BENEFIT GUIDE 201520161129085443 AM... · This guide is divided into four sections, as explained in...

BENEFIT GUIDE 2015

Contents Important Contact Details

Client Services Tel: 0860 100 078 Fax: 0861 019 211 Email: [email protected] Web: www.medipos.co.za

Postal addressMEDiPOS Medical Scheme PO Box 97 Cape Town 8000

Hospital Risk Management Programme (for hospital pre-authorisation) Tel: 0860 100 078 Fax: 0861 019 007 Email: [email protected]

Medicine Risk Management (MRM)Programme (for chronic medication) Tel: 0860 100 078 Fax: 0861 019 008 Email: [email protected]

HIV YourLife Programme Tel: 0861 888 300 Fax: 0861 888 301 Email: [email protected]

Oncology Risk Management Programme (for cancer patients) Tel: 0860 100 078 Fax: 0861 222 552 Email: [email protected] SAPO HR Call Centre Tel: 0860 068 068 Fax: 012 401 7381

Council for Medical SchemesPrivate Bag X34Hatfield0028

Tel: 0861 123 267Fax: 012 431 0608Email: [email protected]

Introduction 2

How to make use of this Benefit Guide 4

Match your profile 5

A comparison of the MEDiPOS options 6

What is covered under insured day-to-day benefits? 8 OptionA:Day-to-DayBenefits 8 OptionB:Day-to-DayBenefits 10 OptionC:Day-to-DayBenefits 12

Services and procedures covered under the Major Medical Expenses benefits 14

Contributions table: How much will it cost? 30

Questions to answer before making a choice 31

Option selection process 31

Annexures

Annexure A: PMB Chronic Disease List and Extended Chronic Disease List 32 Annexure B: Procedures performed in doctors’ rooms 33 Annexure C: Essential radiology 35 Annexure D: Essential pathology 37 Annexure E: Dentalbenefittable/AdditionalSchemeexclusions 40

Introduction

Welcome to MEDiPOS Medical Scheme, the closed medical scheme for South African Post Office (SAPO) employees.

This guide has been developed specificallytohelpyouunderstandthebenefitoptionsavailable to you. It navigates you through the different options and assists you in making the most important decision of choosing an option that best suits your and your family’s needs.

Carefully read through each section and follow the route to your destination – “Choosing your option”.

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MEDiPOSMedicalSchemeoffersdifferentoptionstocaterfordifferenthealthcare needs. We all need medical cover for different reasons, with the same goal of improving our state of health. The following table highlights different scenarios and solutions.

My healthcare needs are higher than average. I need extensive chronic cover, comprehensive everydaybenefitsandhospital cover.

I need comprehensive healthcare cover for myself and my family; some peace of mind.

I am young, healthy and single, and want affordable basic healthcare cover. I hardly use my medical scheme. I just need it in case something happens to me.

No matter how old, healthy or sick you may be, you need medical cover. You neverknowwhenyoumayneeditthemost.Fortunately,MEDiPOSbenefitsaredesignedtoaccommodatedifferentneeds.Thereisdefinitelyanoptionforyou. Now that we know what your needs are, here are some guidelines on what to consider when deciding on the best option.

Substantialin-andout-of-hospital cover and chronic cover.

Doctors’ bills for the kids, specialist visits for you and your spouse and other unforeseen hospital incidents.

For that odd doctor’s visit and unforeseen needs, like being diagnosed with a chronic condition or being involved in a car accident.

Thefollowingoptionbestmatchesyourmedicalprofile.However,itisalsoimportant to carefully read through all of the options as there may be other things to consider.

Option A Option B Option C

This guide is divided into four sections, as explained in the graph below, to help you navigate your way through the information you need to know prior to making your choice. Read through each section carefully.

Section 1 •Matchyourprofile.

For a closer look at what your medical needsare,askwhatthekeybenefitsare that you require and which option complimentsyourprofile.

Section 2 • A quick comparison of theMEDiPOSbenefits.

Foraquicksummaryofbenefitsofferedon each option. This section assists you in making a quick comparison of all three MEDiPOSoptions.

Section 3 •Day-to-daybenefitsandchronicbenefits.

• Major Medical Expenses (MME)benefits.

Now that you have an idea of the most suitable option for you and your family, this section provides a comprehensive list of benefitscoveredunderMME,chronicandday-to-day with sub-limits.

Section 4 • 2015 contributions. • What to consider before

making a choice.

You know exactly which option you want, now all you need to do is check the monthly contributions on your most suitable option. Ifyouarehappywithboththebenefitsandcontributions, you are ready to make your option selection.

A description of the technical terms is included in Annexure B at the end of the Benefit Guide.

How to make use of this Benefit Guide Match your profile

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A comparison of the MEDiPOS options

Option A Option B Option CServicespaidat100%ofcostorMedicalSchemeRate(MSR),whicheveristhelesser.

Unlimited hospital cover, extensive chronic cover and comprehensive day-to-daybenefits.

Comprehensivehospitalcover,significantchronic cover and generous day-to-day cover.

Average hospital cover, reasonable chroniccoverandsufficientday-to-daybenefits.

How much hospital cover do you need? How much hospital cover do you need?Major Medical Expenses (MME) benefits All hospital admissions must be pre-authorisedbytheScheme.

Unlimited MME cover subject to certain sub-limits.

R2 130 000 MME cover subject to certain sub-limits.

R852 000 MME cover subject to certain sub-limits.

Do you need cover for a chronic condition? Do you need cover for a chronic condition? Chronic medication benefits Benefitsaresubjecttoapplicationandapproval. Medication will be subject to genericand/ortherapeuticreferencepricing. If a member chooses to purchaseamedicinenotintheScheme’sformulary, the member will be required to pay the difference between the cost of the medication as a co-payment at point of service.

100%ofmedicineprice. 100%ofmedicineprice.

Non-PrescribedMinimumBenefit(PMB)chronic medication

Limited to R9 500 per family per annum. Limited to R6 400 per family per annum. Limited to R3 100 per family per annum.

PMB chronic medication Unlimited. SubjecttotheR6400non-PMBchronicmedication limit. Once this limit is exceeded, you will continue to have unlimited cover for PMB conditions.

SubjecttotheR3100non-PMBchronicmedication limit. Once this limit is exceeded, you will continue to have unlimited cover for PMB conditions.

What kind of day-to-day cover do you need? What kind of day-to-day cover do you need?Day-to-day benefits (Out-of-hospital services)

Overall Annual Limit Overall Annual LimitR6 660 per member. R6 660 per adult dependant. R1 280 per child dependant. (Subjecttosub-limitsonpage8).

R3 800 per member.R3 800 per adult dependant. R740 per child dependant. (Subjecttosub-limitsonpage10).

R2 270 per member. R2 270 per adult dependant. R600 per child dependant. (Subjecttosub-limitsonpage12).

Optical Benefits Optical BenefitsSubjecttoR3570perbeneficiaryeverytwo years, including a frame sub-limit of R1 980.

SubjecttoR2550perbeneficiaryeverytwo years, including a frame sub-limit of R1 420.

SubjecttoR1020perbeneficiaryeverytwo years, including a frame sub-limit of R510.

