuclear Medicine scans) Dialysis Emergency Evacuation and Ambulance
Services Limited to Europ Assistance (0861 112 162) 25 Chronic
Disease List (CDL) Conditions and HIV Authorisation must be
obtained in advance from the Scheme for all hospitalisation and
other insured benets. No benets shall be granted for (1) the
replacement of existing External Medical Appliance items, without
satisfactory proof that the existing item is obsolete, (2) costs of
maintenance, spares or accessories. Hospice, rehabilitation and
step-down facilities: includes accommodation and visits by a
medical practitioner, except where inclusive global fees are
applicable. CHRONIC MEDICATION BENEFITS Note: Medicine should be
obtained from preferred provider. Medicine is restricted to
formularies, clinical entry criteria and disease management
protocols where applicable. Medicine 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
through Swift Online (SOL) on 0800 132 345. Biometrics (disease
specic measurements) per specic condition needs to be supplied to
register and remain registered for CDL conditions such as blood
pressure, cholesterol etc. Note: CLASSIC 23 24. OUT-OF-HOSPITAL
SERVICES CLASSIC *Principal: R4220 Adult: R3600 Eachchild: R1010
Subjecttoday to day limits.100%ofSchemeRate- - .
CDLconsultationscoveredseparately, subjectto
DiseaseManagementProtocols. Pre-authorisation r .equired
100%ofSchemeRatefor on- ontracted oviders.n c pr c
p150%ofSchemeRatefor ontracted roviders. n c p100%ofSchemeRatefor
on- ontracted roviders. co p150%ofSchemeRatefor ntracted roviders.
-t - .Subjecttoday o daylimits Additionalvisits subjectto PMBand
re-authorisation.p Subjecttoday-to-daylimitsandsub-limitsof: M
R3000 M+ R6000 Limitedto etwork rovidersandthefollowingservices:n p
2Annualcheck-upsperbeneciaryperannum.
2Emergencyconsultationsperbeneciaryperannum. oIntra- ral:
perbeneciaryperannum.8 oExtra- ral: perbeneciaryperannum.1
Perbeneciary: XAtreatmentplanand -rayswillberequestedfor
treatmentplansofmorethan llings. Benetsfor5 llingsare
vailablewheresuchllingsareclinicallya
indicatedandwillbegrantedoncepertoothina year-1
benetcycle.TherearenobenetsforAmalgam(silver)
llingstobereplacedwithcompositellings (whitellingmaterial).
2Annualscaleandpolishtreatmentsperbeneciary.
Fissuresealantsprogramme.Benetforonessure sealantpermolar toothina
yearcycle.-3 Limitedtoindividualsyoungerthan years.16
Subjecttotheconservativedentistrylimitand day-to-daylimit.
1setofplasticdentures( pperand ower)peru l
beneciary.Benetforplasticdenturesgrantedonly onceina earcycle.-y4
Day-to-Day Limits General Practitioners Consultations outside
general practitioner networks may incur a co-payment. Specialist
Consultations Rooms procedures Consultations outside Specialist
networks may incur a co-payment. Conservative Dentistry (Subject to
Scheme Protocols and 100% of Scheme rate) Consultations X-Rays
Fillings Oral Hygiene No benet for oral hygiene or for uoride.
Preventative Extractions per beneciary Root canal treatment per
beneciary Plastic dentures Note: DENTISTRY CLASSIC All conservative
dentistry is subject to the option-specic limits. Note: *This is a
family cumulative benet depending on family size (to max of 3
children) and not a sub-limit per individual. 24 25. DENTISTRY
CLASSIC Subjectto ay to ay imitsandsub-limitsof:d - -d l M R3000 M+
R6000 Included. Included. NoBenet. 1perjawperbeneciaryevery3years.
NoBenet. OR 1 18perlifetime,forbeneciariesunderthe ageof .
Impactedwisdomteethandassociatedcosts.
Surgeryinthedentalchair:Coveredat100%of SchemeRate. OR
Pre-authorisationrequired.Coveredat .100%ofSchemeRate.
Clinicalprotocolsapply 1consultationperbeneciary.
