The Mzansi Network

Option

Front

2012

Tiger Brands Medical SchemeThe Mzansi Network option is an affordable healthcare plan that offers

primary cover within the Universal Healthcare Provider Network.

Unlimited PMB CDL-Chronic Medication

Benefits above Annual Flexi Benefit

Annual Flexi Benefit (AFB)

Major Medical Expenses

Annual Flexi BenefitR2 000 p/bR3 000 p/f

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Unlimited Universal Network GP VisitsBasic RadiologyBasic Pathology

Specialist ConsultationsDentistryOptometry

Unlimited PMB cover100% Agreed TariffUniversal Hospital NetworkAnnual Hospital limit of R250 000 P/B & R500 000 p/f

Here’s why the Mzansi Network option offers exceptional value and benefits in 2012

We cover all your clinically necessary, essential day-to-day primary healthcare benefits e.g. unlimited GP visits, acute and chronic medication, basic radiology and basic pathology

Basic dentistry and optometry benefits

Cover for 27 chronic conditions

Wellness benefit, including preventative screening for blood pressure, glucose, cholesterol, BMI and waist circumference paid from risk

You pay only for the first three child dependants - the rest are free!

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Unlimited Universal Network GP VisitsBasic RadiologyBasic Pathology

Day-to-day services are subject to the utilisation of the Universal Healthcare Provider Network. Services rendered by Universal Network will be paid at an agreed tariff up to specified limits. Some benefits are subject to Annual Flexi Benefit (AFB). The AFB will be pro-rated if you join later during the year.

AFB Limits:R2 000 p/b and R3 000 p/f

Day-to-day Benefits

Day-to-day services paid from the AFB

BENEFITS LIMITS

Specialists

100% of Agreed Tariff (AT), paid from the AFB2 visits per beneficiary max 3 per family per annum. Two additional ante-natal visits per pregnancy. Specialist visits are subject to referral by a Universal Network GP and pre-authorisation of each specialist visit. Referrals limited to specialists located at Universal Network Hospitals only

Basic Dentistry

100% of AT, paid from the AFBOne consultation per beneficiary per annum. Preventative care, infection control, fillings, extractions and dental x-rays, subject to protocols, list of applicable dental codes and use of Universal Network. No benefit for out-of-network dental visits/procedures except for PMB emergencies

Specialised Dentistry 100% of ATNo benefit unless PMB, subject to protocols

Optometry

100% of AT, paid from the AFBTest - 1 p/b every second yearLenses, frames - Clear plastic single vision (limited to R600) or bi-focal lenses (limited to R750) every second year. No benefit for contact lenses, limited to a range of frames within Universal Network

Hospital emergency room/casualty emergency visits (not requiring admissions excluding facility fees

100% of AT, paid from the AFB

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Other Benefits

BENEFITS LIMITSEmergency Assistance and Ambulance Transportation

UnlimitedPreferred Provider - ER 24

Wellness, Lifestyle and Preventative Care

Blood pressure, blood sugar and cholesterol test, limited to R100 p/b and Universal Network Pharmacy

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Day-to-day services not subject to the AFB

BENEFITS LIMITS

GP Consultations

100% of AT, unlimited, subject to clinical necessity. Each beneficiary must select a contracted Universal Network GP for day-to-day care. Two out-of-area visits per beneficiary per annum. Member required to pay the out-of-area provider in cash and claim back. Reimbursement of out-of-area visit at 80% of the cost of the claim to a maximum of R750 per event (i.e. for the GP consultation and all related costs)

Acute Medication

100% of AT, unlimited if prescribed by a Universal Network GP, or by a specialist provided member referred by a Universal Network GP. Subject to formulary. No cover for non-formulary medicines unless otherwise pre-authorised. No cover in cases of voluntary use of non-Universal Network Provider, or voluntary use of a specialist without referral by a Universal Network GP

Specialised Radiology including MRI, CT and PET Scans

PMBs only, subject to pre-authorisation and case management within the Universal Network

Basic Radiology

100% of ATUnlimited when clinically appropriate within the Universal Network and subject to referral by a Universal Network GP. Limited to list of codes. Subject to case management. No benefit if not referred by a Universal Network Provider, or by a specialist following referral by a Universal Network GP (except when involuntary)

Basic Pathology

100% of ATUnlimited when clinically appropriate within Universal Network and subject to referral by a Universal Network GP. Limited to list of codes. Subject to case management. No benefit if not referred by a Universal Network Provider, or by a specialist following referral by a Universal Network GP (except when involuntary)

Auxiliary Services No benefit unless PMB, PMB rules apply, subject to protocolsClinical Psychologist No benefit unless PMB, PMB rules apply, subject to protocolsPsychiatry No benefit unless PMB, PMB rules apply, subject to protocols

Surgical and Medical Appliances No benefit unless PMB, PMB rules apply, subject to protocols. No benefit for hearing aids

The Mzansi Network option offers extensive cover for 27 PMB CDL conditions.

