Membership Handbook

MEMBERSHIP HANDBOOK
Classic, Millennium and Supreme
Dear member
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 crosssubsidisation. 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
Contents
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 Which is your Ideal Resolution Health Option? Membership Details Termination of Membership Monthly Membership Contributions Claims Procedure Benefits Emergency Services Prescribed Minimum Benefits (PMB) Dental Benefits Optical Benefits Maternity Programme Health Assist Chronic Medication: Chronic Disease List (CDL) and Resolution Health Additional Chronic Conditions Pharmacy Preferred Provider Network Oncology Benefits HIV Exclusions (services or events not covered by the Scheme) Hospitalisation Procedure Co-payments Prosthesis Sub-limits Other Insured Benefits External Medical Appliance Sub-limits Childhood Immunisations Contributions Late Joiner Penalties Definitions 5 5 6 8 8 9 9 9 10 10 11 11 11 12 12 13 13 13 14 15 16 17 17 18 19 19 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.
Your needs and your healthcare option

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. 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 FREE access to Zurreal4life, an elementary loyalty and lifestyle programme
Which is your ideal Resolution Health option?

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 FREE access 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
Millennium Option
The Millennium Option combines the flexibility of a medical savings plan, with an above threshold benefit when your dayto-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.
1. Membership details
Change of personal details
To ensure continued communication and prompt claims management, 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.
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 amend@resomed.co.za 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.
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
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 amend@resomed.co.za on an annual basis to maintain their status. If proof is not received, the child dependant will be defaulted to an adult dependant status. 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 resignations@resomed.co.za or fax to 086 513 1438.
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 amend@resomed.co.za. 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.
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 cardrequests@resomed.co.za. 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.
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
2. Termination of membership
Membership may be terminated for the following reasons:
Voluntary termination
Members who do not belong to Resolution Health in terms of
Abuse of privileges, false claims, misrepresentation their conditions of employment, may terminate their membership and non-disclosure of factual information by giving one month written notice. Employers that wish to end
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. their association with the Scheme may do so by giving one calendar month written notice.
Death
Membership is terminated on receipt of a death certificate.
3. Monthly membership contributions
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.
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.
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.
4. Claims procedure
Should your medical service provider not submit claims to us electronically, please submit a signed claim to clientservices@resomed.co.za or send this to: Resolution Health Medical Scheme PO Box 1075 Fontainebleau 2032
5. Benefits
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.
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).
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
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 nonDSP 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. Copayments may be applicable if members choose to use a nonpreferred 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.
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.
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
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 copayments or rejected claims.
12 5.8. Chronic medication: the Chronic Disease List (CDL) and Resolution Health Additional Chronic Conditions
Chronic Disease List (CDL) Conditions (All Options)
Addisons Disease Asthma Bipolar Affective Mood Disorders Bronchiectasis Cardiac Dysrhythmia (Arrhythmia) Cardiac Failure Cardiomyopathy Chronic Obstructive Pulmonary Disorders (COPD) Chronic Renal Failure/Disease Crohns Disease Diabetes Insipidus Diabetes Mellitus Type 1 & 2 Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Ischaemic Heart Disease (Coronary Artery Disease) Multiple Sclerosis Parkinsons Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosis Ulcerative Colitis
Millennium Option Additional Chronic Conditions

Osteoarthritis Gastro-Oesophageal Reflux Disease (GORD) Gout Major Depression Medication
Supreme Option Additional Chronic Conditions

