Resolution Health Comparison Brochure 2014

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HOSPITALISATION SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION

Note: • Pre-authorisationmustbeobtainedinadvanceforallnon-emergencyhospitaladmissions.Inthecaseofatrueemergencyadmission(requiringimmediatetreatment),pre-authorisationmustbeobtainedwithin48hoursoronthefirst

working day after admission. • Pre-authorisation should ideally be obtained 14 days prior to an elective admission to allow time for any outstanding information to be submitted for review.• All authorisations subject to Scheme rules, protocols and policies.• Laparoscopicandsimilarendoscopicproceduresareexcludedfrombenefits,unlesspre-authorisedunderSchemeprotocols.Laparoscopicco-paymentisapplicableonadmissiontohospital.

PRIVATE HOSPITALS Unlimited. Subject to Scheme protocols.

Unlimited. Subject to Scheme protocols.


Unlimited, only at DSP network hospitals. R3 300 co-payment applicable for non-DSP hospitals. Procedure co-payments may also be applicable. Subject to Scheme protocols and option-specificexclusionlist.

Unlimited. Subject to Scheme protocols and option-specificexclusionlist.

Unlimited. Subject to PMBs and only at DSP network hospitals. R3 300 co-payment applicable for non-DSP hospitals. Procedure co-payments may also be applicable. Subject to Scheme protocols and option-specificexclusionlist.

Including:Surgical operations & proceduresTheatre feesLabour and recovery wardsWard accommodationIntensive care and high care unitsX-rays and pathology PhysiotherapyUltrasound scans (other than for pregnancy)Blood transfusions

100% of Scheme rate. 100% of Scheme rate. 100% of Scheme rate. 100% of Scheme rate. 100% of Scheme rate. 100% of Scheme rate.

Medicine dispensed and used in hospital Subject to hospital formulary.

Subject to hospital formulary.





Medicine received on discharge from hospital (TTO) Maximum of 7 days’ supply. Maximum of 7 days’ supply. Maximum of 7 days’ supply. Maximum of 7 days’ supply. Maximum of 7 days’ supply. Maximum of 7 days’ supply.

General Practitioners, including consultations and procedures

Non-contracted providers at 100% of Scheme rate. Contracted providers at 100% of contracted rate.





Non-contracted providers at 100% of Scheme rate. DSP providers at 100% of contracted rate.

Clinical medical specialist fees, including consultations and procedures

Non-contracted providers at 100% of Scheme rate. Contracted providers at 100% of contracted rate (up to 220% of Scheme rate).





Non-contracted providers at 100% of Scheme rate. DSP providers at 100% of contracted rate.

PROVINCIAL HOSPITALSDiagnosis and treatment in respect of the Prescribed MinimumBenefits(PMB)package(asperGovernmentRegulations)







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ANNUAL SUB-LIMITS(PRIVATE HOSPITALS) SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION

CASUALTy / EMERGENCy VISITSClinician and facility fees only, clinician paid at 100% of Scheme rate

Limited to R1 350 for emergency visits per family per annum.

Nobenefit. Nobenefit. Limited to R1 350 for emergency visits per family per annum.

Nobenefit. Nobenefit.

MATERNITy Confinements• Normal delivery Length of stay: 3 days & 2

nights.Length of stay: 3 days & 2 nights.

Length of stay: 3 days & 2 nights.




• Caesarean section (clinically indicated only) Length of stay: 4 days & 3 nights.






• Elective caesarean section Included. Nobenefit. Nobenefit. Nobenefit. Nobenefit. Nobenefit.

• Neonatal intensive care Subject to Scheme protocols.

Subject to Scheme protocols.





Antenatal care • Maternity programme (registration required) Included. Included. Included. Included. Included. Included.

• Baby care products at a preferred provider R780 as per Reso Baby. R690 as per Reso Baby. R640 as per Reso Baby. R510 as per Reso Baby. Nobenefit. Nobenefit.

• 9 Consultations (midwife, GP or specialist) Included (any provider). Subject to MSA and ATB (any provider).

Max 6 specialist visits included.

Max 3 specialist visits included.

Subject to Scheme protocols and PMBs.

GPs or Midwives only. Specialists require authorisation.

• 2D scans 2 Scans included. 2 Scans included. 4 Scans included. 2 Scans included. 2 Scans included. 2 Scans included.

• Antenatal classes Nobenefit. Subject to MSA and ATB. R1 200 Nobenefit. Nobenefit. Nobenefit.

• Postnatal midwife visits Nobenefit. Subject to MSA and ATB. 4 Visits included. Nobenefit. Nobenefit. Nobenefit.

OTHER• Psychiatric disorders Limited to network

providers. Subject to PMBs and Scheme protocols. Non-PMB limited to R25 400 per family per annum.