If you suffer from one of the chronic conditions on the list, you need to register with MEDISCOR.

Chronic medication is subject to the Core formulary, and the Medicine Reference Pricing (MRP). Chronic medication is unlimited only if prescribed by a Universal Network Provider. Any voluntary use of chronic medicine prescribed by out-of-network provider and any non-formulary medicines are for the member’s own account, unless pre-authorised by the medical advisor. PMB rules apply.

Cover for Chronic Conditions

In-hospital benefits

BENEFITS LIMITSOverall Annual Limit (OAL) R250 000 p/b and R500 000 p/f

Private hospitals and nursing homes 100% of AT, subject to pre-authorisation and within Universal Network Hospital

TTO Medication (take home medication) Limited to 7 days supply, subject to OAL

GP and Specialist cost 100% of Agreed Tariff, subject to OAL

Surgical Prosthesis and Electronic Nuclear Devices

PMB benefitsSubject to pre-authorisation and protocols and OAL

Radiology and Pathology 100% of AT, subject to OAL

MRI, CT Scans/PET Scans 100% of AT, subject to OAL, pre-authorisation required

Physiotherapy in hospital 100% of AT, subject to OAL

Organ transplants, Renal Dialysis (includes transportation of the organ, surgically related procedures, professional fees and services, as well as immunosuppressant drugs)

100% of AT, subject to OAL, PMB’s only, subject to pre-authorisation, protocols, and within Universal Network Hospital

Emergency room/casualty 100% of AT, subject to OAL, for emergency medical conditions and injuries resulting from accidents or trauma

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The following in-hospital procedures are not covered on the Mzansi Network option, unless it is a PMB:

Dentistry, back and neck surgery, hip and knee replacement, cochlear implants, auditory brain implants and internal nerve stimulators, Nissen Fundoplication (reflux surgery), treatment for obesity, skin disorders and functional nasal problems, elective caesarean section, refractive eye surgery, brachytherapy for prostate cancer, fibroadenoma.

Exclusions

• Subject to Scheme Protocols• Hospitalisation - 100% AT at Universal Network Provider, unlimited• Medication - CDL conditions are unlimited subject to a formulary and dispensed by Universal Network Provider Medical Management in and out of hospital - 100% AT, subject to protocols and treatment by Universal Network Provider HIV/AIDS disease management program is available to all HIV positive members. The programme aims to support and assist HIV patients in the management of their condition

Prescribed Minimum Benefits (PMB)

Chronic diseases that are covered as PMB’sAddison’s disease Crohn’s disease Hyperlipidaemia Asthma Diabetes mellitus type 1 & 2 HypothyroidismBipolar mood disorder Diabetes insipidus Multiple sclerosisBronchiectasis Dysrhythmias Parkinson’s diseaseCardiac failure Epilepsy Rheumatoid arthritis Chronic renal disease Glaucoma SchizophreniaChronic obstructive pulmonary disorder Haemophilia Systemic lupus erythematosusCardiomyopathy disease HIV Ulcerative colitisCoronary artery disease Hypertension

The Mzansi Network option offers cover for step down nursing facilities, Hospice and Rehabilitation. Cover is subject to pre-authorisation, protocols and case management, and OAL.

Alternatives to hospitalisation

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Abbreviations

AT - Agreed TariffPMB - Prescribed Minimum BenefitAFB - Annual Flexi BenefitCDL - Chronic Disease ListP/B - Per BeneficiaryP/F - Per FamilyMRP - Medicine Reference PricingOAL - Overall Annual Limit

Contribution Table

Salary (Rand) Principal Adult Child

0 – 3 000 372 372 108

3 001 – 4 000 426 426 126

4 001 – 5 000 534 534 156

5 001 – 6 000 588 588 174

6 001 – 7 000 642 642 192

7 001 – 8 000 690 690 204

8001 + 1 602 1 602 480

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2.3 Waiting periods

Prospective members are required to disclose to the Scheme, on the application form, details of any sickness or medical condition for which medical advice, diagnosis, care or treatment was recommended and/or received prior to the 12 month period ending on the date on which application for membership was made.

