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                                ANNEXURE B1                                             Reference in this Annexure and the following
                                                                                                  Annexures to the term:

                                                         KNOWN AS THE
                                                          LOWER PLAN      E ‘Polmed rate’ shall mean: 2006 NHRPL + inflationary figure (i.e. the
                                                                            2006 base tariff increased by the inflationary amounts); and
                                                                          E ‘Agreed tariff’ shall mean: The rate negotiated by and on behalf of the
                                                                            Scheme with one or more providers/groups.

                AQUARIUM SCHEDULE
                                                                                       Benefits for services outside the Republic of
                                                                                                     South Africa (RSA)
                    FROM 1 JANUARY 2016

                Subject to the provisions contained in these Rules,       The Scheme does not grant benefits for services rendered outside the
                including all Annexures, members making monthly           borders of the RSA. A claim for such services will, however, be considered
                                                                          if the benefit category and limitations applicable in the RSA can be
           contributions at the rates specified in Annexure B3 shall be
                                                                          determined. The benefit will be paid according to the Polmed rate.
            entitled to the benefits as set out below, with due regard    However, it remains the responsibility of the member to acquire insurance
            to the provisions in the Act and Regulations in respect of    cover when travelling outside the borders of the RSA.
                       prescribed minimum benefits (PMBs).
GENERAL RULES                                                                           countries. (Travel documents must be         any claims reviewed will not be paid

