CONTACT DETAILS                                                      AQUARIUM BENEFIT SCHEDULE                                               59
                 Contact details and regional offices                          3      General benefit rules                                                 59
                 Additional service points                                     5      In-hospital benefits                                                  61
                 Managed healthcare contact details                            7      Overall out-of-hospital benefits                                      64
                 Designated service providers (DSPs)                           8      Stand-alone benefits                                                  68
                                                                                      Annexure B2: Co-payments                                              72
                                                                                      Annexure B4: Chronic conditions                                       73
                 Annexure A3: Contribution Schedule                            9    ADMINISTRATION
                   1 April 2018 – 31 March 2019                                9      Application for Ex Gratia                                           75
                   1 April 2019 – 31 March 2020                                10     Application for membership                                          77
                 Annexure A1: Schedule of benefits                             11     Claims procedure (Scheme rule 15)                                   79
                   General rules                                               13     Continuaton of membership                                           81
                   Definition of terms                                         17     Five easy steps to plan selection                                   83
                                                                                      Member queries (initial queries)		85
               MARINE BENEFIT SCHEDULE                                         19     Member escalated queries                                            87
                 General benefit rules                                         19     No more queues: access your information via our website             89
                 In-hospital benefits                                          21     POLMED Chat (weekdays only)                                         91
                 Overall out-of-hospital benefits                              24     Third party consent                                                 93
                 Stand-alone benefits                                          27     Your step-by-step guide to the 24-hour telephonic self-help service 95
                 Annexure A2: Co-payments                                      32
                 Annexure A4: Chronic conditions                               33   MANAGED CARE
                                                                                      Complaints and dispute resolution                                     97
               ANNEXURES                                                              Hospital pre-authorisation                                            99
                 Annexure C:                                                   35     Maternity Programme                                                   101
                   Acute medication exclusions                                 35     Medicine management                                                   103
                   General exclusions                                          39     Mental Health Programme (for all members)                             105
                   Prescribed minimum benefits (PMBs)                          41     Oncology management                                                   107
                 Annexure D: Procedures pre-authorised under the auspices of          Prescribed minimum benefits                                           109
                 managed healthcare                                            42     Psychological benefits for serving members only                       110
                 Annexure E: Preventative healthcare benefits 2019             46     Registration to Disease Risk Management (DRM) Programme               111
                                                                                      Registration to HIV Management Programme                              112
                                                                                      Specialised dentistry                                                 113
                 Annexure B3: Contribution schedule                            49
               		 1 April 2018 – 31 March 2019                                 49   OTHER PROVIDERS
               		 1 April 2019 – 31 March 2020                                 50     Emergency Medical Services (EMS): Netcare 911                         115
                                                                                      Five steps to more cost-effective eye care                            117
                 Annexure B1: Schedule of benefits                             51
                                                                                      Motor vehicle accident (MVA) claims                                   119
               		 General rules                                                53
               		 Definition of terms                                          57
                                                                                    MY CONTACTS                                                             121

           1      POLMED 2019 Guide to your Health                                                                       POLMED 2019 Guide to your Health          2

                                                                                                                                                                                                                        CONTACT DETAILS
                                                                                                                                                                           Shop 6
                                                                                                                                                                   Bosveld Boulevard Park
                                                                                                                                                                      Cnr Joe Slovo &          POLOKWANE
                  TEL: 0860 765 633 or 0860 POLMED                                                                                                                   Chris Hani Streets        Checkers Centre
                                                                                                                                                                        Onverwacht           Shop 2, Ground Floor
                  FAX: 0860 104 114                                                                                 RUSTENBURG                                                              Cnr Hans van Rensburg
                  FAX: 0861 888 110 (Membership-related                                                                Shop 23                                                                 & Grobler Streets
                       correspondence)                                                                             Lifestyle Square          ROODEPOORT                                           Polokwane
                  FAX: 011 758 7660 (New claims)                                                                  Beyers Naude Drive         Shop 21 and 22
                                                                                                                      Rustenburg        Flora Centre (Entrance 2)
                                                                                                                                            Cnr Ontdekkers &                      LIMPOPO
                  ROODEPOORT WALK-IN BRANCH                                                 MAHIKENG                                          Conrad Roads             PRETORIA
                  Shop 21 and 22                                                            Office 101A                                       Florida North          Nedbank Plaza            NELSPRUIT
                                                                                     First Floor - East Gallery                                Roodepoort
                  Flora Centre (Entrance 2)                                                                                                                       Shop 17, Ground Floor   Union Square, Unit G2
                                                                                    Mega City Shopping Centre         KLERKSDORP
                  Cnr Ontdekkers & Conrad Roads                                                                                                                   361 Steve Biko Street     44 Mostert Street
                                                                                     Cnr Sekame & Dr James           Medicover Building                             Arcadia, Pretoria           Nelspruit
                  Florida North                                                            Moroka Drive                   Shop 11
                  Roodepoort                                                                 Mmabatho                22 Knowles Street
                                                                                             Mahikeng                                                               GAUTENG
                  POSTAL ADDRESS FOR                                                                                    Klerksdorp         NORTH WEST                           MPUMALANGA
                  CLAIMS, MEMBERSHIP AND
                                                                                           KATHU                                                                                           SECUNDA
                  POLMED                                                                                                                                        VEREENIGING
                                                                                       6 Rietbok Street                                                                               Grand Palace, Unit A2
                  Private Bag X16                                                                                                                               Ground Floor
                                                                                            Kathu                                                                                      2302 Heunis Street
                                                                                                                                                             36 Merriman Avenue
                  Arcadia                                                                                                                                                                   Secunda
                  0007                                                                                                                            FREE
                  EMAIL ADDRESS FOR                                                                                                                                                KWAZULU-
                  SUBMITTING ENQUIRIES                                                                             KIMBERLEY
                                                                                        NORTHERN                      Shop 17                                                       NATAL
                  polmed@medscheme.co.za                                                                           Southey Street
                                                                                          CAPE                                           BLOEMFONTEIN
                  REGIONAL WALK-IN BRANCHES                                                                                             Medical Suites 4 and 5
                                                                                                                                       Middestad Medical Suites
                  Refer to the map.                                                                                                           First Floor                                     DURBAN
                                                                                                                                          Middestad Centre                                  Ground Floor
                  POLMED FRAUD HOTLINE                                                                                                    Cnr Charles & West                          102 Stephen Dlamini Road
                                                                                                                                            Burger Streets                                    Musgrave
                  TEL:   0800 112 811                                                                                                       Bloemfontein                                       Durban
                  EMAIL: fraud@medscheme.co.za
                                                                                                                                          EASTERN CAPE
                  POLMED WEBSITE
                                                                      CAPE TOWN              CAPE
                                                                       Ground Floor
                  POLMED CHAT                                          Icon Building
                  Via mobile device: Download the free app        Cnr Lower Long Street &
                                                                   Hans Strijdom Avenue
                  via http://bit.ly/1YHAtwu or from various app                                                                 PORT ELIZABETH
                                                                        Cape Town
                  stores.                                                                                                            Block 6
                  Via POLMED website: Log in to the Member                                                                    Greenacres Office Park
                                                                                                                                   2nd Avenue
                  zone via your computer and click on the
                                                                                                                                  Newton Park
                  POLMED Chat widget/icon.                                                                                        Port Elizabeth
                  3         POLMED 2019 Guide to your Health                                                                                                            POLMED 2019 Guide to your Health            4

                                                                                                                                                    CONTACT DETAILS
                  NOTE: Please refer to the notices at police stations or South African Police Service
                  (SAPS) buildings for details about dates and times that assistance is offered at these
                  additional service points.
                  Any new offices/service points will be communicated.