The Scheme may impose upon a person in respect of whom an application is made for membership or admission as a dependant, and who was not a beneficiary of a medical scheme for a period of at least 90 days preceding the date of application: • a general waiting period of up to three months • a condition-specific waiting period of up to 12 months• a concurrent waiting period on PMB’s The Scheme may impose upon any person in respect of whom an application is made for membership or admission as a dependant, and who was previously a beneficiary of a medical scheme for a continuous period of up to 24 months, terminating less than 90 days immediately prior to the date of application: • a condition specific waiting period of up to 12 months, except in respect of any treatment or diagnostic procedures covered within the prescribed minimum benefits• a general waiting period of up to 3 months

2.4 Membership card

Every member shall be furnished with a membership card. This card must be exhibited to the supplier of a service on request. It remains the property of the Scheme and must be returned to the Scheme on termination of membership. Members will receive 2 cards. Members may apply for additional membership cards or replacement cards.

1. Rules of the Scheme

The Scheme is governed by a set of Rules submitted to and approved by the Registrar for Medical Schemes. All terms and conditions are set out in detail in the Rules of the Scheme, which can be viewed at the office of the administrator. The Rules of the Scheme always apply during a dispute resolution.

2. Membership

Membership is restricted to all eligible employees.

2.1 Registration of dependants

A member may apply for the registration of his/her dependants at the time of applying for membership. The following persons can qualify as a dependant:

• A spouse or partner • Dependant children under the age of 21 • Dependant children over the age of 21 but under the age of 25 and who are full time students at a recognised tertiary educational institution• Disabled/Mentally challenged children

2.2 Students and children older than 21 years

Children above the age of 21 years are regarded as dependants if they are studying full-time at a recognised tertiary or educational institution. A member should submit annual proof of registration for their dependants who are still studying full-time at an educational institution. A student over the age of 25 years will be cancelled at the end of the year in which he/she turns 25 years of age.This does not apply for disabled or mentally challenged dependants.

Member Guide

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3. Contributions payable The total monthly contributions payable to the Scheme by or in respect of a member are as stipulated in the contribution tables in the Scheme Rules.

4. Benefits

4.1 Choosing a benefit option

Members are entitled to benefits during a financial year, as per the Rules of the Scheme and such benefits extend through the member to his/her registered dependants. A member must, on admission, elect to participate in any one of the available options, detailed in the Rules of the Scheme.

4.2 Option changes

A member is entitled to change from one to another benefit option subject to the following conditions: • The change may be made only with effect from 1 January of any financial year. • Application to change from one benefit option to another must be in writing and lodged with the Scheme within the period notified by the Scheme.

4.3 Pro-rating Benefits

If members join the Scheme later than 1 January during a specific year, pro rata annual benefits will apply until the end of the year. From 1 January the following year members will qualify for the full annual benefit.

2.5 Change of address

A member must notify the Scheme within 30 days of any change of address including his/her domicilium citandi et executandi (address at which legal proceedings may be instituted). The Scheme shall not be held liable if a member’s rights are prejudiced or forfeited as a result of the member neglecting to comply with the requirements of this rule. 2.6 Termination of membership

2.6.1 Resignation

A member who, in terms of his/her conditions of employment is required to be a member of the Scheme, may not terminate his/her membership while he/she remains an employee without the prior written consent of his/her employer.

2.6.2 Deceased members

The dependants of a deceased member, who are registered with the Scheme as his/ her dependants at the time of such member’s death, shall be entitled to continued membership of the Scheme without any new restrictions, limitations or waiting periods. Where a child dependant/s has been orphaned, the eldest child may be deemed to be the member, and any younger siblings, the child dependant/s.

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5.4 Universal Healthcare Provider Network

5.4.1 General Practitioners, Dentists, Optometrists and Hospitals.

It is important to note that members must use a service provider on the Universal Network. To locate your nearest Universal Network Provider phone client services on 0800 002 636.

5.4.2 Specialists

Specialist visits are subject to referral by a Universal Network GP and pre-authorisation of each specialist visit. Referrals limited to specialists located at Universal Network Hospitals only.