1pairofsinglevisionspectaclesinclusiveofaframe
andconsultationperbeneciarylimitedtoR1000. OR 1pairofat
topbifocalspectaclesinclusiveof- aframeandconsultationperbeneciary,
limitedto R1550. OR 1pairofmultifocalspectaclesinclusiveofaframe
andconsultationperbeneciarylimitedto .R1800 OR Limitedto
perbeneciary.R1000 Advanced Dentistry (Includes hospitalisation.
Subject to Scheme Protocols at 100% of Scheme Rate. Requires
pre-authorisation) Crown Bridges Implants Partial metal dentures
Periodontics Orthodontics (xed braces) Surgery, dental
hospitalisation, and anaesthetics and associated costs. Only
approved dental surgery will be covered in-hospital.
Pre-authorisation is required and protocols apply. General
anaesthetic benets are available for children younger than 5 years
of age for extensive dental treatment. Multiple hospital admissions
are not covered. Dental anaesthetics in rooms (laughing gas and IV
sedation) Optometry Limited to Optometry Network Provider and
24-month benet cycle Consultations / Examination Spectacles Contact
lenses OPTOMETRY CLASSIC Any enhancement over and above is for the
members own account. Note: 25 26. PREVENTATIVE CARE CLASSIC
R2000perfamilyperannum,SchemeRateapplies. R95
18perbeneciaryovertheageof yearsatapharmacy.
1Testperbeneciaryperannum.
1Examinationperbeneciaryperannumovertheageof 45years.
1Testperbeneciaryperannum. 1 45Testperbeneciaryperannumovertheageof
years. D1 oseperbeneciaryperannum. AsrecommendedbytheDepartment
ofHealthupto18 monthssubjecttosub-limitof .R1500 Call0861112162
Subjecttosub limitof perbeneciaryperannum- R1200 - permonth.R100
Subjectt ay o aylimits.od -t -d Subjecttoday to daylimits.- -
Subjecttoday to daylimits.- - Subjecttoday to daylimits.- - -
-Subjecttoday to daylimits -t -Subjecttoday o daylimits. d -
-dSubjectto ay to aylimitsandsub-limitsof: M R3000 M+ R6000
Includesasub-limitonSchedule0-2/OTCdrugsof: M R900 M+ R1800 R1626
R1383 R694 Annual Preventative Care Limit (subject to sub-limits as
indicated) (Excludes consultation) Blood pressure Blood sugar
Cholesterol Body Mass Index HIV Test Mammogram (screening) Pap
smears PSA testing Flu vaccinations Childhood immunisations Nurse
Helpline (including Rape Crises Centre) For any emergency medical
condition. Oral contraception Annual Limits NOTE: Pro-rated for
members who join during the year. Alternative Healthcare Services
Biokineticists Chiropodists Chiropractors Dieticians Homeopaths
Naturopaths Occupational therapists Osteopaths Podiatrists Social
workers Acupuncture (excluding specialised radiology)Radiology and
Pathology Physiotherapy Psychology and Psychiatric Treatment Speech
Therapy and Audiology Acute Medication Subject to relevant plan
formulary. Reference and MMAP pricing may apply. Benet protocols
apply Use preferred providers, otherwise co-payment may apply.