                      AREA                        ADDRESS

                      Durban central              SAPS – Durban central, 255 Stalwart Simelane Street,
                                                  Marine Parade, Durban

                      King Williams Town          SAPS – King Williams Town, Buffalo Road, Zwelitsha

                      Mthatha                     SAPS – Mthatha, R61 Sutherland Street, Mthatha

                      Pietermaritzburg            SAPS – Alexandra Road, 101 Alexandra Road,
                                                  Scottsville, Pietermaritzburg

                      Potchefstroom               SAPS – Potchefstroom, 25 OR Tambo Street,

                      Pretoria                    Wachthuis, 231 Pretorius Street, Pretoria

                      Ulundi                      SAPS – Ulundi, Unit A, Ingulube Street, Ulundi

                      Winelands (Paarl East)      SAPS – Paarl East, cnr Meacker and Van der Stel Street,
                                                  Paarl East

                  5            POLMED 2019 Guide to your Health                                             POLMED
                                                                                                            POLMED 2019
                                                                                                                   2019 Guide
                                                                                                                        Guide to
                                                                                                                               to your
                                                                                                                                  your Health
                                                                                                                                       Health   6
MANAGED HEALTHCARE                                                                       DESIGNATED SERVICE PROVIDERS

                                                                                                                                                                                             CONTACT DETAILS
                  CONTACT DETAILS                                                                          (DSPs)
                                                                                                                                 EMERGENCY MEDICAL SERVICES
                  POSTAL ADDRESS                              ONCOLOGY MANAGEMENT
                  POLMED                                      PROGRAMME
                  Private Bag X16                             TEL:   0860 765 633
                  Arcadia                                     FAX: 0860 000 340                                                             Netcare 911
                  0007                                        EMAIL: polmedonco@medscheme.co.za                                             Tel: 082 911

                  CHRONIC MEDICINE                            PRESCRIBED MINIMUM BENEFITS
                                                                                                                                     EYE CARE (OPTOMETRY)
                  MANAGEMENT PROGRAMME                        (PMBs)
                  TEL:   0860 765 633 (members) or            TEL:   0860 765 633
                         0860 104 111 (providers)             EMAIL: polmedapmb@medscheme.co.za
                  FAX: 0860 000 320
                  EMAIL: polmedcmm@medscheme.co.za            SPECIALISED DENTISTRY                                               Preferred Provider Negotiators
                                                              TEL:   0860 765 633                                                        Tel: 0861 103 529
                  DISEASE RISK MANAGEMENT                     FAX:   0860 104 114
                  (DRM) PROGRAMME
                  TEL:    0860 765 633                        In-hospital dental procedures and sedation                    MOTOR VEHICLE ACCIDENT (MVA) CLAIMS
                  EMAIL:                                      pre-authorisation:
                  polmeddiseaseman@medscheme.co.za            EMAIL: polmedauths@medscheme.co.za
                  (DRM Programme)
                  EMAIL: polmedhbc@medscheme.co.za            Out-of-hospital specialised dentistry:
                  (Prolonged Care Programme)                  EMAIL:                                                       Tel: 012 431 9700/0861 303 303/0860 303 303
                  HOSPITAL/MRI AND CT SCAN
                                                                                                                                      ONCOLOGY (CANCER)
                  PRE-AUTHORISATION                           HIV MANAGEMENT PROGRAMME
                  TEL:   0860 765 633 (members) or            TEL:   0860 100 646
                         0860 104 111 (providers)             FAX: 0800 600 773
                  FAX: 0860 104 114                           EMAIL: polmedhiv@medscheme.co.za
                  EMAIL: polmedauths@medscheme.co.za          POSTAL ADDRESS: PO Box 38597                                 Independent Clinical Oncology Network (ICON)
                                                                                Pinelands                                               Tel: 021 944 3750
                  MATERNITY PROGRAMME                                           7430
                  TEL:   0860 765 633                                                                                               RENAL SERVICE FACILITIES

                  TEL:   0860 765 633
                                                                                                                  Fresenius Medical Care                    National Renal Care
                  EMAIL: polpsych@medscheme.co.za
                                                                                                           Website: www.freseniusmedicalcare.com             Tel: 011 726 5206
                                                                                                                                                           Website: www.nrc.co.za

                                                                                                                                                      POLMED 2019 Guide to your Health   8
                  7        POLMED 2019 Guide to your Health

         The contributions for 2018 as set out in the format required by the Registrar in                            The contributions for 2019 as set out in the format required by the Registrar in
         Circular 45 of 2017.                                                                                        Circular 33 of 2018.

         The monthly contributions are payable by or on behalf of the member per registered

             CONTRIBUTION RATES MARINE 2018 (1 APRIL 2018 – 31 MARCH 2019)                                            CONTRIBUTION RATES MARINE 2019 (1 APRIL 2019 – 31 MARCH 2020)

                       MEMBER CONTRIBUTION (SUBSIDISED CONTRIBUTION)                                                            MEMBER CONTRIBUTION (SUBSIDISED CONTRIBUTION)
             INCOME CATEGORY                      MEMBER                    ADULT                    CHILD            INCOME CATEGORY                      MEMBER                    ADULT                    CHILD
             R0 – R6 279                              295                     295                      74             R0 – R6 618                              319                      319                     80
             R6 280 – R8 625                          409                     409                      137            R6 619 – R9 091                          442                      442                     148
             R8 626 – R10 538                         452                     452                      169            R9 092 – R11 107                         488                      488                     183
             R10 539 – R12 325                        532                     532                      213            R11 108 – R12 991                        575                      575                     230
             R12 326 – R14 343                        621                     621                      246            R12 992 – R15 118                        671                      671                     266
             R14 344 – R17 250                        711                      711                     291            R15 119 – R18 182                        7 68                     7 68                    314
             R17 251 – R21 172                        783                     783                      339            R18 183 – R22 315                        846                      846                     366
             R21 173 +                                851                     851                      373            R22 316 +                                919                      919                     403

                     TOTAL CONTRIBUTION (EXCLUDING EMPLOYER SUBSIDY)                                                          TOTAL CONTRIBUTION (EXCLUDING EMPLOYER SUBSIDY)
             NOTE: Total contribution applicable to members who do not qualify for employer subsidy, e.g. parents.    NOTE: Total contribution applicable to members who do not qualify for employer subsidy, e.g. parents.

             INCOME CATEGORY                      MEMBER                    ADULT                    CHILD            INCOME CATEGORY                      MEMBER                    ADULT                    CHILD
             R0 – R6 279                            2 087                    2 087                    970             R0 – R6 618                            2 204                    2 204                    1 023
             R6 280 – R8 625                        2 201                    2 201                    1 033           R6 619 – R9 091                        2 327                    2 327                    1 090
             R8 626 – R10 538                       2 244                    2 244                    1 065           R9 092 – R11 107                       2 373                    2 373                    1 125
             R10 539 – R12 325                      2 325                    2 325                    1 109           R11 108 – R12 991                      2 461                    2 461                    1 172
             R12 326 – R14 343                      2 414                    2 414                    1 142           R12 992 – R15 118                      2 557                    2 557                    1 209
             R14 344 – R17 250                      2 503                    2 503                    1 188           R15 119 – R18 182                      2 653                    2 653                    1 257
             R17 251 – R21 172                      2 575                    2 575                    1 235           R18 183 – R22 315                      2 731                    2 731                    1 308
             R21 173 +                              2 644                    2 644                    1 269           R22 316 +                              2 805                    2 805                    1 346

         9            POLMED 2019 Guide to your Health                                                                                                                      POLMED 2019 Guide to your Health                  10


         ANNEXURE A1                                                                            Reference in this Annexure and
                                                                                                  the following Annexures to
                                                                                                                                            Benefits for the services outside
                                                                                                                                              the Republic of South Africa
                                                                                                           the term:                                      (RSA)
         FROM 1 JANUARY 2019
         Subject to the provisions contained in these rules, including all Annexures, members
         making monthly contributions at the rates specified in Annexure A3 shall be entitled   • ‘POLMED rate’ shall mean:                The Scheme does not grant benefits for
         to the benefits as set out herein, with due regard to the provisions in the Act and      2006 National Health Reference           services rendered outside the borders
         Regulations in respect of prescribed minimum benefits (PMBs).                            Price List (NHRPL) adjusted on an        of the RSA. A claim for such services will,
                                                                                                  annual basis with Consumer Price         however, be considered if the benefit
                                                                                                  Index (CPI).                             category and limitations applicable in the
                                                                                                                                           RSA can be determined. The benefit will
                                                                                                • ‘Agreed tariff’ shall mean:              be paid according to the POLMED rate.
                                                                                                  The rate negotiated by and on behalf     However, it remains the responsibility of
                                                                                                  of the Scheme with one or more 		        the member to acquire insurance cover
                                                                                                  providers/groups.                        when travelling outside the borders of
                                                                                                                                           the RSA.

         11       POLMED 2019 Guide to your Health                                                                                       POLMED 2019 Guide to your Health         12

