2014

Terms and conditions- 3 month general waiting period (subject to the rights of interchangeability)- 12 months condition specific waiting period for pre-existing conditions (subject to the rights of interchangeability)

Disclaimer:

Every effort has been made to ensure that this leaflet is an accurate explanation of the benefits offered by Hosmed Medical Scheme.

Please note that this document does not replace the Rules of the Fund, which take precedence over any wording in this guide.

Pictures for illustration purposes only

Subject to approval from The Council for Medical Schemes

Share Call: 0860 00 00 48Facsimilie: 086 245 1099

e-mail: hosmedenquiries@tybhealth.co.zasales@hosmed.co.za

web: www.hosmed.co.za

Isle of Houghton, Old Trafford 4 Building, Ground Floor Cnr. Boundary & Carse O’Gowrie Rd,

Houghton, Johannesburg

P.O. Box 16148, Doornfontein, 2028 South Africa

Administration

Hosmed Call Centre: 0860 00 00 48Hospital Authorisations

Pre-authorisation of all Hospital Admissions, MRI, CT and Pet scans

Tel: 011 259 5049Fax: 0866 369 067

E-mail: hosmedpreauth@mso.co.za

Medication Authorisations

Mediscor ChroniLine - 0860 119 553Mediscor PMB Helpdesk - 0860 117 705

Mediscor E-mail: helpdesk@mediscor.co.zaMediscor Authorisation: preauth@mediscor.co.za

To obtain pre-authorisation, members must fax or e-mail the relevant doctor’s prescription.

Optical Authorisations

Optical benefit design and Management Provider Network

Customer Care: 0860 103 529E-mail: claims@ppn.co.za

www.ppn.co.za

Dental Authorisations

Dental Benefit and Management Provider Network

Dental queries: hosmedenquiry@shsdent.co.za Dental Authorisations: hosmedauth@shsdent.co.za Customer Care: 086 111 4546

HIV Authorisations

HIV Disease Management Programme

Call centre number: 0860 50 60 80Fax line: 0860 80 49 60Email: results@lifesense.co.za

Website: www.lifesensedm.co.za

Emergency ServicesMedical Emergencies Only 082 911

Customer Services

Telephone: 0860 NETCARE (0860 638 2273)Facsimile: +27 (0)10 209 8405

E-mail: customer.service@netcare.co.za

HOSMED PLUS Contributions 2014

Monthly Income Member (M) Adult (A) Child * (C)

0 + R 3 188 R 1 914 R 478*Maximum 3 children per family charged

HOSMED VALUE Contributions 2014

Monthly Income Member (M) Adult (A) Child * (C)

0 - R 7 000 R 2 127 R 1 275 R 320R 7 001 + R 2 444 R 1 466 R 366

*Maximum 3 children per family charged

HOSMED STEP MEDIUM Contributions 2014

Monthly Income Member (M) Adult (A) Child * (C)

0 - R 7000 R 807 R 661 R 367R 7001 - R 12000 R 1 204 R 985 R 652

R 12001 + R 1 505 R 1 231 R 813*Maximum 3 children per family charged

HOSMED STEP CORE Contributions 2014

Monthly Income Member (M) Adult (A) Child * (C)

0 - R 7000 R 582 R 476 R 264R 7001 - R 12000 R 868 R 709 R 470

R 12001 + R 1 084 R 887 R 586*Maximum 3 children per family charged

40% of Contributions - HOSMED STEP MEDIUM 2014

Monthly Income

Member (M)

Adult (A)

Child * (C)

M + A M + C M+A+C M+A+2C

Family

0 - R 7000 R 323 R 264 R 147 R 587 R 470 R 734 R 881 R 1 028R 7001 - R 12000 R 482 R 394 R 261 R 876 R 742 R 1 136 R 1 397 R 1 658

R 12001 + R 602 R 492 R 325 R 1 094 R 927 R 1 420 R 1 745 R 2 070*Maximum 3 children per family charged

40% of Contributions - HOSMED STEP CORE 2014

Monthly Income

Member (M)

Adult (A)

Child * (C)

M + A M + C M+A+C M+A+2C

Family

0 - R 7000 R 233 R 190 R 106 R 423 R 338 R 529 R 634 R 740R 7001 - R 12000 R 347 R 284 R 188 R 631 R 535 R 819 R 1 007 R 1 195