                                                                                                   submitted as proof.)                         from the chronic medicine benefit,
                                                                                                   Payment in respect of over-the-counter       but from the acute medicine benefit
           In hospital                                  90 days from birth, Scheme Rule 7.1.2
                                                                                                   (OTC), acute and chronic medicine will       if benefits exist. This only applies to
                                                        shall apply.
           All admissions (hospitals and day clinics)                                              be limited to the medicine reference         authorisations that are not on-going
           must be pre-authorised; otherwise a                                                     price. This is the maximum allowed cost      and have an expiry date.
                                                        Benefits shall also be granted if the
           penalty of R5 000 may be imposed if no                                                  and may be based on either generic
                                                        child is stillborn.
           pre-authorisation is obtained.                                                          or ‘formulary’ reference pricing. The        The Scheme shall only consider claims
                                                                                                   balance of the cost needs to be funded       for medicines prescribed by a person
           In the case of emergency, the Scheme         Dental procedures                          by the member.                               legally entitled to prescribe medicine
           must be notified within 48 hours or on       All dental procedures performed in                                                      and which is dispensed by such a
           the first working day after admission.       hospital require pre-authorisation.        Pre-authorisation is required for items      person or a registered pharmacist.
                                                        The dentist’s costs for procedures         funded from the chronic medication
           Pre-authorisation will be managed            that are normally done in a doctor’s       benefit. Pre-authorisation is based          Flu vaccines and vaccines for children
           under the auspices of managed                rooms, when performed in hospital,         on evidence-based medicine (EBM)             under six years of age are obtainable
           healthcare. The appropriate facility has     shall be reimbursed from the out-of-       principles and the funding guidelines        without prescription.
           to be used to perform a procedure,           hospital (OOH) benefit, subject to the     of the Scheme. Once predefined
           based on the clinical requirements,          availability of funds. The hospital and    criteria are met, an authorisation will be   Specialist referral
           as well as the expertise of the doctor       anaesthetist’s costs for non-PMB dental    granted for the diagnosed conditions.
                                                                                                                                                All Polmed beneficiaries need to be
           doing the procedure.                         procedures performed in hospital will      Beneficiaries will have access to
                                                                                                                                                referred to specialists by a general
                                                        be reimbursed from the overall non-        a group (’basket’) of medicines
                                                                                                                                                practitioner (GP). The beneficiary or
           Benefits for private or semi-private         PMB benefit, subject to the availability   appropriate for the management of
                                                                                                                                                the referring GP is required to obtain a
           rooms are excluded unless they are           of funds.                                  their particular conditions/diseases
                                                                                                                                                referral number, which can be obtained
           motivated and approved prior to                                                         for which they are registered. There is
                                                                                                                                                from the Scheme. The Scheme will
           admission upon the basis of clinical         Specialised radiology                      no need for a beneficiary to apply for
                                                                                                                                                impose a co-payment of up to R1 000
           need.                                                                                   a new authorisation if the treatment
                                                        Pre-authorisation is required for all                                                   if the member consults a specialist
                                                                                                   prescribed by the doctor changes
                                                        scans, failing which the Scheme may                                                     without the referral. The co-payment
           Medicine prescribed during                                                              and the medicines are included
                                                        impose a co-payment up to R1 000 per                                                    will be payable by the member to the
           hospitalisation forms part of the                                                       in the condition-specific medicine
                                                        procedure. In the case of emergency                                                     specialist and is not refundable by the
           hospital benefits.                                                                      basket. Updates to the authorisation
                                                        the Scheme must be notified within                                                      Scheme.
                                                                                                   will be required for newly diagnosed
                                                        48 hours or on the first working day of
           Medicine prescribed during                                                              conditions for the beneficiary.
                                                        the treatment of the patient.                                                           (This co-payment is not applicable to
           hospitalisation to take out (TTO) will                                                  Medication that is not included in the
                                                                                                                                                the following specialities/disciplines:
           be paid to a maximum of seven days’                                                     baskets may be available through an
           supply or a rand value equivalent            Medication                                 exception management process, for
                                                                                                                                                Gynaecologists, psychiatrists,
                                                                                                                                                oncologists, ophthalmologists,
           to it per beneficiary per admission,         The chronic medication benefit shall be    which a medicine-specific authorisation
                                                                                                                                                nephrologists [chronic dialysis], dental
           except for anticoagulants post-surgery       subject to registration on the Chronic     may be granted; this process requires
                                                                                                                                                specialists, pathology, radiology and
           and oncology medication, which will          Medicine Management Programme for          motivation from the treating service
                                                                                                                                                supplementary/allied health services.)
           be subject to the relevant managed           those conditions which are managed         provider and will be reviewed based
                                                                                                                                                The Scheme will allow two specialist
           healthcare programme.                        and chronic medication rules will apply.   on the exceptional needs of the
                                                                                                                                                visits per beneficiary per year without
                                                        Payment will be restricted to one          beneficiary.
                                                                                                                                                the requirement of a GP referral to cater
           Maternity: The costs incurred in respect     month’s supply in all cases for acute
                                                                                                                                                for those who clinically require annual
           of a new-born baby shall be regarded         and chronic medicine, except where the     The member needs to re-apply for
                                                                                                                                                and/or bi-annual specialist visits.
           as part of the mother’s cost for the         member submits proof that more than        an authorisation at least one month
           first 90 days after birth. If the child      one month’s supply is necessary, e.g.      prior to expiry of an existing chronic
                                                                                                                                                However, the Scheme will not cover
           is registered on the Scheme within           due to travel arrangements to foreign      medicine authorisation, failing which
                                                                                                                                                the cost of the hearing aid if there is
no referral from one of the following
                                                                                                    DEFINITION OF TERMS