         APPLICATION OF CLINICAL                                                                 Payment will be restricted to one month’s    on its proven clinical efficacy, as well as
                                                        Examples of designated service
         PROTOCOLS AND FUNDING                                                                   supply in all cases for acute and chronic    its cost effectiveness. Generic reference
                                                        providers (where applicable) are:
                                                                                                 medication, except where the member          pricing is applicable where generic
         GUIDELINES                                     •   cancer (oncology) network
                                                                                                 submits proof that more than one             equivalent medication is available. The
                                                        •   general practitioner (GP) network
         POLMED applies clinical protocols,                                                      month’s supply is necessary, e.g. due to     products that are not included in the
                                                        •   optometrist (visual) network
         including ‘best practice guidelines’ as                                                 travel arrangements to foreign countries.    POLMED formulary will attract a 20%
                                                        •   psycho-social network
         well as evidence-based medicine                                                         (Travel documents must be submitted          co-payment.
                                                        •   renal (kidney) network
         (EBM) principles in its funding decisions.                                              as proof.)
                                                        •   specialist network.                                                               The 20% co-payment for medication
         DENTAL PROCEDURES                                                                       Pre-authorisation is required for items      prescribed that is not included in the
                                                                                                 funded from the chronic medication           POLMED formulary can be waived via
         All dental procedures performed in           EMERGENCY MEDICAL                          benefit. Pre-authorisation is based          an exception management process.
         hospital require pre-authorisation. The      SERVICES (EMS):                            on evidence-based medicine (EBM)             This process requires a motivation from
         dentist’s costs for procedures that are      NETCARE 911                                principles and the funding guidelines of     the treating service provider and will
         normally done in a doctor’s rooms,                                                      the Scheme. Once predefined criteria are     be reviewed based on the exceptional
         when performed in hospital, shall be         72-hour post-authorisation rule
                                                                                                 met, an authorisation will be granted for    needs and clinical merits of each
         reimbursed from the out-of-hospital          Subject to authorisation within 72 hours
                                                                                                 the diagnosed conditions.                    individual case.
         (OOH) benefit, subject to the availability   of the event, all service providers will
         of funds. The hospital and anaesthetist’s    need to get an authorisation number        Beneficiaries will have access to a group    The Scheme shall only consider claims
         costs, if the procedure is pre-authorised,   from POLMED’s DSP.                         (formulary) of medication appropriate for    for medication prescribed by a person
         will be reimbursed from the in-hospital                                                 the management of their conditions or        legally entitled to prescribe medication
         benefit.                                     Co-payment of 40% of the claim shall       diseases for which they are registered.      and which is dispensed by such a person
                                                      apply where a member voluntarily uses      There is no need for a beneficiary to        or a registered pharmacist.
         DESIGNATED SERVICE                           an unauthorised service provider           apply for a new authorisation if the
         PROVIDER: OUT-OF-                            (non-DSP). Service providers will                                                       Flu vaccines and vaccines for children
                                                                                                 treatment prescribed by the doctor
         NETWORK RULE                                 be required to provide the hospital                                                     under six years of age are obtainable
                                                                                                 changes and the medication is included
                                                      admission/casualty sticker together with                                                without prescription and paid from the
                                                                                                 in the condition-specific medication
         POLMED has appointed healthcare                                                                                                      preventative care benefits.
                                                      patient report forms when submitting a     formulary. Updates to the authorisation
         providers (or a group of providers) as
                                                      claim to POLMED’s EMS DSP to validate      will be required for newly diagnosed         POLMED GP NETWORK
         designated service providers (DSPs) for
                                                      delivery to a hospital.                    conditions for the beneficiary.
         diagnosis, treatment and care in respect                                                                                             (DESIGNATED GP PROVIDER)
         of one or more prescribed minimum            EX GRATIA BENEFIT                          The beneficiary needs to reapply for
                                                                                                                                              Members are allowed two visits to a
         benefit (PMB) conditions. Where the                                                     an authorisation at least one month
                                                      The Scheme may, at the discretion                                                       general practitioner (GP) who is not part
         Scheme has appointed a DSP and the                                                      prior to the expiry of an existing chronic
                                                      of the Board of Trustees, grant an                                                      of the network per beneficiary per annum
         member voluntarily chooses to use an                                                    medication authorisation, failing which
                                                      Ex Gratia payment upon written                                                          for emergency or out-of-town situations.
         out-of-network provider, all costs higher                                               any claims received will not be paid from
                                                      application from members as per the                                                     Co-payments shall apply once the
         than the Scheme rate will be for the cost                                               the chronic medication benefit, but from
                                                      rules of the Scheme.                                                                    maximum out-of-network consultations
         of the member and must be paid directly                                                 the acute medication benefit, if benefits
                                                                                                                                              are exceeded. PMB rule applies for
         to the provider by the member.               MEDICATION: ACUTE, OVER                    exist. This only applies to authorisations
                                                                                                                                              qualifying emergency consultations.
                                                                                                 that are not ongoing and have an expiry
         Members can access the list of               THE COUNTER (OTC) AND
         providers at www.polmed.co.za, on
                                                                                                 date.                                        POLMED HOSPITAL
         their cellphones via the mobile site, via                                               Payment in respect of over-the-counter       NETWORK (DESIGNATED
         POLMED Chat or request it via the Client     The chronic medication benefit shall be    (OTC), acute and chronic medication, will    HOSPITAL NETWORK)
         Service Call Centre.                         subject to registration on the Chronic     be subject to the medication included
                                                      Medicine Management Programme for                                                       The POLMED Hospital DSP includes
                                                                                                 in the POLMED formulary. Medication is
                                                      those conditions which are managed,                                                     hospitals with a national footprint.
                                                                                                 included in the POLMED formulary based
                                                      and chronic medication rules will apply.                                                Members can access the list of hospitals

         13        POLMED 2019 Guide to your Health                                                                                           POLMED 2019 Guide to your Health         14
in the network at www.polmed.co.za, on           POLMED PHARMACY                               SPECIALIST REFERRAL                          The Scheme will allow two specialist

         their cellphones via the mobile site, via        NETWORK                                                                                    visits per beneficiary per year without the
         POLMED Chat or request it via the Client                                                       All POLMED beneficiaries need to be          requirement of a GP referral to cater for
         Service Call Centre.                             POLMED has established an open                referred to specialists by a GP. The         those who clinically require annual
                                                          pharmacy network for the provision of         Scheme will impose a co-payment of           and/or bi-annual specialist visits.
         All admissions (hospitals and day clinics)       acute, chronic and over-the-counter           up to R1 000 if the member consults
         must be pre-authorised. A penalty of             (OTC) medication. Medication included         a specialist without being referred.         However, the Scheme will not cover
         R5 000 may be imposed if no pre-                 in POLMED’s formulary will be funded in       The co-payment will be payable by the        the cost of the hearing aid if there is
         authorisation is obtained.                       full, subject to the availability of funds.   member to the specialist and is not          no referral from one of the following
                                                          Members who voluntarily opt to use            refundable by the Scheme.                    providers: GP, ear, nose and throat (ENT)
         In the case of an emergency, the
                                                          non-formulary products will be liable                                                      specialist, paediatrician, physician or
         Scheme must be notified within 48                                                              This co-payment is not applicable to
                                                          for a 20% co-payment. POLMED has                                                           neurologist. The specialist must submit
         hours or on the first working day after                                                        the following specialities or disciplines:
                                                          agreed dispensing fees with the network                                                    the referring GP’s practice number in the
         admission.                                                                                     Gynaecologists, psychiatrists,
                                                          pharmacies. A 20% co-payment will                                                          claim.
         Pre-authorisation will be managed under                                                        oncologists, ophthalmologists,
                                                          be levied in the event of voluntary           nephrologists (chronic dialysis), dental
         the auspices of managed healthcare.              utilisation of an out-of-network
         The appropriate facility must be used                                                          specialists, pathology, radiology and
                                                          pharmacy. Members can access the list         supplementary or allied health services.
         to perform a procedure, based on                 of providers at www.polmed.co.za, on
         the clinical requirements, as well as            their cellphones via the mobile site, via
         the expertise of the doctor doing                POLMED Chat or request it via the Client
         the procedure. Benefits for private or           Service Call Centre.
         semi-private rooms are excluded unless
         they are motivated and approved prior to         PRO RATA BENEFITS
         admission upon the basis of clinical need.
                                                          The maximum annual benefits referred
         Medication prescribed during                     to in this schedule shall be calculated
         hospitalisation forms part of the hospital       from 1 January to 31 December each
         benefits. Medication prescribed during           year, based on the services rendered
         hospitalisation to take out (TTO) will           during that year and shall be subject to
         be paid to a maximum of seven days’              pro rata apportionment calculated from
         supply or a rand value equivalent                the member’s date of admission to the
         to it per beneficiary per admission,             Scheme to the end of that budget year.
         except for anticoagulants post-surgery
         and oncology medication, which will              SPECIALISED RADIOLOGY
         be subject to the relevant managed               (MRI AND CT SCANS)
         healthcare programme.
                                                          Pre-authorisation is required for all
         MATERNITY: The costs incurred in                 scans, failing which the Scheme may
         respect of a newborn baby shall be               impose a co-payment of up to R1 000
         regarded as part of the mother’s cost for        per procedure. In the case of an
         the first 90 days after birth. If the child is   emergency the Scheme must be notified
         registered on the Scheme within 90 days          within 48 hours or on the first working
         from birth, Scheme rule 7.1.2 shall apply.       day of the treatment of the patient.
         Benefits shall also be granted if the child
         is stillborn.

