2019 GUIDE TO YOUR HEALTH - AQUARIUM & MARINE - POLMED
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2019 GUIDE TO YOUR HEALTH AQUARIUM & MARINE
CONTENTS
CONTENTS
CONTENTS
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
MARINE
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
AQUARIUM
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
LEPHALALE
CONTACT DETAILS AND REGIONAL OFFICES
CONTACT DETAILS
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
Lephalale
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
Witkoppies
POSTAL ADDRESS FOR Klerksdorp NORTH WEST MPUMALANGA
CLAIMS, MEMBERSHIP AND
CONTRIBUTIONS
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
Vereeniging
0007 FREE
STATE
EMAIL ADDRESS FOR KWAZULU-
SUBMITTING ENQUIRIES KIMBERLEY
NORTHERN Shop 17 NATAL
polmed@medscheme.co.za Southey Street
CAPE BLOEMFONTEIN
Kimberley
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
www.polmed.co.za
WESTERN
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
ADDITIONAL SERVICE POINTS
CONTACT DETAILS
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,
Potchefstroom
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
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
dental.polmeddental@medscheme.co.za
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
EMAIL:
polmedmaternity@medscheme.co.za
MENTAL HEALTH PROGRAMME
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
ANNEXURE A3
MARINE
MARINE
MARINE CONTRIBUTION SCHEDULE
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
member.
ANNUAL MEMBER CONTRIBUTION INCREASES ARE EFFECTIVE 1 APRIL
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
MARINE
MARINE
MARINE
SCHEDULE
ANNEXURE A1 Reference in this Annexure and
the following Annexures to
Benefits for the services outside
the Republic of South Africa
the term: (RSA)
SCHEDULE OF BENEFITS WITH EFFECT
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
GENERAL RULES
MARINE
MARINE
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
CHRONIC
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
MARINE
MARINE
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
DEFINITION OF TERMS
MARINE
MARINE
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.
DISCLAIMER
!
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 18BENEFIT SCHEDULE
MARINE
MARINE
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
GENERAL BENEFIT RULES
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
Scheme
Statutory prescribed minimum There is no overall annual limit for PMBs
benefits (PMBs) or life-threatening emergencies
Tariff 100% of POLMED rate
or
Agreed tariff
or
At cost for involuntary access to PMBs
19 POLMED 2019 Guide to your Health POLMED 2019 Guide to your Health 20DESCRIPTION BENEFIT DESCRIPTION BENEFIT
MARINE
MARINE
Anaesthetists 150% of POLMED rate General practitioners (GPs) 100% of agreed tariff at DSP
100% of POLMED rate at non-DSP
or
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
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
benefit
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
immunosuppressants
Pathology Service will be linked to hospital
pre-authorisation
21 POLMED 2019 Guide to your Health POLMED 2019 Guide to your Health 22DESCRIPTION BENEFIT DESCRIPTION BENEFIT
MARINE
MARINE
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
IN-HOSPITAL BENEFITS
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
or
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)
specialist
· General practitioner (GP)
· Neurologist
· Paediatrician
· Physician
Dentistry (conservative and 100% of POLMED rate
restorative)
Subject to the OOH limit and includes
dentist’s costs for in-hospital, non-PMB
procedures
Routine consultation, scale and polish
are limited to two annual check-ups per
beneficiary
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 24DESCRIPTION BENEFIT DESCRIPTION BENEFIT
MARINE
MARINE
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
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
services
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 26DESCRIPTION BENEFIT DESCRIPTION BENEFIT
MARINE
MARINE
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)
STAND-ALONE BENEFITS
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
resynchronisation
Once every
therapy
4/four years
pacemaker
battery Transcatheter aortic
replacement valve insertion
• Implantable Every 5/five years (TAVI)
cardiac Wheelchair R52 814 per
defibrillator (motorised) beneficiary
battery
replacement Once every
OR
3/three years
CPAP machine R9 442 per family
Wheelchair R15 712 per
Once every 4/four (non-motorised) beneficiary
years
Once every
3/three years
27 POLMED 2019 Guide to your Health POLMED 2019 Guide to your Health 28DESCRIPTION BENEFIT DESCRIPTION BENEFIT
Chronic medication 100% of medication formulary reference Maxillofacial Shared limit with specialised dentistry
MARINE
MARINE
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
prescription
Benefits shall not exceed the set out lenses or one pair of clear flat-top
STAND-ALONE BENEFITS
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
intervals
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
enhancements
Home birth is limited to R16 828 per
Single-vision lenses limited to R175 per
beneficiary per annum
lens
or
Annual limit of R4 727 for ultrasound
Bifocal lenses limited to R410 per lens
scans per beneficiary; limited to 2/two
or
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
annually
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 30ANNEXURE A2
MARINE
MARINE
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
STAND-ALONE BENEFITS
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 32ANNEXURE A4 Pulmonary diseases Treatable cancers
MARINE
MARINE
Asthma As per PMB guidelines
Bronchiectasis
MARINE: CHRONIC CONDITIONS Chronic obstructive pulmonary disease Urological conditions
(COPD)
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
Osteoarthritis
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 34ANNEXURES
ANNEXURES
ANNEXURES
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 36ANNEXURES
ANNEXURES
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
swabs
9.10 Vitamin and/or mineral supplements: Sportron 7.01 Treatment/prevention of substance Revia®
Unregistered vitamins, mineral or food abuse: Opioid
supplements
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®,
Sandimmun
10.02 Naturo- and homeopathic remedies/ Primrose oils, fish
supplements: Natural oils liver oil 23.01 Blood products: Erythropoietin, except Eprex®, Repotin®
PMBs
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 38GENERAL EXCLUSIONS 19. Muscular fatigue tests, except if 27. Sex change operations
ANNEXURES
ANNEXURES
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
disablement)
39 POLMED 2019 Guide to your Health POLMED 2019 Guide to your Health 40PRESCRIBED MINIMUM BENEFITS ANNEXURE D
ANNEXURES
ANNEXURES
(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
plexus
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
marsupialisation
Diathermy to nose and pharynx under
Biopsy of lymph node/muscle/skin/ local anaesthesia
bone/breast/cervix
Dilatation and curettage (excluding
Bleeding control (nasal) aftercare)
Bronchial lavage Drainage of abscess skin/carbuncle/
whitlow/cyst/haematoma/gland
Cast application/removal
41 POLMED 2019 Guide to your Health POLMED 2019 Guide to your Health 42PROCEDURE DESCRIPTION PROCEDURE DESCRIPTION Pre-authorisation for Pre-authorisation for PMB
ANNEXURES
ANNEXURES
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
protocols.
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
Department.
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
formulary.
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.
payment.
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
procedure.
43 POLMED 2019 Guide to your Health POLMED 2019 Guide to your Health 44ANNEXURE E
ANNEXURES
ANNEXURES
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 46You can also read