           providers: GP, ear, nose and throat
                                                          Examples of designated service
           (ENT) specialist, paediatrician, physician
                                                          providers (where applicable) are:
           or neurologist.
                                                          E cancer (oncology) network
                                                                                                    Co-payment                               orthodontic treatment, removal of
                                                                                                                                             impacted teeth, and maxillofacial
                                                          E general practitioner (GP)               A co-payment is an amount payable
           Ex gratia benefit                                                                                                                 surgery. All specialised dentistry
                                                             network                                by the member to the service
                                                                                                                                             services and procedures must be
           The Scheme may, at the discretion              E hospital network                        provider at the point of service. This
                                                                                                                                             pre-authorised, failing which the
           of the Board of Trustees, grant an ex          E optometrist (visual) network            includes all the costs in excess of
                                                                                                                                             Scheme will impose a co-payment
           gratia payment upon written application        E psycho-social network                   those agreed upon with the service
                                                                                                                                             of R500.
           from members as per the Rules of the           E renal (kidney) network                  provider or in excess of what would
           Scheme.                                        E specialist network.                     be paid according to approved
                                                                                                    treatments. A co-payment would not       Registration for chronic
           Pro rata benefits                                                                        be applicable in the event of a life-    medication
                                                                                                    threatening injury or an emergency.      Polmed provides for a specific
           The maximum annual benefits referred         Designated GP provider                                                               list of chronic conditions that are
           to in this schedule shall be calculated
           from 1 January to 31 December each
                                                        (network GP)                                Medicine reference price                 funded from the chronic medicine
                                                        Members are allowed two visits to a         This is the reference pricing system     benefit (i.e. through a benefit that is
           year, based on the services rendered
                                                        GP who is not part of the network per       applied by the Scheme; it may be         separate from the acute medication
           during that year and shall be subject to
                                                        beneficiary per annum for emergency         derived based on either generic          benefit). Polmed requires members
           pro rata apportionment calculated from
                                                        or out-of-town situations. Co-payments      or ‘formulary’ reference pricing.        to apply for authorisation via the
           the member’s date of admission to the
                                                        shall apply once the maximum out-of-        This pricing system refers to the        Chronic Medicine Management
           Scheme to the end of that financial year.
                                                        network consultations are exceeded.         maximum price that Polmed will pay       Programme to access this chronic
                                                                                                    for a particular medication. Should a    medication benefit. Members will
           Designated service provider                                                                                                       receive a letter by post or e-mail
           (out-of-network rule)                        Designated pharmacy network                 reference price be set for a generic
                                                                                                    or therapeutic class of medication,      indicating whether their application
           Polmed has appointed healthcare              Polmed has appointed service                                                         was successful or not. If successful,
                                                                                                    patients are entitled to make use of
           providers (or a group of providers) as       providers for the provision of chronic                                               the beneficiary will be issued with
                                                                                                    any medication within this pricing
           designated service providers (DSPs) for      medication. The Scheme utilises the                                                  a disease-specific authorisation,
                                                                                                    limit, but will be required to make a
           diagnosis, treatment and care in respect     courier pharmacies as the primary                                                    which will allow access to a range of
                                                                                                    co-payment on medication priced
           of one or more prescribed minimum            service provider, with retail pharmacies                                             medicines that are referred to as the
                                                                                                    above the reference pricing limit.
           benefit (PMB) conditions. Where the          providing secondary support for                                                      disease authorisation basket.
                                                                                                    The fundamental principle of any
           Scheme has appointed a DSP and the           those members who prefer personal
                                                                                                    reference pricing system is that it
                                                        interaction. Where the member
           member voluntarily chooses to use an
                                                        chooses to use an alternative provider,
                                                                                                    does not restrict a member’s choice      Enrolment on the Disease
           alternative provider, all costs in excess                                                of medicine, but instead limits          Management Programme
           of the agreed rate will be for the cost of   the member shall be liable for a co-
                                                                                                    the amount that will be paid for it.     Members will be identified and
           the member and must be paid directly         payment of 20% of the costs that must
                                                                                                    Accessibility of products within the     contacted in order to enrol on the
           to the provider by the member.               be paid directly to the provider by the
                                                                                                    reference price groups is taken into     Disease Management Programme.
                                                                                                    account when defining the group.         The Disease Management
           You can access the list of providers at
                                                        You can access the list of providers at                                              Programme aims to ensure that
 , on your cell phone
                                              , on your cell phone        Specialised dentistry                    members receive health information,
           via the mobile site or request it via the
                                                        via the mobile site or request it via the   Specialised dentistry refers to          guidance and management of
           Client Service Department.
                                                        Client Service Department.                  services that are not defined as basic   their conditions, at the same
                                                        E Pharmacy (medicine) DSP                   dentistry. These include periodontal     time improving compliance to
                                                                                                    surgery, crowns and bridges, implant     treatment prescribed by the medical
                                                                                                    procedures, inlays, indirect veneers,    practitioner. Members who are