Principal Member Adult Dependant Child Dependant ADDITIONAL
OUT-OF-HOSPITAL BENEFITS CLASSIC CONTRIBUTIONS CLASSIC 26 27. Note:
Unlimited. Subject to Scheme Protocols. 100% of Scheme Rate. 100%
of Scheme Rate. 100% of Scheme Rate. 100% of Scheme Rate. 100% of
Scheme Rate. 100% of Scheme Rate. 100% of Scheme Rate. 100% of
Scheme Rate. 100% of Scheme Rate. 100% of Scheme Rate. 100% of
Scheme Rate. According to hospital formulary. Maximum of days
supply.7 n p100% of Scheme Rate for on-contracted roviders. c p150%
of Scheme Rate for ontracted roviders. Unlimited. Private Hospitals
Including: General Hospital Fees: Surgical operations and
procedures Theatre fees Labour and recovery wards Ward
accommodation Intensive care and high-care units Visits and
consultations by a GP X-rays and pathology Physiotherapy Ultrasound
scans (other than for pregnancy) Blood transfusions In-Hospital
Medicine: Medicine dispensed and used in-hospital Medicine received
on discharge from hospital In-Hospital Medical Specialist Fees:
Including consultations and procedures by a Specialist Provincial
Hospitals Diagnosis and treatment in respect of the Prescribed
Minimum Benets (PMB) package (as per Government Regulations)
Pre-authorisation is available 24/7 and therefore a maximum of 48
hours will be allowed for legitimate emergencies only, and proof of
emergency status may be required. 14 Days are recommended for
booked cases. Pre-authorisation number: 0861 111 778. Authorisation
does not imply recognition of PMB status until proof of such status
has been received by the Scheme,. This may include clinical
motivation with supporting documentation such as laboratory reports
and imaging etc. All pre-authorisation is subject to case
management, protocols and formularies. Laparoscopic and similar
endoscopic procedures are excluded from benets, unless
pre-authorised under Scheme Protocols. Members need to pay an
amount upfront to the hospital when they are admitted (not
applicable if performed out-of-hospital). HOSPITALISATION
MILLENNIUM 27 28. Subject to out-of-hospital benet. Consultations
only. Length of stay: days nights.3 2and andLength of stay: days
nights.4 3 Subject to Scheme Protocols. No Benet. Included. R650
baby product voucher 9 3Consultations including max specialist
visits. Subject to MSA and ATB. Included. Limited to etwork
roviders and subject to PMBn p and Scheme Protocols. Non PMB
limited to R15 000 per family per annum. In-hospital benet only.
R60 000 per family per annum. Unlimited subject to PMB and Scheme
Protocols. Limited to per family per annum.R50 000 p s lSubject to
rosthesis ub- imits. Subject to psychology and psychiatric
day-to-day benets. R9 000 per family per annum. Subject to PMB and
Scheme Protocols and appliance sub-limits. R9 000 R9 000 R9 000 R6
900 R750 R3 400 R 590 R9 000 R590 R1 190 R 800 R9 000 R9 000 R750
R800 R9 000 5R 000 Limited to per beneciary per annum,R200 000
subject to ICON etwork and standardn protocols, pre-auth required.
Casualty / Emergency Visits (Clinician paid at 100% of Scheme Rate)
Maternity Connements (Normal Delivery) Connements (Caesarean
Section) Neonatal Intensive Care Elective Caesarean Section
Antenatal Care Maternity programme (registration required)
Consultations (Midwife, GP or Specialist) (Subject to
out-of-hospital services consultation rates) 2 x 2D scans: Tari
codes 5104, 3615 or 3617 only Other Psychiatric disorders Cochlear
implants and all related thereto Organ Transplants Internal
Prosthesis Trauma Counselling (Assault Rape Hijacking and Armed
Robbery) NOTE: Pro-rated for members who join during the year
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): Articial
eyes Articial larynx Articial limbs CPAP machine Leg, arm and neck
supports Back support Crutches Disposable bladder and intestinal
excretion bags Elastic stockings for varicose veins External breast
prosthesis after mastectomy Glucometers Hearing aids (3-year
lifespan) Home oxygen Nebulisers / humidiers Orthopaedic footwear
Sleep apnoea monitors (infants < 1 year) Wheelchairs Oncology
Oncologist Chemotherapy Radiotherapy Oncology related blood tests
ANNUAL SUB-LIMITS (PRIVATE HOSPITALS) MILLENNIUM OTHER INSURED
BENEFITS MILLENNIUM 28 29. OTHER INSURED BENEFITS MILLENNIUM HIV
Management Programme. Hospitalisation subject to Scheme Protocols
and PMB. p fLimited to rovincial acility. 10 days per family per
annum. 100% of Scheme Rate. 18 days per family per annum. 100% of