Dentistry Benefits Dentistry BenefitsBasic dentistry R7 650 per family per annum.

Advanced dentistry and dental implants R14 280 per family per annum.

Basic dentistryR6 120 per family per annum.

Advanced dentistry and dental implants R9 180 per family per annum.

Basic dentistryR2 040 per family per annum.

Advanced dentistry Subjecttotheoverallannualday-to-daylimit.Dentalimplants:Nobenefit.

For conditions covered under certain benefits, please refer to: • Annexure A on page 32 for chronic

diseases lists. • Annexure B and C on page 33 and

page 35 for benefits under primary care benefits.

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Service Benefit LimitDENTISTRY BENEFITS

Basic dentistryIncludes routine prophylaxis (prevention and treatment) scaling and polishing (cleaning),fluorideapplication,fillings,non-surgical tooth extraction and root canal treatment.

100%ofcostorMSR,whicheveristhelesser.SubjecttoamaximumlimitofR7 650 per family per annum.


Advanced dentistry and dental implantsIncludesdentures,inlays/onlays,surgicalperiodontal management, crowns and bridges as well as orthodontic treatment and dental implants.

AlldentistrybenefitsaresubjecttotheScheme`smanagedcareprotocolsandbenefits.Allspecialised/advanceddentistry procedures including orthodontic services and dental implants are subject to prior approval. In-hospital dentistry is subject to prior approval and pre-authorisation. Refer to Annexure E for detailsofdentalbenefitsandexclusionsapplicable.

PRIMARY CARE BENEFIT (PCB) (Out of hospital): Subject to MME Annual Limit

Maximum annual limit Limited to R2 500 per family per annum. Allbenefitspayableat100%ofcostorMSR,whicheveristhelesser.

Radiology Limited to R1 590 per family per annum. SubjecttoPCB.

Pathology Limited to R1 590 per family per annum. SubjecttoPCB.

Please note: SpecialistvisitsaresubjecttoreferralbyaGP.

What is covered under insured day-to-day benefits?

Option A: Day-to-Day Benefits Thefollowingtablereflectstheoverallday-to-daybenefitswithsub-limitsonOptionA.

Service Benefit LimitOVERALL DAY-TO-DAY LIMITS

Thisbenefitlimitdependsonthe family size. All sub-limits are subject to the overall day-to-day annual limit.

Maximum annual limits: R6 660 per member. R6 660 per adult dependant. R1 280 per child dependant.

General practitioner (GP) Visits, consultations and out-patient visits

Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallday-to-dayannuallimit.

Specialist Visits, consultations and out-patient visits

Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallday-to-dayannuallimit.ServicessubjecttoreferralbyGP.

Acute medication Prescribed acute, pharmacy-advisedtherapyandfluvaccine

Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallannualday-to-daylimit. Flu vaccine limited to one vaccine per beneficiaryperannum(pbpa).

Auxiliary services Orthotic consultation, occupational therapy, dietician, audiometry, biokinetics, chiropody, chiropractors, orthoptist, speech therapy, remedial therapy, homeopaths and naturopaths

Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttothefollowinglimits:R1 460 per member. R1 460 per adult dependant.R860 per child dependant.Subjecttotheoverallday-to-dayannuallimit.(Service must be obtained by an approved and registered paramedical and auxiliary service provider).

Physiotherapy (Out of hospital)

Limited to R2 320 per family per annum. Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallday-to-dayannuallimit.

Psychology (Out of hospital)

Limited to R4 370 per family per annum. Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallday-to-dayannuallimit.

OPTICAL BENEFITSOverall optical benefits every two yearsIncludes frames, all prescription lenses/add-ons,clearsinglevision,clearaquity,flat-topbifocal, clear aquity multifocal, contact lenses and eye tests.

SubjecttoR3570perbeneficiaryeverytwoyears, including a frame sub-limit of R1 980.

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Option B: Day-to-Day Benefits Thefollowingtablereflectstheoverallday-to-daybenefitswithsub-limitsonOptionB.


Thisbenefitlimitdependsonthefamily size. All sub-limits are subject to the overall day-to-day annual limit.

Maximum annual limits: R3 800 per member. R3 800 per adult dependant. R740 per child dependant.

GP Visits, consultations and out-patient visits

Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallday-to-dayannual limit.

Specialist Visits, consultations and out-patient visits

Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallday-to-dayannuallimit.ServicessubjecttoreferralbyGP.

Acute medication Prescribed acute, pharmacy-advised therapyandfluvaccine

Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallday-to-day annual limit. Flu vaccine limited to one vaccine pbpa.

Auxiliary services Orthotic consultation, occupational therapy, dietician, audiometry, biokinetics, chiropody, chiropractors, orthoptist, speech therapy, remedial therapy, homeopaths and naturopaths

Paidat100%ofcostorMSR,whicheveristhe lesser. Limited to the following limits: R1 280 per member. R1 280 per adult dependant.R630 per child dependant. Subjecttotheoverallday-to-dayannuallimit. (Service must be obtained by an approved and registered paramedical and auxiliary service provider.)

Physiotherapy (Out of hospital)

Limited to R1 920 per family per annum. Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallday-to-dayannual limit.

Psychology (Out of hospital)

Limited to R3 210 per family per annum. Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallday-to-dayannual limit.

OPTICAL BENEFITSOverall optical benefits every two yearsIncludes frames, all prescription lenses/add-ons,clearsinglevision,clearaquity,flat-topbifocal,clearaquity multifocal, contact lenses and eye tests.

SubjecttoR2550perbeneficiaryeverytwoyears, including a frame sub-limit of R1 420.

Service Benefit LimitDENTISTRY BENEFITS

Basic dentistryIncludes routine prophylaxis (prevention and treatment) scaling andpolishing(cleaning),fluorideapplication,fillings,non-surgicaltoothextraction and root canal treatment.

100%ofcostorMSR,whicheveristhelesser.SubjecttoamaximumlimitofR6120per family per annum.

100%ofcostorMSR,whicheveristhelesser.SubjecttoamaximumlimitofR9180per family per annum.

Advanced dentistry and dental implantsIncludesdentures,inlays/onlays,surgical periodontal management, crowns and bridges as well as orthodontic treatment and dental implants.

AlldentistrybenefitsaresubjecttotheScheme`smanagedcareprotocolsandbenefits.Allspecialised/advanceddentistryprocedures including orthodontic services and dental implants are subject to prior approval. In-hospital dentistry is subject to prior approval and pre-authorisation. Refer to Annexure E for details of dental benefitsandexclusionsapplicable.


Maximum annual limit Limited to R2 170 per family per annum. Allbenefitspayableat100%ofcostorMSR,whichever is the lesser.

Radiology Limited to R1 260 per family per annum. SubjecttoPCB.

Pathology Limited to R1 260 per family per annum. SubjecttoPCB.


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Option C: Day-to-Day Benefits Thefollowingtablereflectstheoverallday-to-daybenefitswithsub-limitsonOptionC.


Thisbenefitlimitdependsonthefamilysize. All sub-limits are subject to the overall day-to-day annual limit.

Maximum annual limits: R2 270 per member. R2 270 per adult dependant. R600 per child dependant.