         15        POLMED 2019 Guide to your Health                                                                                                  POLMED 2019 Guide to your Health         16

         BASIC DENTISTRY                               MEDICINE GENERIC                             POLMED will reimburse medication             The claims data for chronic medication,
                                                       REFERENCE PRICE                              intended for an approved chronic             consultations and hospital admissions
         Basic dentistry refers to procedures                                                       condition for up to four months from the     is used to identify the members
         that are used mainly for the detection,       This is the reference pricing system         acute medication benefit. Members will       who are eligible for registration to
         prevention and treatment of oral              applied by the Scheme based on generic       be required to register such medication      the Programme. Members are also
         diseases of the teeth and gums. These         reference pricing or the inclusion of a      as chronic during the four-month period.     encouraged to register themselves on
         include the alleviation of pain and           product in the medication ‘formulary’.                                                    the Programme.
         sepsis, the repair of tooth structures        This pricing system refers to the            REGISTRATION TO DISEASE
         by direct restorations or fillings and the    maximum price that POLMED will pay for
                                                                                                    RISK MANAGEMENT                              SPECIALISED DENTISTRY
         replacement of missing teeth by plastic       a generic medication. Should a reference
         dentures.                                     price be set for a generic medication,       PROGRAMME                                    Specialised dentistry refers to services
                                                       patients are entitled to make use of any     Members will be identified and               that are not defined as basic dentistry.
                                                       generically equivalent medication within     contacted to register to the Disease Risk    These include periodontal surgery,
              Other procedures that fall under         this pricing limit but will be required                                                   crowns and bridges, implant procedures,
              this category are:                                                                    Management Programme. The Disease
                                                       to make a co-payment on medication           Risk Management Programme aims to            inlays, indirect veneers, orthodontic
              • cleaning of teeth, including                                                                                                     treatment and maxillofacial surgery.
                                                       priced above the generic reference           ensure that members receive health
                non-surgical management of                                                                                                       All specialised dentistry services and
                                                       pricing limit. The fundamental principle     information, guidance and management
                gum disease                                                                                                                      procedures must be pre-authorised,
                                                       of any reference pricing system is that it   of their conditions, at the same time
              • consultations                                                                                                                    failing which the Scheme will impose a
                                                       does not restrict a member’s choice of       improving compliance to treatment
              • fluoride treatment and                                                                                                           co-payment of R500.
                                                       medication, but instead limits the amount    prescribed by the medical practitioner.
                fissure sealants
                                                       that will be paid for it.                    Members who are registered on the
              • non-surgical removal of teeth
              • root canal treatment.                                                               Programme receive a treatment plan
                                                       REGISTRATION FOR                             (Care Plan) which lists authorised
                                                       CHRONIC MEDICATION                           medical services, such as consultations,
                                                                                                    blood tests and radiological tests related
         CO-PAYMENT                                    POLMED provides for a specific list

         A co-payment is an amount payable by
                                                       of chronic conditions that are funded
                                                                                                    to the management of their conditions.
                                                       from the chronic medication benefit (i.e.
         the member to the service provider at         through a benefit that is separate from                                                          In the event of a dispute,
         the point of service. This includes all the   the acute medication benefit).
         costs more than those agreed upon with                                                                                                         the registered rules of
         the service provider or more than what                                                                                                         POLMED will apply.
                                                       POLMED requires members to apply for
         would be paid according to approved           authorisation via the Chronic Medicine
         treatments. A co-payment would not            Management Programme to access this
         be applicable in the event of a life-         chronic medication benefit. Members will
         threatening injury or an emergency.           receive communication via email, SMS or
                                                       post indicating whether their application
         FORMULARY                                     was successful or not. If successful, the
         A formulary is a list of cost-effective,      beneficiary will be issued with a disease-
         evidence-based medication for                 specific authorisation, which will allow
         the treatment of acute and chronic            them access to medication included in
         conditions.                                   the POLMED formulary.

         17         POLMED 2019 Guide to your Health                                                                                             POLMED 2019 Guide to your Health          18

                                           DESCRIPTION                                BENEFIT
                                  Benefit design                       This option provides for unlimited
                                                                       hospitalisation paid at the prescribed
                                                                       tariff, as well as for out-of-hospital (day-
                                                                       to-day) benefits

                                                                       This option is intended to provide
                                                                       for the needs of families who have
                                                                       significant healthcare needs

                                  Limits are per annum                 Unless there is a specific indication to
                                                                       the contrary, all benefit amounts and
                                                                       limits are annual

                                  Pre-authorisation, referrals,        Where the benefit is subject to pre-
                                  protocols and management by          authorisation, referral by a designated

                                  programmes                           service provider (DSP) or general
                                                                       practitioner (GP), adherence to
                                                                       established protocols or registration to
                                                                       a managed care programme, members’
                                                                       attention is drawn to the fact that there
                                                                       may be no benefit at all or a much-
                                                                       reduced benefit if the pre-authorisation,
                                                                       referral by a DSP or GP, adherence to
                                                                       established protocols or registration
                                                                       to a management care programme is
                                                                       not complied with (a co-payment may
                                                                       be applied). The pre-authorisation,
                                                                       referral by a DSP or GP, adherence to
                                                                       established protocols or registration to a
                                                                       managed care programme is stipulated
                                                                       to best care for the member and his/her
                                                                       family and to protect the funds of the

                                  Statutory prescribed minimum         There is no overall annual limit for PMBs
                                  benefits (PMBs)                      or life-threatening emergencies

                                  Tariff                               100% of POLMED rate
                                                                       Agreed tariff
                                                                       At cost for involuntary access to PMBs

         19                         POLMED 2019 Guide to your Health                                                  POLMED 2019 Guide to your Health   20
DESCRIPTION                                   BENEFIT                                                    DESCRIPTION                              BENEFIT

                                 Anaesthetists                        150% of POLMED rate                                                 General practitioners (GPs)      100% of agreed tariff at DSP

                                                                                                                                                                           100% of POLMED rate at non-DSP
                                 Annual overall in-hospital limit     Unlimited at DSPs                                                                                    At cost for involuntary access to PMBs
                                 Subject to the Scheme’s relevant
                                 managed healthcare programmes        Subject to PMBs, i.e. no limit in case of                           Medication (non-PMB specialist   100% of POLMED rate
                                 and includes the application         life-threatening emergencies or for PMB                             drug limit, e.g. biologicals)
                                 of treatment protocols, case         conditions                                                                                           Pre-authorisation required
                                 management and
                                 pre-authorisation                    Subject to applicable tariff, i.e. 100% of                                                           Specialised medication sub-limit of
                                                                      POLMED rate                                                                                          R177 402 per family
                                 A R5 000 penalty may be              or
                                 imposed if no pre-authorisation is   Agreed tariff                                                       Mental health                    100% of POLMED rate
                                 obtained                             or                                                                                                   or
                                                                      At cost for involuntary access to PMBs                                                               At cost for PMBs
                                 R8 000 co-payment for admission

                                                                                                                   IN-HOSPITAL BENEFITS
                                 to a non-DSP hospital                                                                                                                     Annual limit of 21 days per beneficiary

                                                                                                                                                                           Limited to a maximum of three days’
                                                                                                                                                                           hospitalisation for beneficiaries admitted
                                 Chronic kidney dialysis              100% of agreed tariff at DSP
                                                                                                                                                                           by a GP or a specialist physician
                                 Preferred providers:
                                 National Renal Care (NRC)
                                                                                                                                                                           Additional hospitalisation to be
                                 Fresenius Medical Care
                                                                                                                                                                           motivated by the medical practitioner

                                                                                                                                          Oncology (chemotherapy and       100% of agreed tariff at DSP
                                 Dentistry (conservative and          100% of POLMED rate                                                 radiotherapy)
                                 restorative)                                                                                             Independent Clinical Oncology    Limited to R464 834 per beneficiary per
                                                                      Dentist’s costs for basic dental                                    Network (ICON) is the DSP        annum; includes MRI/CT or PET scans
                                                                      procedures will be reimbursed from the                                                               related to oncology
                                                                      out-of-hospital (OOH) benefit
                                                                                                                                          Organ and tissue transplants     100% of agreed tariff at DSP
                                                                      The hospital and anaesthetist’s costs                                                                or
                                                                      will be reimbursed from the in-hospital                                                              At cost for PMBs
                                                                                                                                                                           Subject to clinical guidelines used in
                                                                                                                                                                           State facilities
                                 Emergency medical services           Subject to POLMED Scheme rules
                                 (ambulance services)                                                                                                                      Unlimited radiology and pathology
                                                                                                                                                                           for organ transplant and

                                                                                                                                          Pathology                        Service will be linked to hospital

         21                        POLMED 2019 Guide to your Health                                                                                                        POLMED 2019 Guide to your Health          22
DESCRIPTION                                  BENEFIT                                                              DESCRIPTION                                    BENEFIT

                                 Physiotherapy                        Service will be linked to hospital                                          Annual overall out-of-hospital          M0    – R20 143
                                                                      pre-authorisation                                                           (OOH) limit                             M1    – R24 513
                                                                                                                                                  Benefits shall not exceed the           M2    – R29 537
                                 Prostheses (internal and external)   100% of POLMED rate                                                         amount set out in the table             M3    – R33 872
                                                                      or                                                                                                                  M4+   – R36 757
                                                                      At cost for PMBs                                                            PMBs shall first accrue towards
                                                                                                                                                  the total benefit, but are not

                                                                      Subject to pre-authorisation and                                            subject to a limit
                                                                      approved product list
                                                                                                                                                  In appropriate cases the limit
                                                                      Limited to R65 320 per beneficiary                                          for medical appliances shall not
                                                                                                                                                  accrue towards this limit
                                 Refractive surgery                   100% of POLMED rate