R 12001 + R 434 R 355 R 234 R 788 R 668 R 1 023 R 1 257 R 1 492*Maximum 3 children per family charged

40% of Contributions - HOSMED PLUS 2014

Monthly Income

Member (M)

Adult (A)

Child * (C)

M + A M + C M+A+C M+A+2C

Family

0 + R 1 275 R 766 R 191 R 2 041 R 1 466 R 2 232 R 2 501 R 2 979*Maximum 3 children per family charged

40% of Contributions - HOSMED VALUE 2014

Monthly Income

Member (M)

Adult (A)

Child * (C)

M + A M + C M+A+C M+A+2C

Family

0 -

R 7 000R 851 R 510 R 128 R 1 361 R 979 R 1 489 R 1 617 R 1 745

R 7 001 + R 978 R 586 R 146 R 1 564 R 1 124 R 1 710 R 1 857 R 2 003

*Maximum 3 children per family charged

To Join Hosmed SMS “Hosmed” to

38468 (SMS charged at R1.00 per SMS)

To Join Hosmed SMS “Hosmed” to

38468 (SMS charged at R1.00 per SMS)

Kindly visit our website for full benefit details & exclusion lists Kindly visit our website for full benefit details & exclusion lists

VALUE PLUS

Overall annual limitNo Overall Annual Limit

Subject to sub-limits not being exceeded

No Overall Annual Limit Subject to sub-limits not being

exceeded

Hospital BenefitMSO: Pre-authorisation Tel: 011 259 5049 Fax: 0866 369 067

E-mail: hosmedpreauth@mso.co.zaSubject to Pre-Authorisation, PMB’s and Scheme Protocols.

State Hospitals 100% of Cost Unlimited for PMB admissions

100% of Cost Unlimited for PMB admissions

Private Hospitals 100% of Scheme Tariff* 100% of Scheme Tariff*

Accommodation, theatre fees, medicines, intensive care

100% of Scheme Tariff* 100% of Scheme Tariff*

Diagnostic Investigations E.g. Radiology, Pathology, MRI/

PET/CAT scans etc

100% of Scheme Tariff* 100% of Scheme Tariff*

Oncology 100% of DSP Tariff*

Limited to R 222 000 per person per annum

100% of DSP Tariff*

Limited to R 480 000 per person per annum

Accommodation for Confinement 100% of Scheme Tariff*NVD – Limited to 2 daysCaesar – Limited to 3 daysLimited to 2 sonar’s per pregnancyfor In and Out of Hospital

100% of Scheme Tariff*NVD – Limited to 2 daysCaesar – Limited to 3 daysLimited to 2 sonar’s per pregnancyfor In and Out of Hospital

Psychiatric Treatment including Clinical Psychology

100% of Scheme Tariff* PMB - 21 days per family per annum Non PMB - R 16 600 per family per annum

100% of Scheme Tariff* PMB - 21 days per family per annum Non PMB - R 18 700 per family per annum

Organ Transplants Transplantation benefit for the

recipient only

100% of Scheme Tariff* Organ transplants and solid organ transplants collectively limited to R 105 000 per family per annum

100% of Scheme Tariff* Organ transplants and solid organ transplants collectively limited to R 130 000 per family per annum

Renal Dialysis

100% of DSP Tariff*Unlimited benefits for PMB admissions

100% of DSP Tariff*Unlimited benefits for PMB admissions

Sterilization/Vasectomy 100% of Scheme Tariff* Sterilization limited to R 11 700 per person per annum

100% of Scheme Tariff* Sterilization limited to R 12 300 per person per annum

Internal Prosthesis 100% of cost Limited to R 37 000 per family per annum

100% of cost Limited to R 53 200 per family per annum

Circumcision In and out of hospital

100% of Scheme Tariff* 100% of Scheme Tariff*

Back surgery 100% of Scheme Tariff*Subject to pre-authorisation and Scheme Protocols

100% of Scheme Tariff*Subject to pre-authorisation and Scheme Protocols

Laparoscopic Hospitalisation 100% of Scheme Tariff*Subject to pre-authorisation and Scheme Protocols

100% of Scheme Tariff*Subject to pre-authorisation and Scheme Protocols

HIV/AIDSLifesense – 0860 50 60 80

100% of Cost Subject to prior enrolment in and adherence to the HIV/AIDS Management programme In and Out of hospital

100% of CostSubject to prior enrolment in and adherence to the HIV/AIDS Management programmeIn and Out of hospital