Scheme Rate. a . SR12 000 per family per nnum ubject to Scheme
Protocol ( n-and-out of hospital).s i Co-payment of per incident.R1
500 Pre-auth required. 100% of Scheme Rateorisation aCovered at DSP
nd subject to PMB and Scheme Protocols. Pre-auth required.orisation
100% of Scheme Rate. Included. Subject to Millennium Chronic
Formulary. Reference and MMAP pricing applies. M R2 120 M+ R4 240
Benets subject to stated sub-limits and thereafter to PMB CDL .s
HIV Primary care including Voluntary Counselling and Testing and
Treatment Hospitalisation if member is on the HIV Management
Programme (registration required) Hospitalisation if member is not
on the HIV Management Programme, subject to Reg 8 (3) Home Nursing
Hospice, Rehabilitation and Step-Down Facilities Specialised
Radiology: (CT, MRI, PET and Nuclear Medicine scans) Dialysis
Emergency Evacuation and Ambulance Services Limited to Europ
Assistance (0861 112 162) 25 Chronic Disease List (CDL) conditions
and HIV Resolution Health Additional Chronic Conditions NOTE:
Pro-rated for members who join during the year CHRONIC MEDICATION
BENEFITS MILLENNIUM Note: Medication should be obtained from
preferred provider. Medication is restricted to formularies,
clinical entry criteria and disease management protocols where
applicable. Medication 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 through Swift Online (SOL)
on 0800 132 345. Biometrics (disease specic measurements) per
specic condition needs to be supplied to register and remain
registered for CDL conditions such as blood pressure, cholesterol
etc. Note: Authorisation must be obtained in advance from the
Scheme for all hospitalisation and other insured benets. No benets
shall be granted for (1) the replacement of existing External
Medical Appliance items, without satisfactory proof that the
existing item is obsolete, (2) costs of maintenance, spares or
accessories. Hospice, rehabilitation and step-down facilities:
includes accommodation and visits by a medical practitioner, except
where inclusive global fees are applicable. 29 30. OUT-OF-HOSPITAL
SERVICES MILLENNIUM Subject to MSA and ATB. Subject to MSA and ATB.
100% of Scheme Rate. CDL consultations covered separately, subject
to Disease Management Protocols. Pre-authorisation required 100% of
Scheme Rate for on- ontracted roviders.n c p c p150% of Scheme Rate
for ontracted roviders. n c p100% of Scheme Rate for on- ontracted
roviders. c p150% of Scheme Rate for ontracted roviders. Subject to
MSA and ATB. Additional visits subject to PMB and re-
uthorisation.p a Subject to MSA and ATB and sub-limits of: M R4 700
M+1 R6 500 M+2+ R7 750 Limited to etwork roviders and the
followingn p services: 2 Annual check-ups per beneciary per annum.
2 Emergency consultations per beneciary per annum. oIntra- ral: per
beneciary per annum.8 oExtra- ral: per beneciary per annum.1 XPer
beneciary: A treatment plan and -rays will be requested for
treatment plans of more than llings.5 Benets for llings are
available where such llings are clinically indicated and will be
granted once per tooth -in a year benet cycle. There are no benets
for1 amalgam (silver) llings to be replaced with composite llings
(white lling material). 2 Annual scale and polish treatments per
beneciary. Fissure sealants programme. Benet for one ssure sealant
per molar tooth in a 3-year cycle. Limited to individuals younger
than 16 years. Subject to the conservative dentistry limit and MSA
and ATB. Day-to-Day Limits General Practitioners Consultations
outside general practitioner networks may incur a co- payment.
Specialists Consultations Rooms procedures Consultations outside
Specialist networks may incur a co-payment Conservative Dentistry
(Subject to Scheme Protocols and 100% of Scheme Rate) Consultations
X-Rays Fillings Oral Hygiene No benet for oral hygiene or for
uoride Preventative Extractions per beneciary DENTISTRY MILLENNIUM
All conservative dentistry is subject to the option-specic limits.
Note: 30 31. DENTISTRY MILLENNIUM Root canal treatment per
beneciary Plastic dentures (Includes hospitalisation. Subject to
Scheme Protocols atAdvanced Dentistry 100% of Scheme Rate. Requires
pre-authorisation) Crowns Bridges Implants Partial metal dentures
Periodontics Orthodontics (xed braces) Surgery, dental
hospitalisation, and anaesthetics and associated Costs Only
approved dental surgery will be covered in-hospital.