ADHD Angina Pectoris Ankylosing Spondylitis Benign Prostatic Hypertrophy Cerebrovascular Accident (Stroke) Cushings Syndrome Delusional Disorder Female Menopause Gastro-Oesophageal Reflux Disease (GORD) Gout Hyperthyroidism Idiopathic Thrombocytopenic Purpura Interstitial Fibrosis of the Lung Major Depression Menieres Syndrome Motor Neuron Disease Myasthenia Gravis Osteoporosis Ostheoarthritis Peripheral Vascular Disease Pituitary Adenoma Psoriasis Scleroderma Urinary Incontinence Pagets Disease
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
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 preauth@resomed.co.za. Note: MMAP and reference pricing is applicable. 3.2. 3.3. 3.4. 3.5. 3.6. mutations. Reconstruction following prophylactic mastectomy will not be funded Gynaecomastia Hyperhidrosis Eximer laser and radial keratotomy Phakic implants Bariatric surgery and other treatments, services or charges for or related to obesity Keloid and scar revision and any other cosmetic procedures and treatments Dynamic spinal devices CT or virtual colonoscopy Change of sex operations and procedures Growth hormone Sleep and hypnosis therapy Elective Caesarean section (except Supreme Option) Cancer treatment outside network protocols Medicines not registered with or used outside their Medicines Control Council registration or proprietary preparations Medication outside the formulary Pre-hospital admissions Nasal reconstruction Bat-ears Removal of skin blemishes Liposuction Face-lift and eyelid procedures
3.7. 3.8. 3.9. 3.10. 3.11. 3.12. 3.13. 3.14. 3.15.
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 preauth@resomed.co.za 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 by the 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
3.16. 3.17. 3.18. 3.19. 3.20. 3.21. 3.22.
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
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.
Get more out of your life today! Embrace Life with all the 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
Procedure Arthroscopy Circumcision Colonoscopy, sigmoidoscopy, proctoscopy Conservative back treatment Excision nailbed Nasal surgery (including endoscopy) Gastroscopy Hysterectomy Hysteroscopy Joint replacements Laparoscopic procedures Myringotomy Reflux surgery Skin lesions Specialised radiology Spinal surgery Cystoscopy Hernia repair Rotator cuff surgery Tonsillectomy and adenoidectomy Urinary Incontinence repair Dental admissions Procedure Co-payments Gynaecological laparoscopy, endometrial ablation Tympanoplasty Varicose veins Excluded unless PMB proven (protocols apply) * 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. 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. Classic/Millennium R3 000 R2 000 R2 000 R3 000 R1 500 R4 500 R2 000 R3 000 R2 250 R5 720 R3 000 R1 750 R8 600 R1 500 R1 500 R6 250 R2 000 R3 000 R5 720 R1 750 R3 000 R2 000 R3 000 R1 500 R3 000 Supreme R2 000 R3 000 R2 250 R5 720 R3 000 R8 600 R1 500 R6 250 R5 720 R1 750 R3 000 R2 000 R3 000 R1 500 R3 000
Procedure specific co-payments still apply if alternative to endoscopic or laparoscopic surgery is stated in protocol
16
5.14. Prosthesis sub-limits

Prosthesis
Knee Hip Shoulder Elbow Ankle External fixator Spinal Fusion 1 level 2 levels 3 levels 4 or more levels Coronary stents 1 stent 2 stents Total Pelvic floor Hernia mesh Intraocular lens
Classic
R31 000 R28 500
Millennium
R38 000 R34 500
Supreme
R38 000 R34 500
R44 000 R45 000 Cervical R17 750 R27 500 R38 000 R45 000 R19 000 R31 000 R45 000 R6 250 R6 250 R2 500 Lumbar, dorsal R20 000 R32 000 R40 000 R45 000
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