            registered on the programme               Basic dentistry
            receive a treatment plan (care plan)
                                                      Basic dentistry refers to procedures
            which lists authorised medical
                                                      that are used mainly for the                                     Benefit design         This option provides for benefits
            services, such as consultations, blood
                                                      detection, prevention and treatment                                                     to be provided only in appointed
            tests and radiological tests related to
                                                      of oral diseases of the teeth                                                           designated service provider (DSP)
            the management of their conditions.
                                                      and gums. These include the                                                             hospitals
                                                      alleviation of pain and sepsis, the
            The claims data for chronic
                                                      repair of tooth structures by direct                                                    It also provides a reasonable level
            medication, consultations and
                                                      restorations/fillings and replacement                                                   of out-of-hospital (day-to-day) care
            hospital admissions is used to
                                                      of missing teeth by plastic dentures.
            identify the members that are
                                                                                                                                              This option is intended to provide
            eligible for enrolment on the
                                                      Other procedures that fall under the                                                    for the needs of families who have
            programme. Members are also
                                                      category are:                                                                           little healthcare needs or whose
            encouraged to register themselves
                                                                                                                                              chronic conditions are under control
            on the programme.
                                                        E consultations
                                                                                                                                              This option is not intended for
                                                        E fluoride treatment and fissure

                                                                                               GENERAL BENEFIT RULES
                                                                                                                                              members who require medical
                                                                                                                                              assistance on a regular basis, or
                                                        E non-surgical removal of teeth
                                                                                                                                              who are concerned about having
                                                        E cleaning of teeth, including
                                                                                                                                              extensive access to health benefits
                                                          non-surgical management of
                                                          gum disease                                                  Pre-authorisation,     Where the benefit is subject to
                                                        E root canal treatment.                                        referrals, protocols   pre-authorisation, referral by
                                                                                                                       and management by      a designated service provider
                                                                                                                       programmes             (DSP) or general practitioner (GP),
                                                                                                                                              adherence to established protocols
                                                                                                                                              or enrolment upon a managed care
            Disclaimer: In the                                                                                                                programme, members’ attention is
            event of a dispute                                                                                                                drawn to the fact that there may be
           the registered rules                                                                                                               no benefit at all or a much reduced
             of POLMED will                                                                                                                   benefit if the pre-authorisation,
                  apply.                                                                                                                      referral by a DSP or GP, adherence
                                                                                                                                              to established protocols or
                                                                                                                                              enrolment upon a managed 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 enrolment
                                                                                                                                              upon a managed care programme
                                                                                                                                              is stipulated in order to best care for
                                                                                                                                              the member and his/her family and
                                                                                                                                              to protect the funds of the Scheme

                                                                                                                                                   Dentistry (conservative and        100% of Polmed rate
                                                          Limits are per annum   Unless there is a specific indication                                                                Dentist’s costs for all non-PMB
                                  GENERAL BENEFIT RULES                          to the contrary, all benefit amounts                                                                 procedures will be reimbursed from
                                                                                 and limits are annual                                                                                the out-of-hospital (OOH) benefit
                                                          Statutory prescribed   There is no overall annual limit for
                                                          minimum benefits       PMBs/life-threatening emergencies                                                                    The hospital and anaesthetist’s costs
                                                          (PMBs)                                                                                                                      will be reimbursed from the overall
                                                                                                                                                                                      non-PMB limit
                                                          Tariff                 100% of Polmed rate or agreed
                                                                                 tariff or at cost for involuntary                                 Emergency medical assistance       100% of agreed tariff
                                                                                 access to PMBs                                                    Netcare 911 (082 911) is the DSP

                                                                                                                                                   Chronic kidney dialysis            100% of agreed tariff at DSP
                                                                                                                                                   National Renal Care (NRC) and
                                                                                                                                                   Fresenius Medical Care are
                                                                                                                                                   preferred providers

                                                                                                                            IN-HOSPITAL BENEFITS
                                                                                                                                                   Mental health                      100% of Polmed rate or at cost for

                                           Annual overall in-hospital limit           Non-PMB admissions will be subject                                                              Annual limit of 21 days per
                                           In-hospital benefits are subject to        to an overall limit of R200 000 per                                                             beneficiary
                                           the Scheme’s relevant managed              family
                                           healthcare programmes and                                                                                                                  Limited to a maximum of three days’
                                           includes the application of                R8 000 co-payment for admission to                                                              hospitalisation for beneficiaries
                                           treatment protocols, case                  a non-DSP hospital                                                                              admitted by a GP or a specialist
                                           management and pre-authorisation;                                                                                                          physician