Air/Road Ambulance Subject to pre-authorisation by Netcare – 082 911In and Out of hospital

Subject to pre-authorisation by Netcare – 082 911In and Out of hospital

STEP MEDIUM STEP CORE

Overall annual limitLimited to R650 000 Annual

Limit, subject to sub-limits not being exceeded

Limited to R650 000 Annual Limit, subject to sub-limits not

being exceeded

Hospital BenefitMSO: Pre-authorisation Tel: 011 259 5049 Fax: 0866 369 067

E-mail: hosmedpreauth@mso.co.zaSubject to Pre-Authorisation, PMB’s and Scheme Protocols.

Hospital Network Restricted Hospital Network

State Hospitals 100% of Cost Unlimited for PMB admissions

100% of Cost Unlimited for PMB admissions

Private Hospitals 100% of Scheme Tariff* Hospital Network

100% of Scheme Tariff* Restricted Hospital Network Only

Accommodation, theatre fees, medicines, intensive care

100% of Scheme Tariff* 100% of Scheme Tariff*

Diagnostic Investigations E.g. Radiology, Pathology, MRI/

PET/CAT scans etc

100% of Scheme Tariff*Limited to R 5 000 per person per annum MRI/PET/CAT Scans 2 per person per annum for In and Out Hospital

100% of Scheme Tariff*Limited to R 5 000 per person per annum MRI/PET/CAT Scans 2 per person per annum for In and Out Hospital

Oncology 100% of DSP Tariff* 100% of DSP Tariff*

Accommodation for Confinement

In and Out of Hospital

100% of Scheme Tariff*NVD – Limited to 2 daysEmergency Caesarean – Limited to 3 days Limited to 2 sonar’s per pregnancy

100% of Scheme Tariff*NVD – Limited to 2 daysEmergency Caesarean – Limited to 3 daysLimited to 2 sonar’s per pregnancy

Psychiatric Treatment including Clinical Psychology

100% of Scheme Tariff* PMB’s ONLY DSP* State Hospital21 Days per family

100% of Scheme Tariff* PMB’s ONLYDSP* State Hospital21 Days per family

Organ Transplants Transplantation benefit for the

recipient only

100% of Scheme Tariff*Organ transplants and solid organ transplants collectively limited to R 77 000 per family per annum

100% of Scheme Tariff*Organ transplants and solid organ transplants collectively limited to R 77 000 per family per annum

Renal Dialysis 100% of DSP Tariff*Unlimited benefits for PMB admissions

100% of DSP Tariff*Unlimited benefits for PMB admissions

Sterilization/Vasectomy No Benefit No Benefit

Internal Prosthesis 100% of costLimited to R 15 900 per family per annum

100% of costLimited to R 15 900 per family per annum

Circumcision In and out of hospital

100% of Scheme Tariff*Network Provider Only

100% of Scheme Tariff*Restricted Network Provider Only

Back surgery 100% of Scheme Tariff*Subject to back treatment clinical protocols

100% of Scheme Tariff*Subject to back treatment clinical protocols

Laparoscopic Hospitalisation No Benefit No Benefit

Hosmed Care for LifeWellness Programme

Limited to appropriate Referral

from DSP* Nominated GP & Authorised Specialist

1 Free Pap Smear for Females over 18 Years per person per Annum

1 Free Mammogram for Females over 40 Years per person per Annum

1 Free PSA for Males over 40 Years per person per Annum

1 Free Cholesterol Test over 20 Years per person per Annum

1 Free Flu Vaccine per person per Annum

1 Free Blood Sugar Test over 15 Years per person per AnnumNetwork Provider Only

1 Free Pap Smear for Females over 18 Years per person per Annum

1 Free Mammogram for Females over 40 Years per person per Annum

1 Free PSA for Males over 40 Years per person per Annum

1 Free Cholesterol Test over 20 Years per person per Annum

1 Free Flu Vaccine per person per Annum

1 Free Blood Sugar Test over 15 Years per person per AnnumRestricted Network Provider Only

Out of Hospital Benefit

VALUE PLUS

Consultations Including General Practitioners

and outpatient facilities

100% of Scheme Tariff*

10 visits per person limited to 21 visits per family per annum

100% of Scheme Tariff*

16 visits per person limited to 26 visits per family per annum

Additional 5 visits per pregnancy

Specialist Consultations Included in Consultation benefit aboveNB: All specialist consultations require General Practitioner referral or payment will be made at GP rates, except for:Gynaecologists and Pediatricians