External Medical Appliances Frequency cycle Classic R6 000 per family subject to PMB Artificial eyes Artificial larynx Artificial 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/humidifiers Orthopaedic footwear Sleep apnoea monitors (infants < 1 year) Wheelchairs Sleep apnoea monitors (infants < 1 year) Wheelchairs 5-year cycle 5-year cycle 5-year cycle 3-year cycle Annual Annual Annual Annual Annual Annual 3-year cycle Annual Annual 3-year cycle Annual 1/beneficiary per life 3-year cycle 1/beneficiary per life 3-year cycle R6 000 R6 000 R6 000 R6 000 R 650 R3 250 R 590 R6000 R 590 R 825 R 650 R 6000 R 6000 R 650 R 590 R6 000 R4 000 R 6000 R 4000 Millennium R9 000 per family subject to PMB R9 000 R9 000 R9 00 R9 000 R 750 R3 400 R 590 R9 000 R 590 R 1 190 R 800 R9 000 R9 000 R 750 R 560 R9 000 R5 000 R9 000 R5 000 Supreme R12 000 per family R12 000 R12 000 R12000 R7 750 R 825 R3 590 R 590 R12 000 R 590 R1 190 R1 050 R12 000 R12 000 R1 050 R 900 R12 000 R 6000 R12 000 R6 000
NOTE: - Sub-limits for other prostheses determined per case. - Benefits will be pro-rated in proportion to the period of membership.
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)
Age of child At birth 6 weeks
Vaccine recommended OPV(0) Oral Polio Vaccine BCG Bacilles Calmette Vaccine 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 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 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 Measles Vaccine(1) OPV(4) Oral Polio Vaccine DTP Diptheria, Tetanus, Pertussis Measles Vaccine (2)
10 weeks
14 weeks
8. Definitions
9 months 18 months
19
6. Contributions
2013 CONTRIBUTIONS
Benefit Option Classic Supreme Principal: R 1,626 R 2,712 Adult Dependant: R 1,383 R 2,637 Child Dependant: R 651 R 694
Monthly contribution for MILLENNIUM OPTION

Savings: Principal: Adult Dependant : Child Dependant: R 504 R 413 R 121 Risk: R 2014 R 1652 R 483 Total contribution: R 2518 R 2065 R 604
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
8. Definitions
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 according 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 noncontracted 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 according 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 noncontracted provider. A list of contracted providers as well as the optical 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 Schemes Act. 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 adjusted 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 administration 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 number and specific procedure and/or tariff code. In order to avoid possible 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.
HOSPITALISATION
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
CLASSIC
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.
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)
Maximum of 7 days supply.
100% of Scheme Rate for non-contracted providers. 150% of Scheme Rate for contracted providers. Unlimited.
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. 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).
21
ANNUAL SUB-LIMITS (PRIVATE HOSPITALS)

Casualty / Emergency Visits (Clinician paid at 100% Scheme Rate)
CLASSIC
Subject to out-of-hospital benet. Consultations only.
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
Length of stay: 3 days and 2 nights. Length of stay: 4 days and 3 nights. Subject to Scheme Protocols No Benet.
Included. R600 baby product voucher 9 Consultations including max 3-Specialist visits. Subject to day-to-day limits. Included.
Limited to network providers and subject to PMB and Scheme Protocols. Non PMB limited to R12 100 per family per annum. In-hospital benet only. R60 000 per family per annum.
Cochlear implants and all related thereto.
Organ Transplants Internal Prosthesis
Unlimited subject to PMB and Scheme Protocols. Limited to R45 000 per family per annum. Subject to prosthesis sub-limits.
Trauma Counselling (Assault, Rape, hijacking and Armed Robbery)
Subject to psychology and psychiatric MSA and ATB benets.
OTHER INSURED BENEFITS

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
CLASSIC
R6 000 per family per annum. Subject to PMB and Scheme Protocols and appliance sub-limits.
R6 000 R6 000 R6 000 R6 000 R 650 R3 250 R 590 R6 000 R590 R825 R650 R6 000 R6 000 R650 R590 R6 000 R3 125
Limited to R150 000 per beneciary per annum, subject to ICON network and standard protocols, pre-authorisation required.
22