Pre-authorisation is required and protocols apply. General
anaesthetic benets are available for children younger than 5 years
of age for extensive dental treatment. Multiple hospital admissions
are not covered. Dental anaesthetics in rooms (laughing gas and IV
sedation) Optometry Limited to optometry network provider and
24-month benet cycle Consultations / Examination Spectacles Contact
lenses OPTOMETRY Any enhancement over and above is for the members
own account. Note: Subject to the conservative dentistry limit and
MSA and ATB. u l1 set of plastic dentures ( pper and ower) per
beneciary. Benet for plastic dentures granted only once in a year
cycle.-4 Subject to MSA and ATB and sub-limits of: M R4 700 M+1 R6
500 M+2+ R7 750 Included. Included. No Benet. -1 3per jaw per
beneciary every years. No Benet. OR 1 18per lifetime, for
beneciaries under the age of . Impacted wisdom teeth and associated
costs. cSurgery in the dental chair: overed at 100% of Scheme Rate.
OR Pre-authorisation required. Covered at 100% of Scheme Rate
Clinical protocols apply... Subject to MSA and ATB. Sublimit of:
per beneciary.R2 120 MILLENNIUM 31 32. PREVENTATIVE CARE MILLENNIUM
R2 000 per family per annum, Scheme Rate applies. yR95 18per
beneciary over the age of ears at a pharmacy. 1 Test per beneciary
per annum. 1 Examination per beneciary per annum over the age of
years.45 1 Test per beneciary per annum. 1 Test per beneciary per
annum over the age of years.45 Do1 se per beneciary per annum. As
recommended by the Department of Health up to months subject to
sub-limit of .18 R1 500 Call 086 111 2162 Subject to sub limit of
per beneciary- R1 200 per annum - per month.R100 Subject to MSA and
ATB. and ATB.Subject to MSA Subject to MSA and ATB. and ATB.Subject
to MSA and ATB.Subject to MSA and ATB.Subject to MSA Subject to MSA
and ATB and sub-limits of: M R4 700 M+1 R6 500 M+2 R7 750 Includes
a sub-limit on Schedule 0-2 / OTC drugs of: M R1 400 M+1 R1 950 M+2
R2 300 Annual Preventative Care Limit (subject to sub-limits as
indicated) (Excludes consultation) Blood pressure Blood sugar
Cholesterol Body Mass Index HIV test Mammogram (screening) Pap
smears PSA testing Flu vaccinations Childhood immunisations Nurse
Helpline (including Rape Crises Centre) For any emergency medical
condition. Oral contraceptive Annual Limits NOTE: Pro-rated for
members who join during the year. Alternative Healthcare Services
Radiology and Pathology (excluding specialised radiology)
Physiotherapy Psychology and Psychiatric Treatment Speech Therapy
Acute Medication Subject to relevant plan formulary, Reference and
MMAP pricing may apply. Benet protocols apply Use preferred
providers, otherwise co-payment may apply ADDITIONAL
OUT-OF-HOSPITAL BENEFITS MILLENNIUM MONTHLY CONTRIBUTIONS
MILLENNIUM Benet option Principal Member Adult Dependant Child
Dependant SAVINGS R504 R413 R121 RISK R2014 R1625 R483 TOTAL
CONTRIBUTIONS R2518 R2065 R604 32 33. Note: Unlimited. Subject to
Scheme Protocols. 100% of Scheme Rate. 100% of Scheme Rate. 100% of
Scheme Rate. 100% of Scheme Rate. 100% of Scheme Rate. 100% of
Scheme Rate. 100% of Scheme Rate. 100% of Scheme Rate. 100% of
Scheme Rate. 100% of Scheme Rate. 100% of Scheme Rate. According to
hospital formulary. Maximum of days supply.7 100% of Scheme Rate
for non-contracted providers. 220% of Scheme Rate for contracted
providers. Unlimited. Private Hospitals Including: General Hospital
Fees: Surgical operations and procedures Theatre fees Labour and
recovery wards Ward accommodation Intensive care and high-care
units Visits and consultations by a GP X-rays and pathology
Physiotherapy Ultrasound scans (other than for pregnancy) Blood
transfusions In-Hospital Medicine: Medicine dispensed and used
in-hospital Medicine received on discharge from hospital
In-Hospital Medical Specialist Fees: Including consultations and
procedures by a Specialist Provincial Hospitals Diagnosis and
treatment in respect of the Prescribed Minimum Benets (PMB) package
(as per Government Regulations) Pre-authorisation is available 24/7
and therefore a maximum of 48 hours will be allowed for legitimate
emergencies only, and proof of emergency status may be required. 14
Days are recommended for booked cases. Pre-authorisation number:
0861 111 778. Authorisation does not imply recognition of PMB
status until proof of such status has been received by the Scheme.