5.4.3 Pharmacies

The following pharmacies have offered the Scheme a favourable dispensing fee for medicines. These pharmacies have also agreed to dispense generic equivalents that fall within the Scheme’s maximum reference price limit where generic products are available:

• Clicks, Dischem, Link, MediRite, ScriptSaver, Optipharm, Optime and Chronic Medicines Dispensary

This means that you may obtain your acute and chronic medicines from any of the above pharmacies without having to make a co-payment in respect of dispensing fees or generic equivalents. The arrangement with the above pharmacies relates specifically to the dispensing fee and generic equivalents. It is possible that you may have a co-payment should your doctor prescribe a drug that does not appear on the Scheme’s medicine formulary. You may continue to obtain your medicine from the pharmacy of your choice, it should however be noted that different dispensing fees are being charged between the various pharmacies and this may result in a co-payment if the dispensing fee charged by your pharmacy is higher than that of our preferred providers.

5. How to claim

5.1 Electronic claims

Most suppliers i.e. Hospitals, Pharmacies and General Practitioners, etc. submit claims electronically and members do not have to submit such claims. It however remains the member’s responsibility to ensure that the claim reaches the Scheme within four months from treatment date and to check remittance advices for accuracy and validity of the supplier’s claim.

5.2 Paper claims

Claims must be submitted within 4 months from date of service and may be faxed, e-mailed or posted to details below:

Fax 011 208 1028

E-mail admin@universal.co.za

Post Tiger Brands Medical Scheme Private Bag X131 Rivonia 2128

Before submitting a claim, please ensure that the following details appear on the account:• Membership number• Principal member’s details (name, address, etc.)• Supplier’s details (name, address, practice number)• Treatment date• Patient’s details• Details of treatment (diagnosis, tariff and ICD10 codes, amount charged, etc.)

5.3 Payment of claims

Tiger Brands Medical Scheme has two payment runs per month (mid month and at month end) to suppliers and to members.

Members can track the payment of their claims on the Scheme’s website (www.tbms.co.za). Members will receive a monthly statement containing details of all payments made to suppliers.

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6. Exclusions

The following exclusions will apply to a member and/or his dependants unless that particular exclusion is covered under the statutory prescribed minimum benefits (PMBs).

6.1 All costs of whatsoever nature incurred for treatment of sickness conditions or injuries sustained by a member or a dependant and for which any other party is liable.

6.2 Costs arising from wilfully self-inflicted injuries, professional sport, speed contests and speed trials.

6.3 All costs for operations, medicines, treatment and procedures for cosmetic purposes, obesity, infertility and artificial insemination.

6.4 Holidays for recuperative purposes.

6.5 The purchase of:

• Patent medicines and proprietary preparations• Applications, toiletries and beauty preparations• Bandages, cotton wool and similar aids• Patent foods, including baby foods• Tonics; slimming preparations and drugs as advertised to the public• Household and biochemical remedies• Vitamins and minerals (excluding pregnancy specific supplements and supplements for HIV positive beneficiaries)

6.6 All costs that exceed the Annual Routine Care Benefit in terms of the Rules of the Scheme.

6.7 All costs in respect of sickness conditions that were specifically excluded when the beneficiary joined the Scheme.

6.8 Costs for the services rendered by any person not registered with:

• The South African Medical & Dental Council• Chiropractic Association of South Africa• Homeopaths & Allied Health Service Professionals Council of South Africa• South African Nursing Council

6.9 Purchase of chemist supplies not prescribed by a person who is legally entitled to prescribe medicine.

6.10 The cost of gum guards for sports purposes and the use of gold in dental treatment.

6.11 Costs for services rendered by persons or institutions outside South African borders. However, the Board may consider these on an ex-gratia basis at their sole discretion.

6.12 Charges for appointments that a beneficiary fails to keep.

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Notes

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Notes

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Notes

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Tiger Brands Medical Scheme Universal House, 15 Tambach Road, Sunninghill Park, Sandton

Private Bag X131, Rivonia, 2128Tel: 011 208 1000 Fax: 011 208 1028

Email: admin@universal.co.za Website: www.tbms.co.za

Administered by Universal Healthcare Administrators (Pty) Ltd

This brochure is a summary of the benefits of Tiger Brands Medical Scheme. A copy of the current Rules may be obtained from the Administrator, if so required. The Rules of the Scheme will always take precedence over this summary.

Back

Universal Healthcare Administrators(Administrative)

MEDISCOR(Medication authorisation)

Client Services Call Centre 0800 002 636 / 011 208 1010Fax number 011 208 1028E-mail admin@universal.co.zaWebsite www.universal.co.za www.tbms.co.za

Call Centre 0860 119 553Fax number 0866 151 503

Universal Care Emergency ServicesHospital pre-authorisation 0860 102 312Prescribed Minimum Benefit (PMB) Management 0860 111 900HIV/AIDS Disease Management Programme 0860 111 900

ER 24 084 124

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