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:
CLASSIC
HIV Management Programme. Hospitalisation subject to Scheme Protocols and PMB. Limited to provincial facility. 5 days per family per annum. 100% of Scheme Rate. 15 days per family per annum. 100% of Scheme Rate. R10 000 per family per annum subject to Scheme Protocols. (In-and-out of hospital). Co-payment of R1 500 per incident. Pre-authorisation required. 100% of Scheme Rate Covered at DSP and subject to PMB and Scheme Protocols. Pre-authorisation required. 100% of Scheme Rate.
(CT, MRI, PET and Nuclear Medicine scans) Dialysis
Emergency Evacuation and Ambulance Services Limited to Europ Assistance (0861 112 162)
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.
CHRONIC MEDICATION BENEFITS

25 Chronic Disease List (CDL) Conditions and HIV
CLASSIC
Included. Subject to Classic Chronic Formulary. Reference and MMAP pricing applies.
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.
23
OUT-OF-HOSPITAL SERVICES
Day-to-Day Limits
CLASSIC
* Principal: Adult: Each child: R4 220 R3 600 R1 010
General Practitioners Consultations outside general practitioner networks may incur a co-payment.
Subject to day-to-day limits. 100% of Scheme Rate . CDL consultations covered separately, subject to Disease Management Protocols. Pre-authorisation required.
Specialist Consultations 100% of Scheme Rate for non-contracted providers. 150% of Scheme Rate for contracted providers. Rooms procedures 100% of Scheme Rate for non-contracted providers. 150% of Scheme Rate for contracted providers. Consultations outside Specialist networks may incur a co-payment. Subject to day-to-day limits. Additional visits subject to PMB and pre-authorisation.
Note:
DENTISTRY
Conservative Dentistry (Subject to Scheme Protocols and 100% of Scheme rate)
This is a family cumulative benet depending on family size (to max of 3 children) and not a sub-limit per individual.
CLASSIC
Subject to day-to-day limits and sub-limits of: M R3 000 M+ R6 000
Consultations
Limited to network providers and the following services: 2 Annual check-ups per beneciary per annum. 2 Emergency consultations per beneciary per annum. Intra-oral: 8 per beneciary per annum. Extra-oral: 1 per beneciary per annum. Per beneciary: A treatment plan and X-rays will be requested for treatment plans of more than 5 llings. Benets for llings are available where such llings are clinically indicated and will be granted once per tooth in a 1-year benet cycle.There are no benets for Amalgam (silver) llings to be replaced with composite llings (white lling material). 2 Annual scale and polish treatments per beneciary.
X-Rays
Fillings
Oral Hygiene No benet for oral hygiene or for uoride. Preventative Extractions 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 day-to-day limit. 1 set of plastic dentures (upper and lower) per beneciary. Benet for plastic dentures granted only once in a 4-year cycle.
Root canal treatment per beneciary
Plastic dentures
Note:
All conservative dentistry is subject to the option-specic limits.
24
DENTISTRY
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)
CLASSIC
Subject to day -to-day limits and sub-limits of: M R3 000 M+ R6 000 Included. Included. No Benet. 1 per jaw per beneciary every 3 years. No Benet. OR 1 per lifetime, for beneciaries under the age of 18. 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.
OPTOMETRY
Optometry Limited to Optometry Network Provider and 24-month benet cycle Consultations / Examination Spectacles
CLASSIC
1 consultation per beneciary. 1 pair of single vision spectacles inclusive of a frame and consultation per beneciary limited to R1 000. OR 1 pair of at-top bifocal spectacles inclusive of a frame and consultation per beneciary, limited to R1 550. OR 1 pair of multifocal spectacles inclusive of a frame and consultation per beneciary limited to R1 800. OR
Contact lenses
Limited to R1 000 per beneciary.
Note:
Any enhancement over and above is for the members own account.
25
PREVENTATIVE CARE
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
CLASSIC
R2 000 per family per annum, Scheme Rate applies.
R95 per beneciary over the age of 18 years at a pharmacy.
1 Test per beneciary per annum. 1 Examination per beneciary per annum over the age of 45 years. 1 Test per beneciary per annum. 1 Test per beneciary per annum over the age of 45 years. 1 Dose per beneciary per annum. As recommended by the Department of Health up to 18 months subject to sub-limit of R1 500. Call 086 111 2162
Subject to sub-limit of R1 200 per beneciary per annum - R100 per month.
ADDITIONAL OUT-OF-HOSPITAL BENEFITS