                                           a R5 000 penalty may be imposed if         No co-payment if the procedure is
                                           no pre-authorisation is obtained           performed in a DSP and/or a day                                                                 Additional hospitalisation to
                                                                                      clinic                                                                                          be motivated by the medical
                                           Subject to PMBs, i.e. no limit in case                                                                                                     practitioner
                                           of life-threatening emergencies or
                                                                                                                                                   Medication: Non-PMB                100% of Polmed rate
                                           for PMB conditions
                                                                                                                                                   specialist drug limit,             Pre-authorisation required
                                                                                                                                                   e.g. biologicals
                                           Subject to applicable tariff, i.e. 100%
                                                                                                                                                                                      Specialised medicine sub-limit of
                                           of Polmed rate or agreed tariff or at
                                                                                                                                                                                      R69 430 per family
                                           cost for involuntary access to PMBs
                                                                                                                                                   Oncology (chemotherapy and         100% of agreed tariff at DSP
                                                                                                                                                                                      Limited to R231 578 per beneficiary
                                                                                                                                                   Independent Clinical Oncology      per annum; includes MRI/CT or PET
                                                                                                                                                   Network (ICON) is the DSP          scans related to oncology

                                  Organ and tissue transplants   100% of agreed tariff at DSP or at                                          Annual overall out-of-hospital          M0 – R7 865
                                                                 cost for PMBs                                                               (OOH) limit                             M1 – R9 529
                                                                                                                                                                                     M2 – R11 575
                                                                 Subject to clinical guidelines used in                                      Benefits shall not exceed the           M3 – R12 349
                                                                 State facilities                                                            amount set out in the table             M4 + – R14 151

                                                                 Unlimited radiology and                                                     PMBs shall first accrue towards the
                                                                 pathology for organ transplant and                                          total benefit, but are not subject to
                                                                 immunosuppressants                                                          limit

                                  Pathology                      Service will be linked to hospital
                                                                                                                                             In appropriate cases the limit for
                                                                                                                                             medical appliances shall not accrue
                                  Physiotherapy                  Service will be linked to hospital                                          towards this limit

                                                                                                          OVERALL OUT-OF-HOSPITAL BENEFITS
                                                                                                                                             Out-of-hospital benefits are subject
                                  Prostheses (internal and       100% of Polmed rate                                                         to:
                                  external)                                                                                                  • protocols and clinical guidelines

                                                                 Subject to pre-authorisation and                                            • PMBs
                                                                 approved product list                                                       • the applicable tariff, i.e. 100% of
                                                                                                                                               Polmed rate or agreed tariff or at
                                                                 Limited to R57 240 per beneficiary                                            cost for involuntary PMB access

                                  Refractive surgery             No benefit                                                                  Dentistry (conservative and             100% of Polmed rate
                                                                                                                                                                                     Subject to the OOH limit and
                                  General practitioners (GPs)    100% of agreed tariff at DSP, 100%
                                                                                                                                                                                     includes dentist’s costs for in-
                                                                 of Polmed rate at non-DSP or at
                                                                                                                                                                                     hospital, non-PMB procedures
                                                                 cost for involuntary PMB access

                                  Specialists                    100% of agreed tariff at DSP, 100%                                                                                  Routine consultation, scale and
                                                                 of Polmed rate for non-DSP or at                                                                                    polish are limited to two annual
                                                                 cost for involuntary PMB access                                                                                     check-ups per beneficiary

                                  Anaesthetists                  150% of Polmed rate or at cost for                                                                                  Oral hygiene instructions are limited
                                                                 PMBs                                                                                                                to once in 12 months per beneficiary

                                              General practitioners (GPs)    100% of agreed tariff at DSP or at                                       Pathology                              M0 – R2 767
                                              POLMED has a GP network        cost for involuntary PMB access                                                                                 M1 – R4 092
                                                                                                                                                                                             M2 – R4 950
                                                                             The limit for consultations shall                                                                               M3 – R6 127
                                                                             accrue towards the OOH limit                                                                                    M4 + – R7 590