Included in Consultation benefit aboveNB: All specialist consultations require General Practitioner referral or payment will be made at GP rates, except for:Gynaecologists and Pediatricians

Acute Medicines - Including Material, homeopathic medicines

and flu Vaccines

100% of preferred provider reference price*R 2 870 per person Limited to R5 824 per family per annum

100% of preferred provider reference price*R 4 440 per person Limited to R 8 740 per family per annum

Pharmacy Advised Treatment Over the counter medication

Limited to R 570 per family per annumMaximum R 130 per script

Limited to R 920 per family per annum Maximum R 180 per script

Chronic Medication Service Provider:

Mediscor – 0860 119 553

100% of preferred provider reference pricePMB’s UnlimitedOTHER: R 5 600 per person, Limited to R 11 300 per family per annumSubject to registration, treatment protocols and medicine formulary

100% of preferred provider reference pricePMB’s UnlimitedOTHER: R 11 900 per person, Limited to R 22 700 per family per annumSubject to registration, treatment protocols and medicine formulary

Pathology 100% of Scheme Tariff*Limited to R 2 250 per person per annum

100% of Scheme Tariff*Limited to R 4 000 per person per annum

Radiology 100% of Scheme Tariff*Limited to R 1 750 per person per annum

100% of Scheme Tariff*Limited to R 2 940 per person per annum

MRI/PET/CAT Scans Limited to two scans per person per annum, subject to pre-authorisation

Limited to two scans per person per annum, subject to pre-authorisation

Optometry Service Provider:

PPN – 0860 10 35 29

Benefit available every 24 months

100% of PPN TariffEye Test: R 590 per person Frames: R 550 per personR 150 per lens – Single vision or R 325 per lens - Bifocal/Multifocal vision Contact lenses - R 1 712 per person

100% of PPN TariffEye Test: R 590 per personFrames: R 720 per personR 150 per lens – Single vision R 325 per lens – Bifocal vision R 600 per lens - Multifocal vision Contact lenses - R 2 750 per person

Conservative Dentistry Service Provider:

SHS – 086 111 4546

100% of Scheme Tariff* Unlimited, subject to treatment protocols

100% of Scheme Tariff* Unlimited, subject to treatment protocols

Specialised DentistrySubject to pre-authorisation

R 3 500 per person, limited to R 5 000 per family per annum

R 5 350 per person, limited to R 6 740 per family per annum

Dental Therapist 100% of Scheme Tariff*Unlimited, subject to treatment protocols

100% of Scheme Tariff*Unlimited, subject to treatment protocols

Appliances Subject to pre-authorisation

Limited to R 10 800 per family per annum

Limited to R 11 990 per family per annum

Mental health R 2 390 per person, limited to R 6 000 per family per annum

R 3 870 per person, limited to R 7 740 per family per annum

Alternative services e.g Homeopathy, Chiropractic etc

R 2 900 per family per annum R 3 140 per family per annum

Remedial and other therapies e.g Dieticians, Audiology, Speech

Therapy etc

R 2 800 per family per annum R 3 980 per family per annum

Physiotherapy & Biokinetics R 1 330 per person - limited to R 2 280 per family per annum

R 2 120 per person - limited to R 3 540 per family per annum

External Prosthesis Subject to pre-authorisation

R 14 400 per family per annum R 15 940 per family per annum

OVERALL ANNUAL LIMIT ON OUT OF HOSPITAL BENEFITS

FOR:

Acute Medicines, Spesialised Dentistry, Alternative Services,

Biokinetics & Physioterapy, Remedial and Other Therapies,

Mental Health

M - R 8 500M+1 - R 17 950M+2 - R 19 525M+3 - R 21 625

Collectively limited to per family per annum

M - R 9 400M+1 - R 19 800M+2 - R 21 600M+3 - R 23 800

Collectively limited to per family per annum

* Scheme Tariff: The Scheme Tariffs have been set at the NHRPL as published by the Department of Health. The Board of trustees of the Scheme reserves the right to amend this.