This may include clinical motivation with supporting documentation
such as laboratory reports, imaging etc. All pre-authorisation is
subject to case management, protocols and formularies. Laparoscopic
and similar endoscopic procedures are excluded from benets, unless
pre-authorised under Scheme Protocols. Members need to pay an
amount upfront to the hospital when they are admitted (not
applicable if performed out-of-hospital). HOSPITALISATION SUPREME
33 34. Limited to for emergency visits per familyR1 270 per annum.
Consultation and facility fees only. Length of stay: days and
nights.3 2 Length of stay: days and nights.4 3 Subject to Scheme
Protocols. Included. Included. R740 baby product voucher 9
consultations any provider. Included. Limited to network providers
and subject to PMB and Scheme Protocols. Non PMB limited to R24 000
per family per annum. In-hospital benet only. R100 000 per family
per annum. Unlimited. Subject to PMB and Scheme Protocols. Limited
to per family per annum.R50 000 Subject to prosthesis sub-limits. 3
Psychologist visits per beneciary per annum. Subject to Scheme
Protocols. R530 per visit. R12 000 per family per annum. Subject to
appliance sub-limits. R12 000 R12 000 R12 000 R7 750 R 825 R3 590
R590 R12 000 R 590 R1 190 R1 050 R12 000 R12 000 R1 050 R950 R12
000 R5 000 Unlimited, subject to Scheme Protocols and ICON network
and enhanced protocols, pre-authorisation required. Casualty /
Emergency Visits (Clinician paid at 100% of Scheme Rate) Maternity
Connements (Normal Delivery) Connements (Caesarean Section)
Neonatal Intensive Care Elective Caesarean Section Antenatal Care
Maternity programme (registration required) Baby care products at a
preferred provider pharmacy Consultations (Midwife, GP or
Specialist) (Subject to out-of-hospital services consultation
rates) 2 x 2D scans: Tari codes 5104, 3615 or 3617 only Other
Psychiatric disorders Cochlear implants and all related thereto
Organ Transplants Internal Prosthesis Trauma Counselling (Assault,
Rape, hijacking, Armed Robbery) NOTE: Pro-rated for members who
join during the year 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): Articial eyes Articial larynx Articial limbs CPAP
machine Leg, arm and neck supports Back support Crutches Disposable
bladder and intestinal excretion bags Elastic stockings for
varicose veins External breast prosthesis after mastectomy
Glucometers Hearing aids (3-year lifespan) Home oxygen Nebulisers /
humidiers Orthopaedic footwear Sleep apnoea monitors (infants <
1 year) Wheelchairs Oncology Oncologist Chemotherapy Radiotherapy
Oncology related blood tests ANNUAL SUB-LIMITS (PRIVATE HOSPITALS)
SUPREME OTHER INSURED BENEFITS SUPREME 34 35. OTHER INSURED
BENEFITS SUPREME HIV Management Programme. Hospitalisation subject
to Scheme Protocols and PMB. Limited to provincial facility. 12
days per family per annum. 100% of Scheme Rate. 21 days per family
per annum. 100% of Scheme Rate. R15 000 per family per annum
subject to Scheme Protocols (in-and-out of hospital). Co-payment of
per incident. Pre-authorisation required.R1 500 R12 700 per family
per annum. Unlimited cover at DSP provider, subject to Scheme
Protocols. 100% of Scheme Rate. Included. Subject to Supreme
Chronic Formulary. Reference and MMAP pricing applies. M R4 400 M+
R8 800 Benets subject to stated sub-limits and thereafter to PMB
CDLs. HIV Primary care including Voluntary Counselling and Testing
and Treatment Hospitalisation if member is on the HIV Management
Programme (registration required) Hospitalisation if member is not
on the HIV Management Programme, subject to Reg 8 (3) Home Nursing
Hospice, Rehabilitation and Step-Down Facilities Specialised
Radiology: (CT, MRI, PET and Nuclear Medicine scans) Video EEG for
Epilepsy Surgery Dialysis Emergency Evacuation and Ambulance
Services Limited to Europ Assistance (0861 112 162) 25 Chronic
Disease List (CDL) conditions and HIV Resolution Health Additional
Chronic Conditions NOTE: Pro-rated for members who join during the
year CHRONIC MEDICATION BENEFITS SUPREME Note: Medication should be
obtained from preferred provider. Medication is restricted to
formularies, clinical entry criteria and disease management
protocols where applicable. Medication 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