                                                                                                               OVERALL OUT-OF-HOSPITAL BENEFITS
                                                                                                                                                  Out-of-hospital benefits are
                                                                      Subject to pre-authorisation                                                subject to:
                                                                                                                                                  • protocols and clinical guidelines
                                                                      Procedure is performed out of hospital                                      • PMBs
                                                                      and in day clinics                                                          • the applicable tariff, i.e. 100% of
                                                                                                                                                    POLMED rate or agreed tariff
                                 Specialists                          100% of agreed tariff at DSP                                                  or at cost for involuntary access
                                                                                                                                                    to PMBs
                                                                      100% of POLMED rate at non-DSP
                                                                                                                                                  Audiology                               100% of POLMED rate
                                                                                                                                                  Subject to referral by either of the
                                                                      At cost for involuntary access to PMBs
                                                                                                                                                  following doctors/specialists:          Subject to the OOH limit
                                                                                                                                                  · Ear, nose and throat (ENT)
                                                                                                                                                  · General practitioner (GP)
                                                                                                                                                  · Neurologist
                                                                                                                                                  · Paediatrician
                                                                                                                                                  · Physician

                                                                                                                                                  Dentistry (conservative and             100% of POLMED rate
                                                                                                                                                                                          Subject to the OOH limit and includes
                                                                                                                                                                                          dentist’s costs for in-hospital, non-PMB

                                                                                                                                                                                          Routine consultation, scale and polish
                                                                                                                                                                                          are limited to two annual check-ups per

                                                                                                                                                                                          Oral hygiene instructions are limited to
                                                                                                                                                                                          once in 12 months per beneficiary

         23                        POLMED 2019 Guide to your Health                                                                                                                       POLMED 2019 Guide to your Health           24
DESCRIPTION                                  BENEFIT                                                                DESCRIPTION                                BENEFIT

                                             General practitioners (GPs)          100% of agreed tariff at DSP                                                  Pathology                           M0    – R3 361
                                             POLMED has a GP Network              or                                                                                                                M1    – R4 846
                                                                                  At cost for involuntary access to PMBs                                                                            M2    – R5 796
                                                                                                                                                                                                    M3    – R7 138
                                                                                  The limit for consultations shall accrue                                                                          M4+   – R8 753
                                                                                  towards the OOH limit
                                                                                                                                                                                                    The defined limit per family will apply
                                                                                  Subject to maximum number of visits or                                                                            for any pathology service done out
                                                                                  consultations per family                                                                                          of hospital
                                                                                  M0 – 11
                                                                                  M1 – 16                                                                       Physiotherapy                       100% of POLMED rate
                                                                                  M2 – 20
                                                                                  M3 – 24                                                                                                           Annual limit of R4 846 per family

                                                                                                                             OVERALL OUT-OF-HOSPITAL BENEFITS

                                                                                  M4+ – 29
                                                                                                                                                                                                    Subject to the OOH limit
                                             Medication (acute)                   100% of POLMED rate at DSP

                                                                                  M0 – R4 598
                                                                                                                                                                Social worker                       100% of POLMED rate
                                                                                  M1 – R7 816
                                                                                  M2 – R11 035
                                                                                                                                                                                                    Annual limit of R4 957 per family
                                                                                  M3 – R14 253
                                                                                  M4+ – R17 494
                                                                                                                                                                                                    Subject to the OOH limit
                                                                                  Subject to the OOH limit

                                                                                  Subject to the POLMED formulary                                               Specialists                         100% of agreed tariff at DSP
                                                                                                                                                                Referral is not necessary for the   or
                                                                                                                                                                following specialists:              At cost for involuntary access to PMBs
                                             Medication (over the counter         100% of POLMED rate at DSP                                                    · Dental specialists
                                             [OTC])                                                                                                             · Gynaecologists                    The limit for consultations shall accrue
                                                                                  Annual limit of R1 152 per family                                             · Nephrologists (dialysis)          towards the OOH limit
                                                                                                                                                                · Oncologists
                                                                                  Subject to the OOH limit                                                      · Ophthalmologists                  Limited to 5/five visits per beneficiary
                                                                                                                                                                · Psychiatrists                     or
                                                                                  Shared limit with acute medication                                            · Supplementary or allied health    11/eleven visits per family per annum
                                                                                  Subject to the POLMED formulary                                                                                   Subject to referral by a GP
                                                                                                                                                                                                    (2/two specialist visits per beneficiary
                                                                                                                                                                                                    without GP referral allowed)
                                             Occupational and speech therapy      100% of POLMED rate
                                                                                                                                                                                                    R1 000 co-payment if no referral is
                                                                                  Annual limit of R2 795 per family                                                                                 obtained

                                                                                  Subject to the OOH limit

         25                                    POLMED 2019 Guide to your Health                                                                                                                     POLMED 2019 Guide to your Health           26
DESCRIPTION                                   BENEFIT                                                   DESCRIPTION                                  BENEFIT

                                 Allied health services and             100% of POLMED rate                                               Appliances (medical and surgical)   Glucometer             R1 342 per family
                                 alternative healthcare providers                                                                         (continued)
                                                                                                                                                                                                     Once every
                                 • Biokineticists    • Chiropodists     Annual limit of R2 733 per family
                                                                                                                                                                                                     4/four years
                                 • Chiropractors     • Dieticians
                                 • Homeopaths        • Naturopaths                                                                                                            Hearing aids           R14 144 per
                                 • Orthoptists       • Osteopaths                                                                                                                                    hearing aid
                                 • Podiatrists       • Reflexologists                                                                                                                                or
                                 • Therapeutic massage therapists                                                                                                                                    R28 111 per
                                 Benefits will be paid for clinically                                                                                                                                beneficiary per
                                 appropriate services                                                                                                                                                set
                                                                                                                                                                                                     Once every
                                 Appliances (medical and surgical)      100% of POLMED rate                                                                                                          3/three years
                                 Members must be referred for                                                                                                                 Implantable cardiac
                                 audiology services for hearing         Adult nappies         R946/month
                                                                                              (2/two nappies                                                                  defibrillator
                                 aids to be reimbursed
                                                                                              per day)

                                                                                                                                                                              Insulin delivery

                                                                                                                   STAND-ALONE BENEFITS
                                 Pre-authorisation is required for                            R1 419/month                                                                    devices
                                 the listed medical appliances                                (3/three nappies
                                                                                                                                                                              Urine catheters and
                                                                                              per day)
                                 All costs for maintenance are a                                                                                                              consumables
                                 Scheme exclusion                       Blood transfusion     Unlimited
                                                                                                                                                                              Medical assistive      Annual limit of
                                                                        Cochlear implant                                                                                      devices                R3 361 per family
                                 Funding will be based on
                                 applicable clinical and funding        Consumables                                                                                                                  Includes medical
                                 protocols                              associated                                                                                                                   devices
                                                                        implanted devices:                                                                                                           in/out of hospital
                                 Quotations will be required
                                                                        • Cardiac             Every 5/five years                                                              Nebuliser              R1 342 per family
                                                                                                                                                                                                     Once every
                                                                                                                                                                                                     4/four years
                                                                          battery                                                                                             Transcatheter aortic
                                                                          replacement                                                                                         valve insertion
                                                                        • Implantable         Every 5/five years                                                              (TAVI)
                                                                          cardiac                                                                                             Wheelchair             R52 814 per
                                                                          defibrillator                                                                                       (motorised)            beneficiary
                                                                          replacement                                                                                                                Once every
                                                                                                                                                                                                     3/three years
                                                                        CPAP machine          R9 442 per family
                                                                                                                                                                              Wheelchair             R15 712 per
                                                                                              Once every 4/four                                                               (non-motorised)        beneficiary
                                                                                                                                                                                                     Once every
                                                                                                                                                                                                     3/three years

         27                       POLMED 2019 Guide to your Health                                                                                                            POLMED 2019 Guide to your Health         28
DESCRIPTION                                   BENEFIT                                                      DESCRIPTION                                  BENEFIT
                                 Chronic medication                    100% of medication formulary reference                              Maxillofacial                         Shared limit with specialised dentistry