* DSP – Designated Service Provider

Out of Hospital BenefitSTEP MEDIUM

STANDARD NETWORKSTEP CORE

RESTRICTED NETWORK

Consultations 100% of Scheme Tariff*NOMINATED DSP GPNo annual limit subject to member’s choice of nominated DSP* GP

NON-NOMINATED DSP GP:Non-nominated GP’s limited to 1 visit per person and to 2 visits per family per annum to a maximum of R 700 and 20% co-payment

100% of Scheme Tariff*NOMINATED DSP GPNo annual limit subject to member’s choice of nominated Restricted DSP* GP

NON-NOMINATED DSP GP:Non-nominated GP’s limited to 1 visit per person and to 2 visits per family per annum to a maximum of R 700 and 20% co-payment

Specialist ConsultationsNB: All specialist consultations

require General practitioner referral or payment will be made

at GP rates only

Limited to 3 visits per family per annum only on referral from nominated DSP GPSubject to pre-authorisation

Limited to 3 visits per family per annum only on referral from nominated Restricted DSP GPSubject to pre-authorisation

Acute Medicines including Material

100% of preferred provider reference price - Unlimited Subject to medicine dispensed by the nominated DSP GP and Medicine Formulary

100% of preferred provider reference price - Unlimited Subject to medicine dispensed by the nominated DSP GP and Medicine Formulary

Pharmacy Advised Treatment Over the counter medication

Limited to R 200 per family per annumMaximum R 75 per script

Limited to R 200 per family per annumMaximum R 75 per script

Chronic Medication

Service Provider:Mediscor – 0860 119 553

100% of preferred provider reference price - Unlimited Subject to Treatment Protocols and Medicine Formulary and Registration of the Chronic Medicine by the nominated DSP GP

100% of preferred provider reference price - Unlimited Subject to Treatment Protocols and Medicine Formulary and Registration of the Chronic Medicine by the nominated DSP GP

Pathology Limited to R 670 per person per annum

Limited to R 670 per person per annum

Radiology Limited to R 670 per person per annumReferral by Network Provider Only

Limited to R 670 per person per annumReferral by Restricted Provider Only

MRI/PET/CAT ScansSubject to pre-authorisation and

referral by Network Provider only

Limited to 2 scans per person per annum and limited to Hospital Radiology Benefit

Limited to 2 scans per person per annum and limited to Hospital Radiology Benefit

Optometry Service Provider:

PPN – 0860 10 35 29

Benefit available every 24 months

100% of PPN TariffEye Test: R 590 per personFrames: R 150R 150 per lens – single vision orR 325 per lens – bifocal vision orR 325 per lens – multifocal visionContact Lenses: R 420 per person

100% of PPN TariffEye Test: R 590 per personFrames: R 150R 150 per lens – single vision orR 325 per lens – bifocal vision orR 325 per lens – multifocal visionContact Lenses: R 420 per person

Conservative Dentistry Service Provider:

SHS – 086 111 4546

100% of Scheme Tariff*Subject to Treatment Protocol and quantity limitations apply

100% of Scheme Tariff*Subject to Treatment Protocol and quantity limitations apply

Specialised DentistrySubject to pre-authorisation

Only Dentures: One set of full dentures per jaw per person every 4 years

Only Dentures: One set of full dentures per jaw per person every 4 years

Dental Therapistonly DSP*

100% of Scheme Tariff*Subject to Treatment Protocol and quantity limitations apply

100% of Scheme Tariff*Subject to Treatment Protocol and quantity limitations apply

AppliancesReferral from Network Provider

only

Only Hearing Aids: Limited to R 2 000 per person per annum

Only Hearing Aids: Limited to R 2 000 per person per annum

Mental health Subject to PMB’s Subject to PMB’s

Alternative services No Benefit No Benefit

Remedial and other therapies No Benefit No Benefit

Physiotherapy No Benefit No Benefit

External ProsthesisSubject to pre-authorisation

100% of CostSubject to PMB’s Only

100% of CostSubject to PMB’s Only

HIV/AIDSLifesense – 0860 50 60 80

100% of Scheme Tariff* Subject to prior enrolment in and adherence to the HIV/AIDS Management programme

100% of Scheme Tariff* Subject to prior enrolment in and adherence to the HIV/AIDS Management programme

Air/Road Ambulance Subject to pre-authorisation by Netcare – 082 911

Subject to pre-authorisation by Netcare – 082 911

* Scheme Tariff: The Scheme Tariffs have been set at the NHRPL as published by the Department of Health. The Board of trustees of the Scheme reserves the right to amend this.

* DSP – Designated Service Provider