through Swift Online (SOL) on 0800 132 345. Biometrics (disease
specic measurements) per specic condition needs to be supplied to
register and remain registered for CDL conditions such as blood
pressure, cholesterol etc. Note: Authorisation must be obtained in
advance from the Scheme for all hospitalisation and other insured
benets. No benets shall be granted for (1) the replacement of
existing External Medical Appliance items, without satisfactory
proof that the existing item is obsolete, (2) costs of maintenance,
spares or accessories. Hospice, rehabilitation and step-down
facilities: includes accommodation and visits by a medical
practitioner, except where inclusive global fees are applicable. 35
36. OUT-OF-HOSPITAL SERVICES SUPREME * Principal: R12 000 Adult: R9
000 Each child: R1 260 Unlimited. Subject to day-to-day limits.
100% of Scheme Rate CDL consultations covered separately, subject
to Disease Management Protocols. Pre-authorisation required. 100%
of Scheme Rate for non-contracted providers. 220% of Scheme Rate
for contracted providers. 100% of Scheme Rate for non-contracted
providers. 220% of Scheme Rate for contracted providers. M visits
per annum4 M+1 visits per annum5 M+2 visits per annum6 Additional
visits subject to PMB and pre-authorisation. Covered as specied
below. Subject to day-to-day limits. 2 Annual check-ups per
beneciary per annum. 2 Emergency consultations per beneciary per
annum. Intra-oral: per beneciary per annum.8 Extra-oral: per
beneciary per annum.1 Per beneciary: A treatment plan and x-rays
will be requested for treatment plans of more than llings.5 Benets
for llings are available where such llings are clinically indicated
and will be granted once per tooth in a -year benet cycle. There
are no1 benets for Amalgam (silver) llings to be replaced with
composite llings (white lling material). 2 Annual scale and polish
treatments per beneciary. Fissure sealants programme. Benet for one
ssure sealant per molar tooth in a -year cycle. Limited to3
individuals younger than 16 years. Covered at 100% of Scheme Rate.
Covered at 100% of Scheme Rate. 1 set of plastic dentures (upper
and lower) per beneciary. Benet for plastic dentures granted only
once in a year cycle. Benet for metal dentures4- granted only once
in -year cycle. Full metal5 dentures not covered. Day-to-Day Limits
General Practitioners Consultations outside general practitioner
networks may incur a co-payment. Specialists Consultations Rooms
procedures Consultations outside Specialist networks may incur a
co-payment Conservative Dentistry (Subject to Scheme Protocols and
100% of Scheme Rate) Consultations X-Rays Fillings Oral Hygiene No
benet for oral hygiene or for uoride Preventative Extractions per
beneciary Root canal treatment per beneciary Plastic dentures
DENTISTRY SUPREME All conservative dentistry is subject to the
option-specic limits Note: This is a family cumulative benet
depending on family size (to max of 3 children) and not a sub-limit
per individual. Note: * 36 37. DENTISTRY SUPREME Advanced Dentistry
(Includes hospitalisation. Subject to Scheme Protocols at 100% of
Scheme Rate. Requires pre-authorisation) Crowns Bridges Implants
Partial metal dentures Periodontics Orthodontics (xed braces)
Surgery, dental hospitalisation, and anaesthetics and associated
costs Only approved dental surgery will be covered in-hospital.
Pre-authorisation is required and protocols apply. General
anaesthetic benets are available for children younger than 5 years
of age for extensive dental treatment. Multiple hospital admissions
are not covered. Dental anaesthetics in rooms (laughing gas and IV
sedation) Optometry Limited to optometry network provider and
24-month benet cycle Consultations / Examination Spectacles Contact
lenses Annual Preventative Care Limit (subject to sub-limits as
indicated) (Excludes consultation) Blood pressure Blood sugar
Cholesterol Body Mass Index HIV test Mammogram (screening) Pap
smears PSA testing Flu vaccinations Childhood immunisations Subject
to day-to-day and annual limit of: perR8 500 family. Included.