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 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.
CLASSIC
Subject to day-to-day limits.
Subject to day-to-day limits.
Subject to day-to-day limits. Subject to day-to-day limits. Subject to day-to-day limits Subject to day-to-day limits. Subject to day-to-day limits and sub-limits of: M M+ R3 000 R6 000
Includes a sub-limit on Schedule 0-2 / OTC drugs of: M R900 M+ R1 800
CONTRIBUTIONS
Principal Member Adult Dependant Child Dependant
CLASSIC
R1626 R1 383 R694
26
HOSPITALISATION
Private Hospitals
MILLENNIUM
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
100% of Scheme Rate. According to hospital formulary. Maximum of 7 days supply.
Medicine received on discharge from hospital In-Hospital Medical Specialist Fees: Including consultations and procedures by a Specialist
100% of Scheme Rate for non-contracted providers. 150% of Scheme Rate for contracted providers.
Provincial Hospitals Diagnosis and treatment in respect of the Prescribed Minimum Benets (PMB) package (as per Government Regulations)
Unlimited.
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. 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).
27

Casualty / Emergency Visits (Clinician paid at 100% of Scheme Rate)
MILLENNIUM
Subject to out-of-hospital benet. Consultations only.
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
Length of stay: 3 days and 2 nights. Length of stay: 4 days and 3 nights. Subject to Scheme Protocols. No Benet. Included. R650 baby product voucher 9 Consultations including max 3 specialist visits. Subject to MSA and ATB. Included.
Limited to network providers and subject to PMB 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 R50 000 per family per annum. Subject to prosthesis sub-limits. Subject to psychology and psychiatric day-to-day benets.
Cochlear implants and all related thereto Organ Transplants Internal Prosthesis
Trauma Counselling (Assault Rape Hijacking and Armed Robbery)

MILLENNIUM
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 R5 000 Limited to R200 000 per beneciary per annum, subject to ICON network and standard protocols, pre-auth required.
28

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)
MILLENNIUM
HIV Management Programme. Hospitalisation subject to Scheme Protocols and PMB. Limited to provincial facility. 10 days per family per annum. 100% of Scheme Rate. 18 days per family per annum. 100% of Scheme Rate. R12 000 per family per annum. Subject to Scheme Protocols (in-and-out of hospital). Co-payment of R1 500 per incident. Pre-authorisation required. 100% of Scheme Rate Covered at DSP and subject to PMB and Scheme Protocols. Pre-authorisation required. 100% of Scheme Rate.
Dialysis
Note:

25 Chronic Disease List (CDL) conditions and HIV
MILLENNIUM
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 CDLs.
Resolution Health Additional Chronic Conditions NOTE: Pro-rated for members who join during the year
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.
29
Day-to-Day Limits General Practitioners Consultations outside general practitioner networks may incur a co- payment.
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
Specialists Consultations Rooms procedures Consultations outside Specialist networks may incur a co-payment 100% of Scheme Rate for non-contracted providers. 150% of Scheme Rate for contracted providers. 100% of Scheme Rate for non-contracted providers. 150% of Scheme Rate for contracted providers. Subject to MSA and ATB. Additional visits subject to PMB and pre-authorisation.
DENTISTRY
Conservative Dentistry (Subject to Scheme Protocols and 100% of Scheme Rate)
MILLENNIUM
Subject to MSA and ATB and sub-limits of: M R4 700 M+1 R6 500 M+2+ R7 750 Limited to network providers and the following services:
Consultations
2 Annual check-ups per beneciary per annum. 2 Emergency consultations per beneciary per annum. Intra-oral: 8 per beneciary per annum. Extra-oral: 1 per beneciary per annum. Per beneciary: A treatment plan and X-rays will be requested for treatment plans of more than 5 llings. Benets for llings are available where such llings are clinically indicated and will be granted once per tooth in a 1-year benet cycle. There are no benets for amalgam (silver) llings to be replaced with composite llings (white lling material). 2 Annual scale and polish treatments per beneciary.
X-Rays
Fillings
Oral Hygiene No benet for oral hygiene or for uoride Preventative
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.
Extractions per beneciary
Note:
All conservative dentistry is subject to the option-specic limits.
30
DENTISTRY
Root canal treatment per beneciary
MILLENNIUM
Subject to the conservative dentistry limit and MSA and ATB. 1 set of plastic dentures (upper and lower) per beneciary. Benet for plastic dentures granted only once in a 4-year cycle. 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 per jaw per beneciary every 3-years. No Benet. OR 1 per lifetime, for beneciaries under the age of 18.
Plastic dentures
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.
Impacted wisdom teeth and associated costs. Surgery in the dental chair: covered at 100% of Scheme Rate. OR
Dental anaesthetics in rooms (laughing gas and IV sedation)
Pre-authorisation required. Covered at 100% of Scheme Rate. Clinical protocols apply..
OPTOMETRY
Optometry Limited to optometry network provider and 24-month benet cycle Consultations / Examination Spectacles Contact lenses
MILLENNIUM
Subject to MSA and ATB. Sublimit of: R2 120 per beneciary.
Note:
31
PREVENTATIVE CARE
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
MILLENNIUM
1 Test per beneciary per annum. 1 Examination per beneciary per annum over the age of 45 years. 1 Test per beneciary per annum. 1 Test per beneciary per annum over the age of 45 years. 1 Dose per beneciary per annum. As recommended by the Department of Health up to 18 months subject to sub-limit of R1 500. Call 086 111 2162 Subject to sub-limit of R1 200 per beneciary per annum - R100 per month.
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
MILLENNIUM
Subject to MSA and ATB.
Subject to MSA and ATB. Subject to MSA and ATB. Subject to MSA and ATB. Subject to MSA and ATB. Subject to MSA and ATB. 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
MONTHLY CONTRIBUTIONS
Benet option Principal Member Adult Dependant Child Dependant SAVINGS R504 R413 R121
MILLENNIUM
RISK R2014 R1625 R483 TOTAL CONTRIBUTIONS R2518 R2065 R604
32
HOSPITALISATION
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
SUPREME
100% of Scheme Rate. According to hospital formulary. Maximum of 7 days supply.
100% of Scheme Rate for non-contracted providers. 220% of Scheme Rate for contracted providers.
Provincial Hospitals Diagnosis and treatment in respect of the Prescribed Minimum Benets (PMB) package (as per Government Regulations)
Unlimited.
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. 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).
33

Casualty / Emergency Visits (Clinician paid at 100% of Scheme Rate)
SUPREME
Limited to R1 270 for emergency visits per family per annum. Consultation and facility fees only.
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
Length of stay: 3 days and 2 nights. Length of stay: 4 days and 3 nights. 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 R50 000 per family per annum. Subject to prosthesis sub-limits. 3 Psychologist visits per beneciary per annum. Subject to Scheme Protocols. R530 per visit.
Cochlear implants and all related thereto Organ Transplants Internal Prosthesis
Trauma Counselling (Assault, Rape, hijacking, Armed Robbery)

SUPREME
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.
34

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)
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 R1 500 per incident. Pre-authorisation required. R12 700 per family per annum. Unlimited cover at DSP provider, subject to Scheme Protocols. 100% of Scheme Rate.
Video EEG for Epilepsy Surgery Dialysis
Note:

25 Chronic Disease List (CDL) conditions and HIV
SUPREME
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.
Resolution Health Additional Chronic Conditions NOTE: Pro-rated for members who join during the year
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.
35
Day-to-Day Limits
SUPREME
* Principal: Adult: Each child: R12 000 R9 000 R1 260
General Practitioners Consultations outside general practitioner networks may incur a co-payment.
Unlimited. Subject to day-to-day limits. 100% of Scheme Rate CDL consultations covered separately, subject to Disease Management Protocols. Pre-authorisation required.
Specialists Consultations Rooms procedures 100% of Scheme Rate for non-contracted providers. 220% of Scheme Rate for contracted providers. Consultations outside Specialist networks may incur a co-payment M M+1 M+2 4 visits per annum 5 visits per annum 6 visits per annum 100% of Scheme Rate for non-contracted providers. 220% of Scheme Rate for contracted providers.
Additional visits subject to PMB and pre-authorisation.
Note:
This is a family cumulative benet depending on family size (to max of 3 children) and not a sub-limit per individual.
DENTISTRY
Conservative Dentistry (Subject to Scheme Protocols and 100% of Scheme Rate) Consultations
SUPREME
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: 8 per beneciary per annum. Extra-oral: 1 per beneciary per annum. Per beneciary: A treatment plan and x-rays will be requested for treatment plans of more than 5 llings. Benets for llings are available where such llings are clinically indicated and will be granted once per tooth in a 1-year benet cycle. There are no 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 3-year cycle. Limited to 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 4-year cycle. Benet for metal dentures granted only once in 5-year cycle. Full metal dentures not covered.
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:
All conservative dentistry is subject to the option-specic limits
36
DENTISTRY
Advanced Dentistry (Includes hospitalisation. Subject to Scheme Protocols at 100% of Scheme Rate. Requires pre-authorisation) Crowns Bridges Implants Partial metal dentures Periodontics
SUPREME
Subject to day-to-day and annual limit of: R8 500 per family. Included. Included. Included. Included. Included. OR
Orthodontics (xed braces)
Benets on pre-authorisation will be applied to cases accessed as treatment mandatory, as per orthodontic indices. Limited to individuals younger than 38 years. 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.
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
Optometry Limited to optometry network provider and 24-month benet cycle Consultations / Examination Spectacles
SUPREME
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
Contact lenses
Limited to R1 900 per beneciary.
Note:
PREVENTATIVE CARE
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
SUPREME
1 Test per beneciary per annum. 1 Examination per beneciary per annum over the age of 25 years. 1 Test per beneciary per annum. 1 Test per beneciary per annum over the age of 45 years. 1 Dose per beneciary per annum. As recommended by the Department of Health up to 18 months.
37
PREVENTATIVE CARE
HPV (cervical cancer vaccine)
SUPREME
HPV (cervical cancer) vaccine. (1 Course per lifetime per female beneciary between the age of 9 and 46).
Nurse Helpline (including Rape Crises Centre) For any emergency medical condition. Oral contraception
Call 086 111 2162 Subject to sublimit of R1 200 per beneciary per annum - R100 per month.

Annual Limits NOTE: Pro-rated for members who join during the year.
SUPREME
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.
Alternative Healthcare Services
Radiology and Pathology (excluding specialised radiology)
Physiotherapy
Subject to sub-limits of R1 110 per family. 100% of Scheme Rate, subject 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 R1 270 per family 100% of Scheme Rate, subject to annual limit
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 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
CONTRIBUTIONS
Principal Member Adult Dependant Child Dependant
SUPREME
R2 712 R2 637 R 694
38
Notes
Contact Details
Head Office Boskruin Office Park President Fouch Avenue Boskruin (Entrance Boskruin Village Centre) www.resomed.co.za Client Services (Office hours: Mon - Fri: 7:30 - 17:00) PO Box 1075 Fontainebleau 2032
Tel: 0861 796 6400 Fax: 086 559 7830 clientservices@resomed.co.za Tel: 0800 132 345 Tel: 0861 112 162 Tel: 0861 117 778 Tel: 0861 111 778 preauth@resomed.co.za Tel: 0861 ZURREAL (9877 325) Tel: 011 796 6464
Chronic Medication Authorisation (Doctors and Pharmacists only) Evacuation and Ambulance Assistance: Europ Assistance HIV/AIDS: Pre-authorisation Zurreal Zurreal Healthcard
National Footprint
EMBRACE LIFE