                                                                             Subject to maximum numbers of                                                                                   The defined limit per family will
                                                                             visits/consultations per family per                                                                             apply for any pathology service
                                                                             annum, as follows:                                                                                              done out of hospital
                                                                             M0 – 8
                                                                             M1 – 12                                                                  Physiotherapy                          100% of Polmed rate
                                                                             M2 – 15
                                                                             M3 – 18                                                                                                         Annual limit of R2 141 per family

                                                                                                                   OVERALL OUT-OF-HOSPITAL BENEFITS
                                                                             M4 + – 22
                                                                                                                                                                                             Subject to the OOH limit
                                              Medication (acute)             100% of Polmed rate
                                                                                                                                                      Social worker                          100% of Polmed rate
                                                                             Annual limit of R8 544 per family
                                                                                                                                                                                             Annual limit of R2 020 per family
                                                                             Subject to the OOH limit and the
                                                                             medicine reference price                                                                                        Subject to the OOH limit

                                              Medication (over-the-counter   100% of Polmed rate                                                      Specialists                            100% of agreed tariff at DSP or at
                                                                                                                                                      Referral is not necessary for          cost for involuntary PMB access
                                                                             Annual limit of R850 per family                                          gynaecologists, psychiatrists,
                                                                                                                                                      oncologists, ophthalmologists,         The limit for consultations shall
                                                                             Subject to the OOH limit; shared                                         nephrologists (dialysis), dental       accrue towards the OOH limit
                                                                             limit with acute medication                                              specialists and supplementary/allied
                                                                                                                                                      health services (excluding audiology   Limited to four visits per beneficiary
                                              Audiology                      100% of Polmed rate                                                      services)                              and eight visits per family per
                                                                             Subject to the OOH limit
                                                                                                                                                                                             Subject to referral by a GP (two
                                                                             Subject to referral by GP, ear,                                                                                 specialist visits per beneficiary
                                                                             nose and throat (ENT) specialist,                                                                               without GP referral allowed)
                                                                             paediatrician, physician or
                                                                             neurologist                                                                                                     R1 000 co-payment if no referral is
                                              Occupational and speech        PMBs only
                                                                             Benefit first accrues to the OOH
Allied health services and              No benefit                                                    Appliances (medical and          Medical           Annual limit of

                                  alternative healthcare                                                                                surgical)                        assistive         R2 406 per family
                                  providers                                                                                             (continued)                      devices           and includes
                                  Includes biokineticists,                                                                                                                                 medical devices in/
                                  chiropractors, dieticians,                                                                                                                               out of hospital
                                  homeopaths, chiropodists,
                                  podiatrists, reflexologists,                                                                          Dentistry (specialised)          No benefit except for PMBs
                                  naturopaths, orthoptists, osteopaths                                                                  Pre-authorisation required
                                                                                                                                                                         Only covers specialised dental
                                  and therapeutic massage therapists
                                                                                                                                                                         procedures done in/out of hospital
                                                                                                                                                                         that meet PMB criteria
                                  Benefit is subject to clinically
                                  appropriate services                                                                                  Maternity benefits, including    100% of agreed tariff at DSP, 100%
                                                                                                                                        home birth                       of Polmed rate at non-DSP or at
                                  Appliances (medical and                 100% of Polmed rate and subject to:
                                                                                                                                        Pre-authorisation required and   cost for involuntary PMB access
                                                                          Blood           No limit                                      treatment protocols apply
                                  Pre-authorisation is required for the
                                                                          transfusions                                                                                   The limit for consultations shall not
                                  supply of oxygen
                                                                                                                                                                         accrue towards the OOH limit