                                 refers to non-PMB conditions          price                                                               Pre-authorisation required
                                                                                                                                                                                 Excludes osseointegrated implants
                                 Subject to prior application and/or
                                 registration of the condition         Subject to access at DSP                                            Optical                               PROVIDER NETWORK
                                                                                                                                           Includes frames, lenses and
                                 Approved PMB CDL conditions           Member with no dependants:                                                                                100% of cost for a composite
                                                                                                                                           eye examinations
                                 are not subject to a limit            Annual limit of R9 756                                                                                    consultation, inclusive of the refraction,
                                                                                                                                           The eye examination is per            a glaucoma screening and visual field
                                                                                                                                           beneficiary every two years           screening, Authenticate IT and biometric
                                 The extended list of chronic          Member with registered dependants:
                                                                                                                                           (unless prior approval for clinical   readings
                                 conditions (non-PMBs) are subject     Annual limit of R17 512                                             indication has been obtained)
                                 to a limit                                                                                                                                      WITH EITHER SPECTACLES
                                                                                                                                           Benefits are not pro rata, but
                                 Dentistry (specialised)               100% of POLMED rate                                                 calculated from the benefit           R1 300 towards a frame and/or lens
                                 Pre-authorisation required            or                                                                  service date                          enhancements
                                                                       At cost for PMBs
                                                                                                                                           Each claim for lenses or frames       LENSES
                                                                       An annual limit of R14 205 per family                               must be submitted with the lens
                                                                                                                                                                                 Either one pair of clear single-vision
                                                                       Benefits shall not exceed the set out                                                                     lenses or one pair of clear flat-top

                                                                                                                    STAND-ALONE BENEFITS

                                                                       limit                                                               Benefits shall not be granted for     bifocal lenses or one pair of clear base
                                                                                                                                           contact lenses if the beneficiary     multifocal lenses
                                                                       Includes any specialised dental
                                                                                                                                           has already received a pair of
                                                                       procedures done in/out of hospital                                  spectacles in a two-year              OR CONTACT LENSES
                                                                       Includes metal-based dentures                                       benefit cycle                         Contact lenses to the value of R1 596
                                                                       Excludes osseointegrated implants                                                                         annually
                                                                                                                                           Contact lens re-examination can       Contact lens re-examination to a
                                                                       Subject to dental protocols
                                                                                                                                           be claimed for in six-monthly         maximum cost of R233 per consultation
                                                                                                                                                                                 NON-PROVIDER NETWORK
                                 Maternity benefits (including         The limit for consultations shall not
                                 home birth)                           accrue towards the OOH limit                                                                              One consultation limited to a maximum
                                 Pre-authorisation required                                                                                                                      cost of R300
                                                                       The benefit shall include three specialist
                                 Treatment protocols apply                                                                                                                       WITH EITHER SPECTACLES
                                                                       consultations per beneficiary per
                                                                       pregnancy                                                                                                 R910 towards a frame and/or lens
                                                                       Home birth is limited to R16 828 per
                                                                                                                                                                                 Single-vision lenses limited to R175 per
                                                                       beneficiary per annum
                                                                       Annual limit of R4 727 for ultrasound
                                                                                                                                                                                 Bifocal lenses limited to R410 per lens
                                                                       scans per beneficiary; limited to 2/two
                                                                       2D scans per pregnancy
                                                                                                                                                                                 Multifocal lenses limited to R710 per lens
                                                                       Benefits relating to more than                                                                            OR CONTACT LENSES
                                                                       2/two antenatal ultrasound scans and
                                                                                                                                                                                 Contact lenses to the value of R1 000
                                                                       amniocenteses after 32 weeks of
                                                                       pregnancy are subject to
                                                                       pre-authorisation                                                                                         Contact lens re-examination to a
                                                                                                                                                                                 maximum cost of R233 per consultation
         29                       POLMED 2019 Guide to your Health                                                                                                               POLMED 2019 Guide to your Health           30

                                       DESCRIPTION                                 BENEFIT
                                 Radiology (basic)                    100% of agreed tariff
                                 i.e. black and white X-rays and      or                                        CO-PAYMENTS
                                 soft tissue ultrasounds              At cost for PMBs

                                                                      Limited to R6 532 per family                    OUT OF NETWORK                 CO-PAYMENT
                                                                                                                General practitioner (GP)   Allows for 2/two out-of-network
                                                                      Includes any basic radiology done                                     consultations per beneficiary
                                                                      in or out of hospital
                                                                                                                                            Co-payments shall apply once
                                                                      Claims for PMBs first accrue towards                                  maximum out-of-network

                                                                      the limit                                                             consultations are exceeded

                                 Radiology (specialised)              100% of agreed tariff
                                 Pre-authorisation required           or
                                                                      At cost for PMBs                          Hospital                    R8 000

                                                                      Includes any specialised radiology
                                                                      service done in or out of hospital

                                                                      Claims for PMBs first accrue towards
                                                                      the limit
                                                                                                                Pharmacy                    20% of costs for using a non-designated
                                 2/two MRI scans                      Subject to a limit of 2/two scans per                                 service provider (non-DSP) pharmacy
                                                                      family per annum, except for PMBs
                                                                                                                                            20% co-payment for voluntarily using a
                                 3/three CT scans                     Subject to a limit of 3/three scans per                               non-formulary product
                                                                      family per annum, except for PMBs

         31                        POLMED 2019 Guide to your Health                                                                         POLMED 2019 Guide to your Health         32
ANNEXURE A4                                                                          Pulmonary diseases                          Treatable cancers

                                                                                              Asthma                                      As per PMB guidelines
         MARINE: CHRONIC CONDITIONS                                                           Chronic obstructive pulmonary disease       Urological conditions
                                                                                                                                          Benign prostatic hypertrophy
                                                                                              Cystic fibrosis
                 Prescribed minimum benefits (PMBs), including chronic Diagnosis                                                          Chronic renal failure
                                  and Treatment Pairs (DTPs)                                                                              Nephrotic syndrome and
                                                                                              Special category conditions                 glomerulonephritis
                                                                                              HIV/AIDS                                    Renal calculi
                                                                                              Organ transplantation
         Chronic medication is payable from chronic medication benefits. Once the benefit     Tuberculosis
         limit has been reached, it will be funded from the unlimited PMB pool.

         Auto-immune disorder                         Gynaecological conditions                                    Extended chronic disease list: Non-PMB
         Systemic lupus erythematosus (SLE)           Endometriosis
                                                      Menopausal treatment
         Cardiovascular conditions
                                                                                              Chronic medication for the conditions listed below is payable from the chronic
         Cardiac dysrhythmias                         Haematological conditions
                                                                                              medication benefit. Benefits subject to the availability of funds.
         Cardiomyopathy                               Anaemia
         Coronary artery disease                      Haemophilia                             Dermatological conditions                   Neurological conditions
         Heart failure                                Idiopathic thrombocytopenic purpura
                                                                                              Acne (clinical photos required)             Alzheimer’s disease
         Hypertension                                 Megaloblastic anaemia
                                                                                              Eczema                                      Meniere’s disease
         Peripheral arterial disease
                                                                                              Onychomycosis (mycology report              Migraine prophylaxis
         Thromboembolic disease                       Metabolic condition                     required)                                   Narcolepsy
         Valvular disease
                                                      Hyperlipidaemia                         Psoriasis                                   Tourette’s syndrome
                                                                                                                                          Trigeminal neuralgia
         Endocrine conditions                         Musculoskeletal condition               Ear, nose and throat condition
         Addison’s disease                                                                                                                Ophthalmic condition
                                                      Rheumatic arthritis                     Allergic rhinitis
         Cushing’s disease
                                                                                                                                          Dry eye or keratoconjunctivitis sicca
         Diabetes insipidus
         Diabetes mellitus type I                     Neurological conditions                 Gastrointestinal condition
         Diabetes mellitus type II                    Cerebrovascular incident                Gastro-oesophageal reflux disease           Psychiatric condition
         Hyperprolactinaemia                          Epilepsy                                (GORD) (special motivation required)        Attention deficit hyperactivity disorder
         Hypo- and hyperthyroidism                    Multiple sclerosis                                                                  (ADHD)
         Polycystic ovaries                           Parkinson’s disease                     Metabolic condition
         Primary hypogonadism                         Permanent spinal cord injuries                                                      Urological condition
                                                                                              Gout prophylaxis
                                                                                                                                          Overactive bladder syndrome
         Gastrointestinal conditions                  Ophthalmic condition
                                                                                              Musculoskeletal conditions
         Crohn’s disease                              Glaucoma
                                                                                              Ankylosing spondylitis
         Peptic ulcer disease (requires
         special motivation)                          Psychiatric conditions                  Osteoporosis
         Ulcerative colitis                           Affective disorders (depression and     Paget’s disease
                                                      bipolar mood disorder)                  Psoriatic arthritis
                                                      Post-traumatic stress disorder (PTSD)
                                                      Schizophrenic disorders
         33        POLMED 2019 Guide to your Health                                                                                       POLMED 2019 Guide to your Health           34


            ANNEXURE C                                                                              CATEGORY             DESCRIPTION                          EXAMPLE

            ACUTE MEDICATION EXCLUSIONS                                                             4.04       Patent medication: Food/nutrition          Infasoy, Ensure