Membership Handbook - Classic, Millennium and Supreme

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Membership Handbook - Classic, Millennium and Supreme

Încărcat de

Drepturi de autor:

Formate disponibile

Classic, Millennium and Supreme

Mark Arnold Principal Officer

Your needs and your healthcare option

Which is your ideal Resolution Health option?

3. Monthly membership contributions

Employer resignation from the Scheme

Failure to pay amounts due to the Scheme

Resignation from employment

5.1. Emergency services (0861 112 162)

10 5.2. Prescribed Minimum Benefits (PMB)

5.3. Dental benefits

5.5. Maternity programme

5.6. Health Assist (Nurse helpline 0861 112 162)

5.4. Optical benefits

Millennium Option Additional Chronic Conditions

Supreme Option Additional Chronic Conditions

5.9. Pharmacy Preferred Provider Network

13 5.10. Oncology benefits

3.7. 3.8. 3.9. 3.10. 3.11. 3.12. 3.13. 3.14. 3.15.

5.12. Exclusions (services or events not covered by the Scheme)

3.16. 3.17. 3.18. 3.19. 3.20. 3.21. 3.22.

5.14. Prosthesis sub-limits

17 5.15. Other insured benefits

5.16. External medical appliances sub-limits

18 5.17. Childhood immunisations

Age of child At birth 6 weeks

Monthly contribution for MILLENNIUM OPTION

7. Late Joiner Penalties

100% of Scheme Rate. According to hospital formulary.

Maximum of 7 days supply.

ANNUAL SUB-LIMITS (PRIVATE HOSPITALS)

Cochlear implants and all related thereto.

Organ Transplants Internal Prosthesis

Trauma Counselling (Assault, Rape, hijacking and Armed Robbery)

Subject to psychology and psychiatric MSA and ATB benets.

OTHER INSURED BENEFITS

OTHER INSURED BENEFITS

(CT, MRI, PET and Nuclear Medicine scans) Dialysis

CHRONIC MEDICATION BENEFITS

Root canal treatment per beneciary

Limited to R1 000 per beneciary.

R95 per beneciary over the age of 18 years at a pharmacy.

ADDITIONAL OUT-OF-HOSPITAL BENEFITS

Subject to day-to-day limits.

Includes a sub-limit on Schedule 0-2 / OTC drugs of: M R900 M+ R1 800

100% of Scheme Rate. According to hospital formulary. Maximum of 7 days supply.

ANNUAL SUB-LIMITS (PRIVATE HOSPITALS)

Trauma Counselling (Assault Rape Hijacking and Armed Robbery)

OTHER INSURED BENEFITS

OTHER INSURED BENEFITS

CHRONIC MEDICATION BENEFITS

Oral Hygiene No benet for oral hygiene or for uoride Preventative

Extractions per beneciary

Dental anaesthetics in rooms (laughing gas and IV sedation)

Pre-authorisation required. Covered at 100% of Scheme Rate. Clinical protocols apply..

Subject to MSA and ATB. Sublimit of: R2 120 per beneciary.

R95 per beneciary over the age of 18 years at a pharmacy.

ADDITIONAL OUT-OF-HOSPITAL BENEFITS

100% of Scheme Rate. According to hospital formulary. Maximum of 7 days supply.

ANNUAL SUB-LIMITS (PRIVATE HOSPITALS)

Included. R740 baby product voucher 9 consultations any provider. Included.

Trauma Counselling (Assault, Rape, hijacking, Armed Robbery)