                                                                                                                STAND- ALONE BENEFITS

                                                                          Hearing aids    R10 102 per
                                  All costs for maintenance are a                         hearing aid or                                                                 The benefit shall include three
                                  Scheme exclusion                                        R20 076 per                                                                    specialist consultations per
                                                                                          beneficiary per set                                                            beneficiary per pregnancy
                                  Members must be referred for                            every three years
                                  audiology services for hearing aids
                                                                          Nebuliser       R1 145 per family                                                              Home birth is limited to R12 868 per
                                  to be reimbursed
                                                                                          once every four                                                                beneficiary per annum
                                                                                                                                                                         Annual limit of R3 604 for ultrasound
                                                                          Glucometer      R1 145 per family                                                              scans per family; limited to two 2D
                                                                                          once every four                                                                scans per pregnancy
                                                                                                                                                                         Benefits relating to more than two
                                                                          CPAP            R8 183 per family
                                                                                                                                                                         antenatal ultrasound scans and
                                                                          machine         once every four
                                                                                                                                                                         amniocenteses after 32 weeks
                                                                                                                                                                         of pregnancy are subject to pre-
                                                                          Wheelchair      R10 695 per                                                                    authorisation
                                                                          (non-           beneficiary once
                                                                                                                                        Maxillofacial                    No benefit except for PMBs
                                                                          motorised)      every three years
                                                                                                                                        Pre-authorisation required
                                                                          Wheelchair      R30 676 per                                                                    Surgical removal of impacted teeth
                                                                          (motorised)     beneficiary once                                                               is covered subject to overall non-
                                                                                          every three years                                                              PMB limit

                                                                          Insulin         Paid from the
                                                                          delivery        hospital benefit up
                                                                          devices         to the mean price
                                                                          and urine       of three quotations

                                  Chronic medication refers to             No benefit except for PMBs                                      Optical       OR CONTACT LENSES
                                  non-PMB conditions                                                                                       (continued)
                                                                           Subject to the medicine reference                                             Contact lenses to the value of R580
                                  Subject to prior application and/or      price
                                  registration of the condition                                                                                          Contact lens re-examination to
                                                                                                                                                         a maximum cost of R210 per
                                  Approved PMB-CDL conditions are                                                                                        consultation
                                  not subject to a limit
                                                                                                                                                         Non-PPN provider would be:
                                  Designated service providers:
                                  Courier pharmacies: Medipost and                                                                                       One consultation limited to a
                                  Pharmacy Direct                                                                                                        maximum cost of R325

                                  Retail pharmacies: Clicks and                                                                                          AND EITHER SPECTACLES
                                                                                                                                                         R580 towards a frame and/or lens
                                  Optical                                  The benefit per beneficiary (per                                              enhancements

                                                                                                                    STAND-ALONE BENEFITS

                                  Includes frames, lenses and eye          24-month benefit cycle) at a PPN
                                  examinations                             provider would be:                                                            WITH EITHER

                                  The eye examination is per               One composite consultation,                                                   One pair of clear Aquity single-
                                  beneficiary every two years (unless      inclusive of refraction, tonometry                                            vision lenses, limited to R150 per
                                  prior approval for clinical indication   and visual field screening; collection                                        lens, or one pair of clear Aquity
                                  has been obtained)                       of blood pressure, glucose and                                                bifocal lenses, limited to R325,
                                                                           cholesterol readings                                                          or multifocal clear Aquity lenses
                                  Benefits are not pro rata, but                                                                                         covered up to the value of clear
                                  calculated from the benefit service      AND EITHER SPECTACLES                                                         bifocal lens limit
                                                                           A PPN frame to the value of                                                   OR CONTACT LENSES
                                  Each claim for lenses or frames          R150 and R430 towards lens
                                  must be submitted with the lens          enhancements                                                                  Contact lenses to the value of R580
                                                                           OR                                                                            Contact lens re-examination to
                                  Benefits shall not be granted for                                                                                      a maximum cost of R210 per
                                  contact lenses if the beneficiary has    R580 towards the cost of any                                                  consultation
                                  already received a pair of spectacles    alternative frame and/or lens
                                  in a two-year benefit cycle              enhancements

                                  Annual contact lens limit is specified   WITH EITHER

                                  Contact lens re-examination can be       One pair of clear Aquity single-
                                  claimed for in six-monthly intervals     vision or clear Aquity bifocal lenses
                                                                           or clear Aquity multifocal lenses
                                  Preferred Provider Negotiators           covered up to the value of clear
                                  (PPN) is the preferred provider          bifocal lens limit

                                  Preventative care (refer to            100% of Polmed rate or agreed tariff                           Radiology (specialised)               100% of agreed tariff or at cost for