Services coveredGP and specialist visits, acute medication (including one vaccine pbpa),specialised/advanceddentistry,physiotherapy, psychology and other auxiliary services

Paidat100%ofcostorMSR,whicheveristhelesser.Subjecttotheoverallday-to-dayannuallimit.Allspecialised/advanced dentistry procedures (including orthodontic services) are subject to prior approval.

OPTICAL BENEFITSOverall optical benefits every two yearsIncludesframes,allprescriptionlenses/add-ons, clear single vision, clear aquity, flat-topbifocal,clearaquitymultifocal,contact lenses and eye tests.

SubjecttoR1020perbeneficiaryeverytwo years, including a frame sub-limit of R510.

DENTISTRY BENEFITSBasic dentistryIncludes routine prophylaxis (prevention and treatment) scaling andpolishing(cleaning),fluorideapplication,fillings,non-surgicaltoothextraction and root canal treatment.

AlldentistrybenefitsaresubjecttotheScheme`smanagedcareprotocolsandbenefits.In-hospitaldentistryissubjectto prior approval and pre-authorisation. Refer to Annexure E for details of dentistrybenefitsandexclusionsapplicable.



Maximum annual limit Limited to R1 360 per family per annum. Allbenefitspayableat100%ofcostorMSR,whicheveristhelesser.

Radiology Limited to R680 per family per annum. SubjecttoPCB.

Pathology Limited to R680 per family per annum. SubjecttoPCB.


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Services and procedures covered under the Major Medical Expenses (MME) benefits ThefollowingtableisasummaryofyourMMEbenefits.Thesebenefitsareeffectivefrom 1 January 2015.

Option A Option B Option CMME benefits annual limit

Unlimited R2 130 000 R852 000

All sub-limits are subject to the MME benefits annual limitHospitalisation (Subjecttopre-authorisation) Ward and theatre fees, recovery rooms and confinements

100%ofcostorMSR,whicheveristhelesser.Privatewardaccommodation will be at general ward rate unless approved bytheScheme.

Specialised intensive care (Subject to pre-authorisation every 24 hours)

100%ofcostorMSR,whicheveristhelesser.

Medication in hospital

100%ofmedicineprice.

Medication dispensed on discharge from hospital (To-take-out (TTO) medication - limited to seven days supply of medication)

100%ofmedicineprice.

Materials used in hospital

100%ofcost.

Option A Option B Option CProcedures in doctors’ rooms (Out of hospital) Refer to Annexure B for a list of procedures

100%ofcostorMSR,whicheveristhelesser.Subjecttothelist of procedures and approval.

Chronic medication26 listed on the PMB and non-PMB ailment list and medicationbenefitlimit

Benefitsaresubjectto prior application and approval.Medication will be subject to generic and/ortherapeuticreference pricing. If a member chooses to purchase a medicine not in theScheme’sformulary, the member will be required to pay the difference between the cost of the medication as a co-payment at point of service.

Limited to a chronic medication limit of R9 500 per family per annum for specifiednon-PMBchronic conditions.

Limited to a chronic medication limit of R6 400 per family per annum for PMBandspecifiednon-PMB chronic conditions.

Limited to a chronic medication limit of R3 100 per family per annum for PMBandspecifiednon-PMB chronic conditions.

PMB unlimited. Unlimited PMB once chronic medication limit exhausted.

Unlimited PMB once chronic medication limit exhausted.

Psychiatric institutions Subjecttopre-authorisation and approval by the Scheme

100%ofcostlimitedtoR53000perfamilyperannumforallrelated costs and subject to PMB legislation requirements.Costs include psychiatrist, GP, anaesthetist, psychologist, occupational therapist, social worker, dietician, physiotherapist, pathology, radiology, medication and accommodation.

Services and procedures covered under the Major Medical Expenses (MME) benefits (continued)

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Option A Option B Option CSubstance and alcohol abuse Subjecttopre-authorisation and approval by the Scheme

100%ofcostlimitedtoR30500perfamilyperannumforallrelated costs and subject to PMB legislation requirements.

Rehabilitation centres Subjecttopre-authorisation and approval by the Scheme

100%ofcostlimitedtooverallannuallimitandinlieuofhospitalisation. NOTE: This benefit covers beneficiaries who had become temporarily disabled as a result of acute injuries caused by trauma, infection, spinal cord injury, brain injury or bleeding or infarction resulting in stroke. Available only immediately following such an event. Progressive conditions such as multiple sclerosis and Parkinson’s disease are not included. Pre-authorisation is required and a medical report must be submitted by the attending physician.

Medical specialists and GPs Surgeryandin-hospital procedures, hospital visits, anaesthetics, perfusionist services, clinical technology


Radiology and pathologyRadiology and pathology whilst hospitalised (excluding MRI, CAT, radio-isotope scans and ultrasound scans)

100%ofcostorMSR,whicheveristhelesser.Subjecttopre-authorisationandapprovalbytheScheme.

Advanced radiology (In and out of hospital)MRI, CAT, radio-isotope and ultrasound scans

Limited to R22 500 per family per annum. Paid at100%ofcostorMSR,whicheveristhe lesser.



Option A Option B Option CCircumcision (Out of hospital)

Limited to a global fee of R1 460 per beneficiaryperannum. Paid at 100%ofcostorMSR,whicheveristhe lesser.



Maternity 100%ofcostorMSR,whicheveristhelesser.Antenatal classes Limited to R1 230

per pregnancy.Limited to R1 120 per pregnancy.

Nobenefit.

Antenatal consultations

Limited to R2 980 per pregnancy.

Limited to R2 230 per pregnancy.

PMBsonly.Subjectto pre-authorisation and approval bytheScheme.Beneficiaryenrolment on the Maternity Programme is encouraged.

Ultrasound scans for pregnancy

Limited to four 2D scans per pregnancy.

Limited to two 2D scans per pregnancy.

Confinement in a registered birthing unit and confinement out of hospital

100%ofthenegotiatedfeeorMSR.Limited to and included in maternity benefits:fourpost-natalmidwifeconsultations per event.

PMBonly.Subjectto pre-authorisation and approval bytheScheme.Beneficiaryenrolment on the Maternity Programme is encouraged.

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Option A Option B Option COncology (Cancer) Patients are encouraged to enrol on the Oncology BenefitManagementProgramme.

Benefitissubjecttothe submission of a 12-month treatment plan by the treating oncologist and the approval of the treatment plan prior to the commencement of treatment

On registration on the programme, benefitsinrespectof cancer-related medication, radiotherapy, chemotherapy, oncologist, pathology, mammogram, X-ray, MRI, CT and radio-isotope scans will be paid from the oncology limit

100%ofMSRifserviceisobtainedfromaDesignatedServiceProvider(DSP).75%ofMSRforanon-DSP.ICON-IndependentClinicalOncologyNetworkistheDSPforall oncology services. Limited to R350 000 per beneficiaryperannum, for PMBs and non-PMBs. Thereafter unlimited for PMBs.

Limited to R210 000 per beneficiaryperannum, for PMBs and non-PMBs. Thereafter unlimited for PMBs.

SubjecttoPMBsonly.

NOTE: Approved medication for the diagnosed condition must be registered with the Medicines Control Council. This will be paid at 100% of medicine price.