                                                                                                    4.05       Patent medication: Soaps and cleansers     Brasivol®, Phisoac®
            The following categories of medication to be excluded from acute medication benefits:
                                                                                                    4.06       Patent medication: Cosmetics               Classique
             CATEGORY                      DESCRIPTION                         EXAMPLE
                                                                                                    4.07       Patent medication: Contact lens            Bausch + Lomb®
             1.03                Gender/sex related: Treatment of           Clomid®, Profasi®,                 preparations
                                 female infertility                         Cyclogest®
                                                                                                    4.08       Patent medication: Patent sunscreens       Piz Buin
             1.05                Gender/sex related: Androgens and          Sustanon®
                                 anabolic steroids                                                  4.10       Patent medication: Medicated shampoo       Denorex®,
                                                                                                                                                          Niz shampoo
             2.00                Slimming preparations                      Thinz®, Obex LA®
                                                                                                    4.11       Patent medication: Veterinary products
             4.01                Patent medication: Household remedies      Lennons
                                                                                                    5.04       Appliances, supplies and devices:          Thermometers,
             4.02                Patent medication: Patent and products     Choats                             Medical appliances or devices              hearing aid batteries
                                 with no robust scientific evidence to
                                 support cost-effectiveness
                                                                                                    5.06       Appliances, supplies and devices:          Cotton wool, gauze
             4.03                Patent medication: Emollients              Aqueous cream                      Bandages and dressings

            35       POLMED 2019 Guide to your Health                                                                                  POLMED 2019 Guide to your Health         36

             CATEGORY                      DESCRIPTION                      EXAMPLE              CATEGORY                      DESCRIPTION                          EXAMPLE
             5.07               Appliances, supplies and devices:                                14.00               Medication where cost/benefit ratio         Xigris®, Zyvoxid®
                                Disposable cholesterol supplies                                                      cannot be justified                         Herceptin, Gleevac®

                                                                                                 20.00               All newly registered medication
             5.11               Appliances, supplies and devices:        Nappies, molipants,
                                Incontinence products                    linen savers, except
                                                                         Stoma-related          Other items and categories that can be excluded according to evidence-based
                                                                         supplies               medicine principles as approved by the Scheme from time to time.

                                                                                                The following categories are not available on acute medication benefits:
             6.00               Diagnostic agents                        Clear View
                                                                         pregnancy tests
                                                                                                 CATEGORY                      DESCRIPTION                           EXAMPLE
             8.05               Vaccines or immunoglobulins: Other       Beriglobin®             1.06                Gender/sex related: Treatment of            Viagra®, Cialis®,
                                immunoglobulins                                                                      impotence/sexual dysfunction                Caverject®

                                                                                                 5.03                Appliances, supplies and devices:           Stoma bags,
             9.02               Vitamin and/or mineral supplements:      Pharmaton SA®
                                                                                                                     Stoma products and accessories,             adhesive paste,
                                Multivitamins or minerals
                                                                                                                     except where it forms part of PMB-          pouches and
                                                                                                                     related services                            accessories
             9.03               Vitamin and/or mineral supplements:      Gericomplex®
                                Geriatric vitamins and/or minerals                               5.08                Appliances, supplies and devices:           Opsite®, Intrasite®,
                                                                                                                     Medicated dressings, except where           Tielle®, Granugel®
             9.05               Vitamin and/or mineral supplements:      Bioplus®                                    these form part of PMB-related services
                                Tonics and stimulants
                                                                                                 5.10                Appliances, supplies and devices:           Catheters, urine
                                                                                                                     Surgical appliances/products for home       bags, butterflies,
             9.08               Vitamin and/or mineral supplements:      Magnesit®
                                                                                                                     nursing                                     drip sets, alcohol
                                Magnesium diet supplementation

             9.10               Vitamin and/or mineral supplements:      Sportron                7.01                Treatment/prevention of substance           Revia®
                                Unregistered vitamins, mineral or food                                               abuse: Opioid
                                                                                                 7.03                Treatment/prevention of substance           Antabuse®, Sobrial®,
             10.01              Naturo- and homeopathic remedies/        Weleda Natura                               abuse: Alcohol, except PMBs                 Esperal implants
                                supplements: Homeopathic remedies
                                                                                                 22.00               Immunosuppressives: Except PMBs             Azapress®,
             10.02              Naturo- and homeopathic remedies/        Primrose oils, fish
                                supplements: Natural oils                liver oil               23.01               Blood products: Erythropoietin, except      Eprex®, Repotin®

             12.00              Veterinary products                                              23.02               Blood products: Haemostatics, except        Konakion®, Factor
                                                                                                                     PMBs                                        VIII
             13.00              Growth hormones                          Genotropin®
                                                                                                 25.01               Oxygen: Masks, regulators and oxygen        Oxygen, masks

            37       POLMED 2019 Guide to your Health                                                                                        POLMED 2019 Guide to your Health           38
GENERAL EXCLUSIONS                                                                         19. Muscular fatigue tests, except if        27. Sex change operations

                                                                                                           requested by a specialist and a
                                                                                                           doctor’s motivation is enclosed          28. Sleep therapy
            The following services/items are excluded from benefits with due regard to
            prescribed minimum benefits (PMBs) and will not be paid by the Scheme:                     20. Non-clinically essential or              29. The artificial insemination of a
                                                                                                           non-emergency transport via an 		            person in or outside the human body
            1.   Accommodation in an old-age               10. Benefits for organ transplant donors        ambulance                                    as defined in the Human Tissue Act,
                 home or other institution that                to recipients who are not members                                                        1983 (Act 65 of 1983) provided that,
                 provides general care for the aged            of the Scheme                           21. Non-functional prostheses used               in the case of artificial insemination,
                 and/or chronically ill patients, unless                                                   for reconstructive or restorative            the Scheme’s responsibility on the
                 approved by the Scheme                    11. Blood pressure appliances: Provided         surgery, excluding PMB diagnoses,            treatment will be:
                                                               that the Board may decide to grant          provided that the Board may decide           • as it is prescribed in the public
            2. Accommodation in spas, health or                benefits in exceptional                     to grant the benefit in exceptional 		   		hospital
               rest resorts                                    circumstances                               circumstances                                • as defined in the prescribed
                                                                                                                                                    		 minimum benefits (PMBs)
            3. Accounts of providers not registered        12. Charges for appointments that a 		      22. Operations, treatments and 		                • subject to pre-authorisation and
               with a recognised professional                  member or dependant fails to keep           procedures, by choice, for cosmetic      		 prior approval by the Scheme
               body constituted in terms of an Act             with service providers                      purposes where no pathological
               of Parliament                                                                               substance exists which proves the        30. The treatment of obesity, provided
                                                           13. Claims relating to the following:           necessity of the procedure,                  that with prior motivation the
            4. Aids for participation in sport,                • aptitude tests                            and/or which is not life-saving, 		          Scheme may approve benefits for
               e.g. mouthguards                                • IQ tests                                  life-sustaining or life-supporting           the treatment of morbid obesity
                                                               • school readiness
            5. Any health benefit not included in              • questionnaires                        23. Prenatal and/or post-natal exercises     31. Unless otherwise decided by the
               the list of prescribed benefits                 • marriage counselling                                                                   Board, benefits in respect of
               (including newly developed                      • learning problems                     24. Reports, investigations or tests             medication obtained on a
               interventions or technologies where             • behavioural problems                      for insurance purposes, admission            prescription is limited to one
               the long-term safety and cost to                                                            to universities or schools, fitness          month’s supply for every such
               benefit cannot be supported) shall          14. Compensation for pain and suffering,        tests and examinations, medical              prescription or repeat thereof
               be deemed to be excluded from                   loss of income, funeral expenses or         court reports, employment,
               the benefits                                    claims for damages                          emigration or immigration, etc.          32. Unless otherwise indicated by the
                                                                                                                                                        Board, costs for services rendered
            6. Any orthopaedic and medical aids            15. Cosmetics and sunblock; sunblock        25. Reversal of sterilisation procedures,        by any institution not registered in
               that are not clinically essential,              may be considered for clinical 		           provided that the Board may                  terms of any law.
               subject to PMBs                                 reasons in albinism                         decide to grant benefits in
                                                                                                           exceptional circumstances
            7. Any treatment as a result of                16. Fixed orthodontics for beneficiaries
               surrogate pregnancy                             above the age of 21 years               26. Services not mentioned in the
                                                                                                           benefits as well as services which,
            8. Beneficiaries’ travelling costs, except     17. Gold inlays in dentures, soft and           in the opinion of the Scheme, are
               services according to the benefits in           metal base to new dentures, invisible       not aimed at the treatment of
               Annexure A and B                                retainers, osseointegrated implants         an actual or supposed illness or
                                                               and bleaching of vital (living) teeth       disablement which impairs or
            9. Benefits for costs of repair,                                                               threatens essential body functions
               maintenance, parts or accessories           18. Holidays for recuperative purposes          (the process of ageing will not be
               for appliances or prostheses                                                                regarded as an illness or a

            39        POLMED 2019 Guide to your Health                                                                                              POLMED 2019 Guide to your Health           40
PRESCRIBED MINIMUM BENEFITS                                                              ANNEXURE D

            (PMBs)                                                                                   PROCEDURES PRE-AUTHORISED
            The Scheme will pay in full, without co-payment or use of deductibles, the diagnosis,    UNDER THE AUSPICES OF
            treatment and care costs of the PMBs as per Regulation 8 of the Act. Furthermore,
            where a protocol or a formulary drug preferred by the Scheme has been ineffective        MANAGED HEALTHCARE
            or would cause harm to a beneficiary, the Scheme will fund the cost of the appropriate
            substitution treatment without a penalty to the beneficiary as required by Regulation    The following elective procedures will be funded from the hospital benefits if
            15H and 15I of the Act.                                                                  done in the doctor’s rooms and/or day clinics and as a day procedure in an acute
                                                                                                     hospital. If these procedures are done in the doctor’s rooms, there is no need for
                                                                                                     pre-authorisation. Pre-authorisation is required when procedures are done in the day
                                                                                                     clinic or in hospital. A R1 000 co-payment will be levied when the length of stay for an
                                                                                                     Annexure D procedure is voluntarily extended beyond the agreed day rate period.