Included. Included. Included. Included. OR Benets on
pre-authorisation will be applied to cases accessed as treatment
mandatory, as per orthodontic indices. Limited to individuals
younger than years.38 Orthognathic surgery is not covered. Impacted
wisdom teeth and associated costs. Surgery in the dental chair:
Covered at 100% of Scheme Rate. OR Pre-authorisation required.
Covered at 100% of Scheme Rate. Clinical protocols apply. 1
consultation per beneciary. 1 pair of single vision spectacles
inclusive of a frame and consultation per beneciary limited to R1
680. OR 1 pair of at-top bifocal spectacles inclusive of a frame
and consultation per beneciary, limited to R2 020. OR 1 pair of
multifocal spectacles inclusive of a frame and consultation per
beneciary limited to R2 540. OR Limited to per beneciary.R1 900 R3
000 per family per annum, Scheme Rate applies. R95 18per beneciary
over the age of years at a pharmacy. 1 Test per beneciary per
annum. 1 Examination per beneciary per annum over the age of
years.25 1 Test per beneciary per annum. 1 Test per beneciary per
annum over the age of 45 years. D1 ose per beneciary per annum. As
recommended by the Department of Health up to 18 months. OPTOMETRY
PREVENTATIVE CARE Any enhancement over and above is for the members
own account. Note: SUPREME SUPREME 37 38. PREVENTATIVE CARE SUPREME
HPV (cervical cancer) vaccine. ( Course per lifetime1 per female
beneciary between the age of 9 and 46). Call 086 111 2162 Subject
to sublimit of per beneciaryR1 200 per annum - per month.R100 M R5
960 M+1 R10 450 M+2+ R11 350 Subject to sub-limit of: M R2 540 M+1
R3 760 M+2+ R4 980 Subject to sub-limits of: M R2 540 M+1 R3 125
M+2+ R3 760 100% of Scheme Rate Subject to annual limit.. Subject
to sub-limits of per family.R1 110 , s .100% of Scheme Rate ubject
to annual limit Subject to sub-limits of per family.R1 270 , s100%
of Scheme Rate ubject to annual limit. Subject to sub-limits of R1
270 per family 100% of Scheme Rate, subject to annual limit Subject
to sub-limits of: M R5 960 M+1 R10 450 M+2+ R11 350 Includes a
sub-limit on Schedule 0-2 / OTC drugs of: M R 1 800 M+1 R3 100 M+2+
R3 400 R2 712 R2 637 R 694 HPV (cervical cancer vaccine) Nurse
Helpline (including Rape Crises Centre) For any emergency medical
condition. Oral contraception Annual Limits NOTE: Pro-rated for
members who join during the year. Alternative Healthcare Services
Radiology and Pathology (excluding specialised radiology)
Physiotherapy Psychology and Psychiatric Treatment Speech Therapy
and Audiology Acute Medication Subject to relevant plan formulary,
Reference and MMAP pricing may apply. Benet protocols apply Use
preferred providers, otherwise co-payment may apply Principal
Member Adult Dependant Child Dependant ADDITIONAL OUT-OF-HOSPITAL
BENEFITS SUPREME CONTRIBUTIONS SUPREME 38 39. Notes 40. Contact
Details Head Office Boskruin Office Park President Fouch Avenue
Boskruin (Entrance Boskruin Village Centre) www.resomed.co.za PO
Box 1075 Fontainebleau 2032 Client Services (Office hours: Mon -
Fri: 7:30 - 17:00) Tel: 0861 796 6400 Fax: 086 559 7830
[email protected] Chronic Medication Authorisation
(Doctors and Pharmacists only) Tel: 0800 132 345 Evacuation and
Ambulance Assistance: Europ Assistance Tel: 0861 112 162 HIV/AIDS:
Tel: 0861 117 778 Pre-authorisation Tel: 0861 111 778
[email protected] Zurreal Tel: 0861 ZURREAL (9877 325) Zurreal
Healthcard Tel: 011 796 6464 EMBRACE LIFE National Footprint
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