Dental implants(Including surgeon`s fees) Subjecttopre-authorisation and approval by the Scheme

100%ofcostorMSRwhicheveristhe lesser, subject to the dentistry benefit.

100%ofcostorMSRwhicheveristhe lesser, subject to the dentistry benefit.

Nobenefit.

Option A Option B Option CMaxillo-facial and oral surgery Subjecttopre-authorisation and approval by the Scheme

100%ofcostorMSRwhicheveristhelesser,subjecttoamaximum limit of R13 400 per family per annum.

Internal prosthesis/device Subjecttoapplication and approval (including all accompanying temporary or permanent devices)

100%ofcostorMSR,whicheveristhe lesser subject to a maximum of R62 100 per family per annum and subject to the following sub-limits:

100%ofcostorMSR,whicheveristhe lesser subject to a maximum of R50 800 per family per annum and subject to the following sub-limits:

100%ofcostorMSR,whicheveristhe lesser subject to a maximum of R21 300 per family per annum.

Cardiac stents SubjecttoalimitofR21 300 per stent per annum. Limited to three stents per beneficiaryperannum. Included in the above sub-limit the following limits apply:Drug eluting:R15 800Bare metal: R8 900

SubjecttoalimitofR20 300 per stent per annum. Limited to three stents per beneficiaryperannum. Included in the above sub-limit the following limits apply:Drug eluting: R12 400Bare metal: R6 700

Aorta stent graft SubjecttoalimitofR46 100 per beneficiaryperannum.

SubjecttoalimitofR39 100 per beneficiaryperannum.

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Option A Option B Option CPeripheral arterial stent graft



Cardiac pacemakers



Cardiac valves SubjecttoalimitofR32 400 per valve per annum. Limited to two valves per beneficiaryperannum.

SubjecttoalimitofR28 800 per valve per annum. Limited to two valves per beneficiaryperannum.

Total hip replacement

SubjecttoalimitofR51 800 per beneficiaryperannum, which includes the cost of cement and antibiotics.

Subjecttoalimitof R38 000 per beneficiaryperannum, which includes the cost of cement and antibiotics.

Total knee replacement

SubjecttoalimitofR47 500 per knee perbeneficiaryper annum, which includes the cost of cement and antibiotics.

SubjecttoalimitofR38 300 per knee perbeneficiaryper annum, which includes the cost of cement and antibiotics.

Total shoulder replacement

SubjecttoalimitofR44 500 per shoulder per beneficiaryperannum, which includes the cost of cement and antibiotics.

Subjecttoalimitof R36 700 per shoulder per beneficiaryperannum, which includes the cost of cement and antibiotics.

Elbow replacement Subjecttolimitof R44 500 per beneficiaryperannum.

Subjecttolimitof R31 500 per beneficiaryperannum.

Option A Option B Option CTemperoman-dibular (TM) joint replacement



Ankle replacement Subjecttolimitof R44 500 per beneficiaryperannum.


Finger replacement Subjecttolimitof R29 300 per beneficiaryperannum.


Toe (total or partial) replacement



Bryan`s and other intervertebral disc prosthesis



Mesh grafts Subjecttolimitof R25 900 per beneficiaryperannum.


Intra-stromal corneal ring segments



Spinal instrumentation

Subjecttoalimitof R44 500 per beneficiaryperannum.


Other approved spinal implantable devices and intervertebral discs


SubjecttoalimitofR36 100 per family per annum.

Bone lengthening devices



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Option A Option B Option CNeuro-stimulation (ablation devices for Parkinson’s)



Vagal stimulator for intractable epilepsy



Detachable platinum coils



Embolic protection devices



Intraocular lens Subjecttoalimitof R3 900 per lens perbeneficiaryperannum.

Subjecttoalimitof R3 100 per lens perbeneficiaryperannum.

Carotid stent Subjecttoalimitof R17 100 per beneficiaryperannum.


Any other internal prosthesis



General prosthesis/devices benefit

100%ofcostorMSR,whicheveris the lesser. Limited to the internalprosthesis/devicesbenefitand a sub-limit of R16 900 per beneficiaryperannum subject to the following sub-limits:

100%ofcostorMSR,whicheveris the lesser. Limited to the internalprosthesis/devicesbenefitand a sub-limit of R8 900 per beneficiaryperannum subject to the following sub-limits:

Option A Option B Option C

General prosthesis/devices benefit

Middle ear bone implants:R16 900 R8 900

Vocal cord prosthesis: R16 900 R8 900

Macroplasty injection – urethra: R16 900 R8 900

Penile prosthesis:R16 900 R8 900

Vascular/arterialgraftsandpatches:R16 900 R8 900

Atrium- and ventricular septum patches: R16 900 R8 900Mammary/breastimplants:

R6 400 R3 200TVT sling device:

R3 100 R1 500Proctor Livingstone and Celestin tubes:

R6 300 R3 300Renal artery stent:

R11 300 R4 500Oesophagus stent:

R11 300 R5 600Ureter stent:

R11 300 R5 600Urethra stent:

R11 300 R5 600Ductus choledochus stent:

R11 300 R5 600Other blood vessels stent:

R11 300 R5 600Permanent supra-pubic catheters:

R4 500 R2 200Testis prosthesis:

R11 300 R5 600Gold weight implants upper eyelid:

R11 300 R6 700Anal and other sphincter stimulating device:

R11 300 R5 600

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Option A Option B Option CExternal medical appliances, aids and supporting devices Subjecttoapproval

Limited to R7 200 per family per annum. Paid at 100%ofcostorMSR,whicheveris the lesser, as approved by the Scheme.



Hearing aids (Every two years)

Limited to R17 000 perbeneficiaryevery two years. Paidat100%ofcostorMSR,whichever is the lesser, as approved by the Scheme.



Cochlear implants Subjecttopre-authorisation and approval by the Scheme

Limited to R275 100 per family per annum with the following applicable sub-limits:



Pre-op evaluation and associated costs:R11 200

Intra-operative audiology testing:R670

Post-op rehabilitation:R24 800

Upgradeofsoundprocessor(80%ofcost):R50 800

Repairs outside warranty: Subjecttocochlearimplantbenefit.

Batteries and spares:Subjecttoexternalmedicalappliancesbenefit.

Option A Option B Option CArtificial limbs and artificial eyes Subjecttopre-authorisation and approval by the Scheme

100%ofcostorMSR,whicheveristhe lesser.



Artificial limbs Limited to R57 200 perartificiallegorarm per family per annum.

Limited to R44 500 perartificiallegorarm per family per annum.

Limited to R23 000 perartificiallegorarm per family per annum.

Artificial eyes Limited to R19 000 per artificialeyeperfamily per annum.

Limited to R19 000 per artificialeyeperfamily per annum.

Limited to R15 900 per artificialeyeperfamily per annum.

Radial keratotomy/ excimer laser (Including Holmium procedures,LASIK,Phakic lenses and intrastromal rings) SubjecttoapprovalbytheScheme

Limited to R8 800 per family per annum. Paid at 100%ofcostorMSR,whicheveristhe lesser.

Limited to R5 400 per family per annum. Paid at 100%ofcostorMSR,whicheveristhe lesser.

Nobenefit.