                                                                                                                STAND-ALONE BENEFITS
                                  Annexure E)                            where applicable                                               Pre-authorisation required            PMBs
                                  One wellness measure per year,
                                  including:                             Early detection screening limited to                                                                 Limited to R34 610 per family
                                  • Blood pressure test                  periods specified in Annexure E
                                  • Body mass index test                                                                                                                      Includes any specialised radiology
                                  • Waist-to-hip ratio measurement       Funded from the risk pool; the                                                                       service done in/out of hospital
                                  • Cholesterol screening (Z13.8)        benefit shall not accrue to the OOH
                                  • Glucose screening (Z13.1)            limit                                                                                                Claims for PMBs first accrue towards
                                  • Healthy diet counselling (Z71.3)                                                                                                          the limit
                                  • Risk assessment tests:
                                    – Baby immunisation (as per                                                                                                               Subject to a limit of two scans per
                                       the Department of Health                                                                                                               beneficiary per annum, except for
                                       guidelines)                                                                                                                            PMBs
                                    – Bone densitometry scan
                                    – Circumcision
                                    – Contraceptives (as per

                                       the Department of Health
                                    – Dental screening (codes 8101,
                                       8151 and 8102)
                                    – Flu vaccine
                                    – Glaucoma screening
                                    – HIV tests
                                    – Mammogram
                                    – Pap smear
                                    – Pneumococcal vaccine
                                    – Prostate screening
                                    – Psycho-social services                                                                           ANNEXURE B2
                                  Radiology (basic)                      100% of agreed tariff or at cost for
                                  i.e. black and white X-rays and soft   PMBs
                                  tissue ultrasounds
                                                                         Limited to R4 950 per family           CO-PAYMENTS
                                                                         Includes any basic radiology done       OUT OF NETWORK                                      CO-PAYMENT
                                                                         in/out of hospital
                                                                                                                 General practitioner (GP)                           Allows for two out-of-network consultations
                                                                         Claims for PMBs first accrue towards
                                                                         the limit                                                                                   Co-payment shall apply once maximum out-
                                                                                                                                                                     of-network consultations are exceeded

                                                                                                                 Hospital                                            R8 000

                                                                                                                 Pharmacy                                            20% of costs
Pulmonary diseases

                ANNEXURE B4                                                               Asthma
           AQUARIUM: CHRONIC CONDITIONS                                                   Cystic fibrosis

           Prescribed minimum benefits (PMBs), including chronic                          Psychiatric conditions
           diagnostic treatment pairs (DTPs)                                              Affective disorders (depression and
           Chronic medication is payable from chronic medication benefits. Once           bipolar mood disorder)
           the benefit limit has been reached, it will be funded from the unlimited       Schizophrenic disorders
           PMB pool.
                                                                                          Special category conditions
           Auto-immune disorder                     Gynaecological conditions             HIV/AIDS
           Systemic lupus erythematosis (SLE)       Endometriosis
                                                                                          Organ transplantation
                                                    Menopausal treatment
           Cardiovascular conditions                                                      Treatable cancers
           Cardiac dysrhythmias                     Haematological conditions
                                                                                          As per PMB guidelines
           Coronary artery disease                  Haemophilia
           Cardiomyopathy                           Anaemia
           Heart failure                            Idiopathic thrombocytopenic purpura   Urological
           Hypertension                             Megaloblastic anaemia                 conditions
           Peripheral arterial disease                                                    Chronic renal failure
           Thromboembolic disease                   Metabolic condition                   Benign prostatic
           Valvular disease                                                               hypertrophy
                                                                                          Nephrotic syndrome and
           Endocrine conditions                     Musculoskeletal condition
           Addison’s disease                                                              Renal calculi
                                                    Rheumatic arthritis
           Diabetes mellitus type I
           Diabetes mellitus type II
           Diabetes insipidus                       Neurological conditions
           Hypo- and hyperthyroidism                Epilepsy
           Cushing’s disease                        Multiple sclerosis
           Hyperprolactinaemia                      Parkinson’s disease
           Polycystic ovaries                       Cerebrovascular incident
           Primary hypogonadism                     Permanent spinal cord injuries

           Gastro-intestinal conditions             Ophthalmic condition
           Crohn’s disease                          Glaucoma
           Ulcerative colitis
           Peptic ulcer disease (requires special
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