                                                                                                      PROCEDURE DESCRIPTION                          PROCEDURE DESCRIPTION
                                                                                                      Adenoidectomy                                  Cataract surgery

                                                                                                      Anoscopies                                     Cauterisation of cervix/lazer ablation

                                                                                                      Arthrocentesis                                 Circumcision

                                                                                                      Arthrodesis of hand/elbow/foot                 Colonoscopy

                                                                                                      Arthroscopy                                    Colposcopy

                                                                                                      Arthrotomy of finger/hand/elbow/               Continuous nerve block infusion –
                                                                                                      knee/toe/hip                                   sciatic nerve/femoral nerve/lumbar
                                                                                                      Ascites or pleural tapping
                                                                                                                                                     Cystoscopy for diagnosis/dilatation/
                                                                                                      Aspiration/injection                           stent/stone removal

                                                                                                      Aspiration/intra-articular injection of        Debride nails six or more – any
                                                                                                      joints                                         method

                                                                                                      Bartholin’s gland drainage/excision/           Debride skin/subcutaneous tissue
                                                                                                                                                     Diathermy to nose and pharynx under
                                                                                                      Biopsy of lymph node/muscle/skin/              local anaesthesia
                                                                                                                                                     Dilatation and curettage (excluding
                                                                                                      Bleeding control (nasal)                       aftercare)

                                                                                                      Bronchial lavage                               Drainage of abscess skin/carbuncle/
                                                                                                      Cast application/removal

            41       POLMED 2019 Guide to your Health                                                                                              POLMED 2019 Guide to your Health           42
PROCEDURE DESCRIPTION                       PROCEDURE DESCRIPTION                        Pre-authorisation for                           Pre-authorisation for PMB

                                                                                                      hospitalisation                                 CDL/chronic condition
             Drainage of subcutaneous abscess            Inject therapeutic carpal tunnel e.g.
                                                         local corticosteroids                        All elective/scheduled hospital                 • The Disease Risk Management
             Drainage of submucous abscess                                                            admissions must be pre-authorised and             (DRM) Care Plan Programme will grant
                                                         Intrapleural block                           where indicated, a hospital network will          each registered beneficiary a certain
             Endoscopy                                                                                apply.                                            number of consultations and
                                                         Laparoscopy diagnostic abdomen/                                                                investigations according to clinical
             Excision benign lesion scalp/neck/          peritoneum/omentum                           ·   You may obtain a hospital
             hand/feet                                                                                    authorisation number by phoning the
                                                         Ludwig’s angina – drainage                                                                   • The beneficiary is notified about
                                                                                                          Hospital Risk Management Programme
             Excision benign lesion trunk/limbs                                                                                                         these benefits at the beginning of
                                                         Myringotomy aspiration incision                                                                each calendar year or shortly after
                                                                                                      ·   Payment to a hospital is subject to
                                                                                                                                                        being diagnosed with the condition.
             Excision ganglion/cyst/tumour
                                                                                                          meeting the stipulated standards such
                                                         Opening of quinsy at rooms                                                                   • No co-payment applies for the
             Excision of meibomian cyst                                                                   as pre-authorisation, clinical necessity,
                                                                                                                                                        treatment of a PMB CDL and/or
                                                         Proctoscopy with removal of polyps               appropriate treatment, benefit limits
                                                                                                                                                        chronic condition if you use the
             Excision sweat gland axilla/inguinal                                                         and prescribed minimum benefits
                                                                                                                                                        medication within the medicine
             simple repair                               Proof puncture at rooms – unilateral/            (PMBs).
                                                                                                                                                        reference price or medication
                                                         bilateral                                    ·   If you are admitted to an intensive
             Fine-needle aspiration cytology                                                              care unit (ICU) or high care (HC) ward,
                                                         Radical nail bed removal
             Fine-needle aspiration for soft tissue
                                                                                                          the hospital is required to motivate        Pre-authorisation of high-cost
                                                         Removal of foreign body                          your continued accommodation in             or non-effective procedures
             – all areas including breast
                                                                                                          either of these facilities every 72
             Flexible nasopharyngo-laryngoscope          Repair layer wound scalp/axillae/                hours.                                      High-cost and non-effective procedures
             examination                                 trunk/limbs                                  ·   You may be liable for a co-payment,         are pre-authorised at the auspices of
                                                                                                          except in the case of an emergency:         managed healthcare.
             Gastroscopy/                                Repair wound lesion scalp/hands/                   − if your option stipulates that you
             esophagogastroduodenoscopy                  neck/feet                                             use a hospital network
                                                                                                                                                      Pre-authorisation policies and
                                                                                                            − if you have not obtained pre-           procedures
             Incision and drainage of abscess/           Tonsillectomy – adenoidectomy < 12
             haematoma (anal/vaginal)                    years                                                 authorisation.                         Where applicable, pre-authorisation must
                                                                                                      ·    In the case of an emergency the            be obtained for clinical services and will
             Inject nerve block                          Treatment by chemo-cryotherapy –                 Scheme must be notified within 48           be subject to benefit limits. Managed
                                                         additional lesions                               hours or first working day after            healthcare may require a clinical
             Inject tendon/ligament/trigger points/                                                       treatment or admission.                     motivation for certain services and is
             ganglion cyst                               Vasectomy – uni/bilateral                    ·   An authorisation does not guarantee         subject to clinical protocols.
                                                                                                                                                      Specialised dentistry
            Basic dentistry                             • Registration is necessary when more
                                                          than four fillings or two root canals are                                                   • All specialised dentistry services and
            • The Scheme must authorise dental 		         required.                                                                                     procedures must be pre-authorised.
              procedures that require general                                                                                                         • If any of the procedures involve
              anaesthesia.                                                                                                                              hospitalisation, the member must
            • Procedures done under general 		          Maxillofacial surgery
                                                                                                                                                        obtain a pre-authorisation number
              anaesthesia are only permitted for 		     All procedures performed by a                                                                   via the managed healthcare
              children under the age of seven years     maxillofacial surgeon in hospital must be                                                       organisation.
              or in the case of the surgical removal    authorised.                                                                                   • Where there is an alternative option
              of impacted wisdom teeth.                                                                                                                 of treatment, the Scheme might limit
                                                                                                                                                        the benefit to the price of the open

            43       POLMED 2019 Guide to your Health                                                                                                 POLMED 2019 Guide to your Health       44

                                                    PREVENTATIVE HEALTHCARE
                                                    BENEFITS 2019
                                                    These benefits allow for risk assessment tests to ensure the early detection of
                                                    conditions that may be completely cured or successfully managed if treated early. All
                                                    services as per the specified benefit to be covered from the in-hospital benefits and
                                                    will not deplete your out-of-hospital benefits.

                                                             MEASURE AND ICD-10 CODES                      CARE, SCREENING, TEST

                                                                                    CHILD HEALTH
                                                     All child immunisation provided by the              As per DOH age schedule as
                                                     Department of Health (DOH) for children             per the Road to Health chart
                                                     twelve (12) years old and younger

                                                                                   DENTAL HEALTH
                                                     Caries risk assessment for children aged            Once every second year
                                                     0-14 years
                                                     (Clinical information to be submitted to
                                                     managed care)

                                                     Consultation and topical fluoride application       Annually
                                                     for children aged 0-6 years

                                                     Periodontal disease and caries risk                 Once every second year
                                                     assessment for adults 19 years of age
                                                     and older
                                                     (Clinical information to be submitted to
                                                     managed care)

                                                     Topical fluoride application for children aged      Annually
                                                     7-18 years

                                                             FEMALE HEALTH (women and adolescent girls)
                                                     Breast cancer screening ICD: Z12.3 and              Once every two years, unless
                                                     ICD: Z01.6                                          motivated
                                                     Mammogram: all women aged 40-69 years old

                                                     Cervical cancer screening ICD: Z12.4                Pap smear test once every
                                                     For all females aged 21-64 years old, except        third year
                                                     for those women who have had a complete
                                                     hysterectomy with no residual cervix

            45   POLMED 2019 Guide to your Health                                                POLMED 2019 Guide to your Health       46
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