Home oxygen Subjecttopre-authorisation and approval by the Scheme,anduse of preferred provider

Limited to R13 700 per beneficiaryperannum. Paid at 100%ofcostorMSR,whicheveristhe lesser.

LimitedtoR12600perbeneficiaryperannum.Paidat100%ofcostorMSR,whichever is the lesser.

Hyperbaric oxygen Subjecttopre-authorisation and approval by the Scheme

Limited to R42 100 per registered patient per annum. Paid at 100%ofcostorMSR,whicheveristhelesser.

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Option A Option B Option CKidney dialysis (Includes the cost of all related approved medication, provided that authorisation has been obtained via the Medicine Risk Management Programme) Subjecttopre-authorisation

100%ofcostorMSR,whicheveristhe lesser limited to R350 300 per family per annum.

100%ofcostorMSR,whicheveristhe lesser limited to R280 200 per family per annum.

PMB only. Medication paid at 100%ofmedicineprice.

Medication is subject to kidney dialysis limit,paidat100%ofmedicineprice.

Organ transplants Subjecttopre-authorisation and approval by the Scheme.Includesthe cost of all related approved anti-rejection medication, provided authorisation has been obtained via the Medicine Risk Management Programme

Limited to R318 500 per family per annum. Paid at100%ofcostofmedicine price.

Limited to R267 600 per family per annum. Paidat100%ofmedicine price.

PMBs only.

NOTE: Services rendered to donor, costs related to searching for a donor and transportation of organ are included in this benefit, provided the recipient is a beneficiary of the Scheme.

Hospice nursing, private nursing and healthcare institute At accredited facilities only, subject to treatment offered by a registered nurse

Limited to R28 200. Paid at 100%ofcost,orMSR,whicheveristhe lesser.



NOTE: This benefit covers the acute phase after or instead of hospitalisation. Not for long term or chronic care. Subject to pre-authorisation and approval by the Scheme.

Option A Option B Option CHIV/AIDSPatient enrolment ontheHIV/AIDSmanagement programme is encouraged

HIV resistance test is subject to pre-authorisation and approval

R25900perregisteredbeneficiaryperannum.Paidat100%ofcostorMSR,whicheveristhelesser.Medicationpaidat100%ofmedicine price.

NOTE: This includes medication, doctors’ consultation and the blood tests required for the treatment of the condition, as well as the cost of prophylaxis (action taken) for preventative treatment.

Ambulance services

Limited to R6 300 per family per annum.



Other services Blood transfusions

Medical auxiliaries (In-hospital psychology, orthotic consultation, occupational therapy, dietician, physiotherapy, social worker and speech therapy)



Please note• Allservicesarepaidat100%ofcostorMSR,whicheveristhelesser,unless

indicated otherwise. • PMBservicesaresubjecttotheuseofaDSPandprotocols.• IndependentClinicalOncologyNetwork(ICON)istheDSPforalloncologybenefits.

What else do I need to know about my cover? In addition to the services and procedurescoveredbyMMEbenefitsandcoverforday-to-daybenefits,youwill also receive assistance, support and education on the following programmes:

• PrescribedMinimumBenefits(PMBs)• OncologyBenefitsManagement• ChronicBenefits• HIV/AIDS

Please refer to your Member Guide for more details on these programmes.

30 31

Didyoucarefullyreadthroughthebenefitsofferedoneachoption?

Are you comfortable that the option that you are about to choose is the mostsuitableforyourmedicalneeds?

Are you comfortable with the monthly contributions you will be required to payforthisoption?

Are you expecting an additional dependant during the course of the benefityear?

Ifyouareonchronicmedication,isthebenefitamountadequateforyourneeds?

Help is at hand

When you have carefully read through the brochure and you still need clarity on some ofthebenefits,pleasecontacttheSchemeon0860 100 078 for queries relating to the benefitsandcontributions.

Are you ready to make your choice?

Please follow the option selection process below:

New Member Existing Member

If you are a new member, you will need to indicate your option choice on the application form for membership.

Existing members are given the opportunity to changetheiroptionannually.ABenefitOptionSelectionFormwillbeprovided,whichmemberswill need to complete and return before the communicated deadline.

Contributions table: How much will it cost?

Before you make your choice, please answer the following questions:

Youhavecarefullyreadthroughthebenefitsofferedoneachoptionandyouhavealreadyidentifiedanoptionthatmatchesyourneeds.Thetablesbelowindicatethemonthly contributions on each option.

2015 Contributions tableYourtotalmonthlycontributiontotheSchemeisbasedontheoptionyouhavechosen, the number and type of dependants registered on your membership and your income.

Option A Monthly income Principal member Adult dependant Child dependant All income levels R4 089 R4 008 R978 Option B Monthly income Principal member Adult dependant Child dependant R0 – R6 800 R1 650 R1 605 R489 R6 801 – R9 200 R1 713 R1 674 R510 R9 201 – R11 400 R1 770 R1 743 R534 R11 401+ R1 815 R1 788 R549 Option C Monthly income Principal member Adult dependant Child dependant R0 – R6 800 R864 R747 R231R6 801 – R9 200 R951 R837 R282R9 201 – R11 400 R1 011 R891 R303R11 401+ R1 041 R912 R309

Please note • Adultdependantsincludespouse/partner,registeredchild/childrenovertheage

of 21 (except children who are younger than 25 years of age and who are full-time students at a recognised tertiary institution), parents and siblings.

• Your portion of the contribution will depend on your subsidy. • If you are unsure of your subsidy, please check with your Human Resources

Department.

32 33

Annexure A PMB Chronic Disease List and Extended Chronic Disease List

PMB Chronic Disease List Extended Chronic Disease List

This is a list of all the PMB diseases covered by the Schemeintermsoflegislationgoverning all medical schemes.

In addition to all the diseases on the PMB list, all members will also be covered for the following diseases.

• Addison’s disease • Asthma • Bipolar mood disorder • Bronchiectasis • Cardiac failure • Cardiomyopathy disease • Chronic renal disease • Chronic obstructive

pulmonary disease (emphysema)

• Coronary artery disease (angina pectoris and ischaemic heart disease)

• Crohn’s disease • Diabetes insipidus • Diabetes mellitus type I & II • Dysrythmias • Epilepsy • Glaucoma • Haemophilia • HIV/AIDS• Hyperlipidaemia • Hypertension (high blood

pressure) • Hypothyroidism • Multiple sclerosis • Parkinson’s disease • Rheumatoid arthritis • Schizophrenia• Systemiclupuserythromatosis• Ulcerative colitis

• Acne • Allergic rhinitis • Alzheimer’s disease • Ankylosing

spondylitis • Anti-migraine • Attentiondeficit

syndrome • Benign prostatic

hypertrophy (BPH) • Chronic anaemia • Chronic urinary tract

infection • Cysticfibrosis• Deep vein

thromboses • Depression/mood

disorder • Dermatitis • Dermatomyocitis • Dry eye syndrome • Dystonia • Eating disorders • Endocarditis • Enuresis/incontinence• Erythromatosis • Gastro-oesophageal

refluxdisorder(GORD)

• Generalised anxiety disorder

• Gout/hyperuricaemia• Hypoparathyroidism• Hypotension • Meniere’s disease

(anti-vertigo) • Menopause (hormone

replacement therapy)• Motor neuron disease • Myasthenia gravis • Myelodysplastic

anaemia • Osteoarthritis • Osteoporosis • Paget’s disease • Panic attacks • Para/quadriplegia• Pemphigus • Peptic ulcer • Peripheral vascular

disease • Pituitary adenomas • Post-bowel surgery • Post-stroke treatment• Psoriasis • Scleroderma• Sjogren’ssyndrome• Thrombocytopaenia • Tourette’s syndrome • Zollinger-Ellison

syndrome

Annexure B Procedures performed in doctors’ rooms

Tariff code Description Further description

0201 Cost of material Cost of materials used in hospital. 0202 Settingofsteriletray0300 Sutureoflaceration Stitchingofanopenwound.0301 Sutureaddlaceration Further stitches to above. 0307 Excision and repair Removal of a foreign object from the

body (e.g. a piece of glass).1192 PEF 1232 EGG without effort normal conditions Measurement of heart rate under

normal conditions.1233 EGG with effort exercising Measurement of heart rate when

exercising.1234 EGG with bike ergometer Measurement of heart rate while

cycling. 0311 Excision of large benign tumour Removal of tumour from the body.0314 Repair by large skin graft Usually for burn victims. 0315 Repair by small skin graft Usually for burn victims.1545 Oesophogoscopy with rigid

instrumentExamination of oesophagus (gullet) using a scope.

1547 Oesophageal acid perfusion test Measurement of the level of acidity within the oesophagus.

1549 Oesophagoscopy and dilation of stricture

As per tariff 1545, but with dilation of stricture for further analysis.

1550 Oesophagoscopy and removal of foreign body

As per tariff 1545, but includes removal of foreign body.

1557 Oesophageal dilation Dilation of oesophagus. 1587 Uppergastro-intestinalfibreoptic

endoscopyExamination of the stomach using a fibreopticdevice.

1588 Endoscopy plus polypectomy As per tariff 1587, with removal of bodies (polyps) from the stomach.

1591 Upper gastro-intestinal endoscopy and removal of foreign body

As per tariff 1587, but only examination of the upper stomach and oesophagus area.

1642 Gastro tract imaging, intraluminal, hire fee

Imaging of the intestines and other gastric areas.

34 35

Annexure B Procedures performed in doctors’ rooms (continued)

Annexure C Essential radiology

Service Treatment tariff code Description

Skull X-ray of skull 10100 X-ray facial bones 11100 X-ray nasal bones 11120 X-ray mandible 14100

Skeleton (limbs) Hand left 65100 Hand right 65105 Finger 65120 Wrist left 65130 Wrist right 65135 Scaphoidleft 65140 X-ray of the small bones in the wrist.Scaphoidright 65145 Forearm (radius & ulna) left 64100 Forearm (radius & ulna) right 64105 Elbow left 63100 Elbow right 63105 Humerus left 62100 X-ray of the upper arm. Humerus right 62105 Shoulderleft 61130 Shoulderright 61135 Acromio-clavicular joint left 61120 X-ray of the joint that joins the collar

bone and the bone at the root of the shoulder.

Acromio-clavicular joint right 61125 Clavicle left 61100 X-ray of the collar bone. Clavicle right 61105 Scapulaleft 61110 X-ray of the shoulder blade. Scapularight 61115 Foot left 74120 Foot right 74125

Tariff code Description Further description

1643 Gastrointestinal tract imaging, intraluminal, doctors report

As per tariff 1642, with doctor’s report on any abnormalities.

1653 Colonoscopy with own equipment Imaging of the colon to check for abnormalities.

1654 Colonoscopy and removal of polyps As per tariff 1653, with removal of bodies (polyps) from the stomach.

1656 Left-sidedfibreopticcolonoscopy Colonoscopy of the left part of the colon. 1676 Fibre optic sigmoidoscopy Examination of the lower large bowel.1677 Sigmoidoscopy:firstandsubsequent As per tariff 1676, but limited to a

certain part of the bowel.1678 Plus polypectomy, add to 1676 As per tariff 1676, with removal of any

foreign bodies (e.g. polyps from the bowel).

1678 Fibre optic sigmoidoscopy and polypectomy

As per tariff 1676, but not with use of fibreopticequipment.

1679 Sigmoidoscopyandremovalofpolyps As per tariff 1676.1681 Protoscopy:firsttime Examination of the colon with rigid

instrument; sigmoid is not examined.1683 Protoscopy: subsequent times As per tariff 1681, performed more

than once. 1949 Cytoscopy Examination of the bladder with a scope. 1961 Removal of foreign body from urethra2137 Circumcision: surgical excision2207 Vasectomy 2435 Hysterosalpingogram Test for infertility in women by X-ray of

the uterus and fallopian tube.2436 Hysteroscopy Examination of the uterus. 2437 Hysteroscopy and D&C Examination and cleaning of the

uterus (e.g. after an abortion).2438 Hysteroscopy and removal of septum As per tariff 2436, with removal of any

infection. 2440 Hysteroscopy and Divis-Endmet Bands Gynaecological procedure.2441 Hysteroscopy and myomectomy Surgicalremovalofabnormalgrowths

in the uterus.3039 Prophylaxis and treatment Prevention and treatment.

36 37


Ankle left 74100 Ankle right 74105 Calcaneus left 74130 X-ray of the heel bone. Calcaneus right 74135

Lower leg left 73100 Lower leg right 73105 Kneeleft 72100 Kneeright 72105 Patella left 72140 X-ray of the kneecap.Patella right 72145 Femur left 71100 X-ray of the thigh bone. Femur right 71105 Toe 74145 Hip left 56100 Hip right 56110

Spinal column Lumbar spine - one or two views 53110 Thoracic spine - one or two views 52100 Cervical spine - one or two views 51110 Chest Chest - single view 30100 Chest PA and lateral - two views 30110 X-ray of ribs 30150 Abdomen Abdomen X-ray 40100 Describing the position of the patient

during the X-ray: Supine-patientlyingflat.Erect - patient in an upright position.Decubitus-patientlyingonhis/herside.

Abdomen supine, erect or decubitus

40105

General 13300 CT paranasal sinuses - limited study contrast material

00390

Annexure C Essential radiology (continued)

Annexure D Essential pathology


Chemistry (blood) Amilase 4006 ALT(SGPT)(liver) 4131 AST(SGOT) 4130 Amylase 4006 Bilirubin (total and neonatal) 4009 It is used to diagnose or monitor

liver diseases (e.g. cirrhosis, hepatitis, jaundice).

Bilirubin (total and conjugated) 4010 Creatinine 4032 It is used to evaluate kidney

functioning and evaluate treatment effectiveness.

Lipogram 4025 Cholesterol (total only) 4027 Creatine kinase 4132 Used to test for heart attack, severe

muscle breakdown and kidney failure.

Creatinekinase-MB(CK-MB) 4138 CK-MB:CKpresentscreatinekinase while MB represents cardiac muscle.

Lactate dehydrogenise (LD (LDH))

4133 Used to determine the disease or condition causing cellular damage and to identify organs and tissues involved.

Potassium 4113 Sodium 4114 Gammaglutamyl-transferase (GGT)

4134 Used to identify abnormality in the liver.

Urate (uric acid) 4155 Urea 4151 Calcium 4016 Glucose fasting quantitive 4057 Glucose tolerance test 4053 Glycated haemoglobin (HbA1c) 4064 Used to measure how well

diabetes is controlled.

38 39


Phosphate 4109

Endocrinology Endocrinology is the study of the body’s hormone-secreting glands.

Thyroid stimulating hormone (TSH)

4507 Used to evaluate the function of the thyroid gland.

Free thyroxine (FT4) 4482 Free thyroxine (FT4) is a hormone that regulates the metabolism.

Blood pregnancy (BHCG) 4450

Cytology The study of cells.

Pap smear 4566

Haematology The study of blood.

Erythrocyte sedimentation rate (ESR)

3743 Measure of the amount of inflammationinthebody.Alsousedfor infection and cancer.

Haemoglobin (Hb) 3762 Used to measure the severity of anaemia and polycythemia (too many red blood cells).

Platelets 3797 A platelet count is done to determine any abnormalities with a patient’s blood.

White blood cells count (WBC) 3783

Diff. count 3785 Used to diagnose any immune system abnormalities.

International normalised ratio (INR)

3805 Used to evaluate the ability of blood to clot properly; they can be used to assess both bleeding and clotting tendencies.

Blood group (antenatal only) 3764 Rh(antenatal):Thistestidentifieswhether your red blood cells have Rhesus (Rh) factor.

Rh (antenatal only) 3765

Annexure D Essential pathology (continued)


Malaria concentration and staining 3786

Microscopic

Blood smear – malaria 3865

Concentration malaria 3883

Zn stain micro 3881 Zn stain micro is used to test if a patient has TB.

HIV

HIV (Elisa) 3932

CD4 3816

Viral load (quantitive PCR) 4429

Microbiology

Sputum/urineM,C&S 3867/3893/4650/3887

Immunology The study of all aspects of the immune system. The ferritin test is ordered to see how much iron your body has stored for future use.

Ferritin 4528

Serology Serologyisabloodtesttodetectthe presence of antibodies against a microorganism.

C-reactive protein 3947 C-reactiveproteintestidentifieslevels of C-reactive protein in the blood. C-reactive protein is an indicatorofinflammation.

RPR 3951 To screen for syphilis infection.

Paul Bunnell 3956 Test for a particular herpes virus.

Annexure D Essential pathology (continued)

40 41

Annexure E Dental benefit table

DentalbenefitsarepaidattheMEDiPOSdentaltariff(MDT).Hospitalisationandallspecialiseddentistryproceduresmustbepre-authorised.Dentalbenefitsaresubjecttoclinicalprotocolsandmanagedcareinterventionswhichmayrequiretreatmentplansand/orradiographspriortobenefitapplication.Schemeexclusionsapplytodentalbenefits.

Intermsofthefundingofdentalbenefits,thesewillbecoveredattheMDTwhichisequaltothemedicalschemerate(MSR)asdefinedintermsoftheSchemeRules.

Option A Option B Option CBasic dentistry

Consultations Two annual consultations per beneficiary.

Benefitissubjectto clinical protocols.

Covered at the MDT rates and paid from basic dentistry.

Two annual consultations per beneficiary.



Two annual consultations per beneficiary.



X-rays: Intra-oral Benefitissubjectto clinical protocols.






Option A Option B Option CX-rays: Extra-oral One per

beneficiaryinatwo-year period.



Additionalbenefitmay be granted where specialised dental treatment planning/followupis required.

One per beneficiaryinatwo-year period.




One per beneficiaryinatwo-year period.




Oral hygiene Two annual scale and polish treatments per beneficiary.Benefitissubjectto clinical protocols.

Benefitforfissuresealants is limited to individuals younger than 16 years of age.

Two annual scale and polish treatments per beneficiary.Benefitissubjectto clinical protocols.


Two annual scale and polish treatments per beneficiary.Benefitissubjectto clinical protocols.


Annexure E Dental benefit table (continued)

42 43

Option A Option B Option COral hygiene(continued)

Oral hygiene instruction will be covered once annually per beneficiary.

Professionally appliedfluoridewill be covered for a maximum of two per annum.

Scheme exclusions:

• Oral hygiene evaluation

• Dental bleaching




Scheme exclusions:






Scheme exclusions:




Fillings Once per tooth within 12 months. Benefitforre-treatment of a tooth is subject to clinical protocols.


Once per tooth within 12 months. Benefitforre-treatment of a tooth is subject to clinical protocols.


Once per tooth within 12 months. Benefitforre-treatment of a tooth is subject to clinical protocols.


Option A Option B Option CFillings(continued)

Scheme exclusions:

• Resin bonding for restorations that are charged as a separate procedure to the restoration

• The polishing of restorations

• Gold foil restorations

• Ozone therapy

Scheme exclusions:




• Ozone therapy

Scheme exclusions:




• Ozone therapy

Root canal therapy and extractions



Scheme exclusions:

• Direct pulp capping procedures



Scheme exclusions:



Covered at the MDT Rates and paid from basic dentistry.

Scheme exclusions:




44 45

Option A Option B Option CSpecialised/Advanced dentistry

Plastic dentures and associated laboratory costs

Benefitlimitedto once per beneficiaryperjaw(frame) every 24 months.Benefitissubject to clinical protocols. Benefitisavailablefor denture repairs and denture tooth replacements. Covered at the MDT rates and paid from advanced dentistry.Scheme exclusions:• Diagnostic

dentures and associated laboratory costs

• Snoringappliances and associated laboratory costs

• The cost of gold, precious metal, semi-precious metal and platinum foil

• Provisional dentures and associated laboratory costs

• Mouthguards

Benefitlimitedto once per beneficiaryperjaw(frame) every 24 months.Benefitissubject to clinical protocols. Benefitisavailablefor denture repairs and denture tooth replacements. Covered at the MDT rates and paid from advanced dentistry.Scheme exclusions:• Diagnostic





• Mouthguards

Benefitlimitedto once per beneficiaryperjaw(frame) every 24 months.Benefitissubject to clinical protocols. Benefitisavailablefor denture repairs and denture tooth replacements. Covered at the MDT rates and paid from day-to-daybenefit.Scheme exclusions:• Diagnostic





• Mouthguards

Option A Option B Option CPlastic dentures and associated laboratory costs(continued)

Partial metal frame dentures and associated laboratory costs

• Metal inlays in artificialteethor attached to metal dentures frames and plates

Benefitlimitedto once per beneficiaryperjaw(frame) every 24 months.Benefitissubject to clinical protocols.Pre-authorisation required.Covered at the MDT rates and paid from advanced dental benefit.Scheme exclusions:• The metal base

to full dentures and associated laboratory costs

• High impact acrylic


• Gold plating of metal denture plates and frames


Benefitlimitedto once per beneficiaryperjaw(frame) every 24 months.Benefitissubject to clinical protocols.Pre-authorisation required.Covered at the MDT rates and paid from advanced dental benefit.Scheme exclusions:• The metal base






Benefitlimitedto once per beneficiaryperjaw(frame) every 24 months.Benefitissubject to clinical protocols.Pre-authorisation required.Covered at the MDT rates and paid from day-to-daybenefit.Scheme exclusions:• The metal base







46 47

Option A Option B Option CPartial metal frame dentures and associated laboratory costs(continued)




Crown and bridge and associated laboratory costs, including porcelain/ceramic inlays/onlays

Pre-authorisation is required. Limited to once per tooth every 36 months.


Covered at the MDT rates and paid from advanced dental benefit.

Scheme exclusions:• Provisional

crowns and associated laboratory costs as per guidelines

• Emergency crowns that are not placed as temporary crowns during crown preparation and associated laboratory costs









Covered at the MDT rates and paid from day-to-daybenefit.




Option A Option B Option CImplants and associated laboratory costs

Pre-authorisation is required. Limited to one implant per tooth site for lifetime.Benefitissubject to clinical protocols.

Covered at the MDT rates and paid from advanced dentistry and implant dental benefit.

Cost of implant components is limited to R3 500 per implant per five-yearperiodper implant site, inclusive of all components related to the implant and superstructure.

Pre-authorisation is required. Limited to one implant per tooth site for lifetime.Benefitissubject to clinical protocols.

Covered at the MDT rates and paid from advanced dentistry and implant dental benefit.

Cost of implant components is limited to R3 500 per implant per five-yearperiodper implant site, inclusive of all components related to the implant and superstructure.

Nobenefit.

Orthodontics and associated laboratory costs

Pre-authorisation is required for removable appliance therapy, functional appliance therapy, partialfixedappliance therapy (preliminary treatment) and comprehensive fixedappliancetherapy.





48 49

Option A Option B Option COrthodontics and associated laboratory costs(continued)

Benefitissubjecttoclinical protocols.

Authorisedbenefitsare payable from an advanced dentistry and dental implantbenefit.

Pre-authorisation cases will be clinically assessed using orthodontic indices.

Previous orthodontic treatment phases carried out by the same provider to be deducted from the currently intended phase (excluding the preceding space maintainers or subsequent retention phase), except where the case involves a cleft palate history. Initial fee of active fixedorpartiallyfixedorthodonticslimited for funding to approximately 20%ofthetotalcost (excluding the diagnostic and retainer procedures).

Benefitissubjecttoclinical protocols.

Authorisedbenefitsare payable from an advanced dentistry and dental implantbenefit.


Previous orthodontic treatment phases carried out by the same provider to be deducted from the currently intended phase (excluding the preceding space maintainers or subsequent retention phase), except where the case involves a cleft palate history.

Initial fee of active fixedorpartiallyfixedorthodonticslimited for funding to approximately 20%ofthetotalcost (excluding the diagnostic and retainer procedures).




Previous orthodontic treatment phases carried out by the same provider to be deducted from the currently intended phase (excluding the preceding space maintainers or subsequent retention phase), except where the case involves a cleft palate history.

Initial fee of active fixedorpartiallyfixedorthodonticslimited for funding to approximately 20%ofthetotalcost (excluding the diagnostic and retainer procedures).

Option A Option B Option COrthodontics and associated laboratory costs(continued)


Benefitislimitedto individuals younger than 21 years of age.

Scheme exclusions:

• Orthodontic re-treatment and any related laboratory costs

• Orthognathic (jaw correction) surgery and any related hospital and laboratory costs except where related to PMB scenarios

• Invisible retainer material

• Lingual orthodontics



Scheme exclusions:







Scheme exclusions:





Periodontics Pre-authorisation is required.Benefitissubject to clinical protocols.

Benefitislimitedtoconservative, non-surgical therapy only (root planning) limited to once per site per two year period.

Pre-authorisation is required.Benefitissubject to clinical protocols.


Pre-authorisation is required.Benefitissubject to clinical protocols.




50 51

Option A Option B Option CPeriodontics(continued)

Covered at the MDT rates and paid from advanced dental benefit.Scheme exclusions:• Surgical

periodontics which includes periodontalflapsurgery, tissue grafting and the hemisection of a tooth

• Perio chip placement

Covered at the MDT rates and paid from advanced dental benefit.Scheme exclusions:• Surgical



Covered at the MDT rates and paid from day-to-daybenefit.Scheme exclusions:• Surgical



Maxillo-facial surgery and oral pathology (including wisdom teeth removal)

Benefitissubjectto clinical protocols.Subject to clinical protocols:

The claims for oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours) will only be covered if supported by a laboratory report thatconfirmsdiagnosis.





Option A Option B Option CMaxillo-facial surgery and oral pathology (including wisdom teeth removal)(continued)

Covered at the MDT rates and paid from maxillo-facial and oral surgerybenefit.

Scheme exclusions:

• Orthognathic (jaw correction) surgery

• The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) isaSchemeexclusion

• The auto-implantation of teeth


Scheme exclusions:


• The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) isaSchemeexclusion.



Scheme exclusions:


• The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) isaSchemeexclusion




52 53

Option A Option B Option CHospitalisation and anaesthetics

Hospitalisation (general anaesthetic)

Pre-authorisation is required.

Admission protocols apply.

In-hospital dental admissions will only be considered for the following procedures:

• Dependants under the age of eight years for multiple procedures

• Excision of lesions greater than 1.25 cm in size

• Patients with either physical, mental or medically compromising conditions which inhibit dental treatment under local anaesthesia

• Mentally retarded patients or physically impaired patients















Option A Option B Option CHospitalisation (general anaesthetic)(continued)

• Patients with oro-facial or dental trauma including fractures

• Management of acute infection

• Patients who have proven allergy to local anaesthetic

• Removal or extraction of two or more impacted teeth

• Surgicalextraction of teeth in more than one quadrant

• Full dental clearance/extractions in both jaws

• More than one quadrant of periodontal surgery on the same day

• Root removal in the maxillary antrum

• Surgicalexposures of unerupted canines





















54 55

Option A Option B Option CHospitalisation (general anaesthetic) (continued)

• Stomatoplastyorvestibuloplasty

• Removal of exostosis

• Placement of more than one endosteal implants

• Posterior apicectomies

Scheme exclusions:• Where the

only reason for admission to hospital is dental fear and anxiety

• Where the only reason for the admission request is for a sterile facility

• The cost of dental materials for procedures performed under general anaesthesia

















Laughing gas in dental rooms

Pre-authorisation required, subject to clinical protocols.



IV conscious sedation in rooms

Pre-authorisation required, subject to clinical protocols. All anaestheticcostswillbepaidfromtheday-to-daybenefitfordental procedures performed under conscious sedation.

• Any dental procedure deemed to be cosmetic.

• Electrognathographic recordings, pantographic recordings and other such electronic analyses.

• Nutritional and tobacco counselling.

• Caries susceptibility and microbiological tests.

• Fissure sealants on patients 16 years and older.

• Pulp tests.

• Cost of mineral trioxide.

• Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments.

• Appointment not kept.

• Specialreport.

• Dental testimony including dento-legal fees.

• Treatment plan completed (currently code 8120).

• Enamel microabrasion.

• Behaviour management.

• Intramuscular or subcutaneous injection.

• Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures.

• Metal or gold restorations on anterior teeth.

• Orthodontic treatment for beneficiaries above the age of 21 years.


Annexure E Additional Scheme exclusions:

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