Limited to network providers. Subject to PMBs and Scheme protocols. Non-PMB limited to R15 900 per family per annum.

Limited to network providers. Subject to PMBs and Scheme protocols. Non-PMBs limited to R12 800 per family per annum.

Limited to network providers. Subject to PMBs and Scheme protocols.



• Cochlear implants and all related thereto (once per lifetimeperbeneficiary)

R106 000 per family per annum.



Nobenefit. Nobenefit. Nobenefit.

• Organ transplants Unlimited. Subject to PMBs and Scheme protocols.

Unlimited. Subject to PMBs and Scheme protocols.

Unlimited. Subject to PMBs and Scheme protocols.

R95 400 per family per annum. Subject to PMBs and Scheme protocols.

Limited to PMBs at a provincial hospital in accordance with public sector protocols, waiting lists and Regulation 8(3) of the Act.

Limited to PMBs at a provincial hospital in accordance with public sector protocols, waiting lists and Regulation 8(3) of the Act.

INTERNAL PROSTHESES Limited to R53 000 per family per annum. Subject to prosthesis sub-limits and Scheme protocols.

Limited to R53 000 per family per annum. Subject to prosthesis sub-limits and Scheme protocols.

Limited to R47 700 per family per annum. Subject to prosthesis sub-limits and Scheme protocols.

Limited to R47 700 per family per annum. No benefitotherthanPMBfor joint replacements and spinal procedures. Subject to prosthesis sub-limits and Scheme protocols.

Limited to R31 800 per family per annum. No benefitotherthanPMBfor joint replacements and spinal procedures. Subject to prosthesis sub-limits and Scheme protocols.

Limited to R31 800 per family per annum. Subject to prosthesis sub-limits, Scheme protocols and PMBs.

TRAUMA COUNSELLING(Assault, rape, hijacking and armed robbery)

3 Psychologist visits per beneficiaryperannum.Subject to Scheme protocols. R560 per visit.

Nobenefit. Nobenefit. Nobenefit. Nobenefit. Nobenefit.

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OTHER INSURED BENEFITS SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION

ExternalmedicalappliancesIncludes the following if prescribed by a registered healthcare practitioner and obtained from a supplier registered with the Board of Healthcare Funders (BHF):

R12 700 per family per annum. Subject to appliance sub-limits.

R9 540 per family per annum. Subject to PMBs, Scheme protocols and appliance sub-limits.





Artificialeyes(5-yearcycle) R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Artificiallarynx(5-yearcycle) R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Artificiallimbs(5-yearcycle) R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Back supports (annual) R3 800 R3 600 R3 450 R3 310 R3 310 R1 685

CPAP Machine (3-year cycle, only at DSPs) R8 210 R7 310 R6 350 R3 310 R3 310 R1 685

Crutches (annual) R625 R625 R625 R625 R625 R625

Disposable bladder and intestinal excretion bags (annual) R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Elastic stockings for varicose veins (annual) R625 R625 R625 R625 R625 R625

External breast prosthesis after mastectomy (annual) R1 260 R1 260 R875 R875 R875 R875

Glucometers (3-year cycle) R1 100 R850 R690 R625 R625 R625

Hearing aids (annual, 3-year lifespan/appliance) R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Home oxygen (only at DSPs, annual) R12 700 R9 540 R6 350 R3 310 R3 310 R 1 685

Leg, arm and neck supports (annual) R875 R800 R690 R625 R625 R625

Nebulisers/humidifiers(3-yearcycle) R1 100 R800 R690 R625 R625 R625

Orthopaedic footwear (annual) R1 000 R850 R625 R625 R625 R625

Sleep apnoea monitors (infants < 1 year and only at pharmacy,1/beneficiary/life)

R12 700 R9 540 R6 350 R3 310 R3 310 R1 685

Wheelchairs (3-year cycle) R6 360 R5 300 R4 240 R3 310 R 3 310 R1 685

ONCOLOGy • Oncologist • Chemotherapy • Radiotherapy• Oncology-related blood tests

Unlimited. Subject to Scheme protocols and preferred provider network. Pre-authorisation required.

Limited to R212 000 per beneficiaryperannum.Subject to ICON Network and standard protocols. Pre-authorisation required.





HIV / AIDS Primary care including Voluntary Counselling and Testing and Treatment.

HIV Management Programme.






Hospitalisation if member is on the HIV Management Programme (registration required)

Hospitalisation at network provider hospitals. Subject to Scheme protocols and PMBs.


Hospitalisation at network provider hospitals. Subject to Scheme Protocols and PMBs.




Hospitalisation if member is not on the HIV Management Programme, subject to Reg 8 (3)

Limited to provincial facility.



Limited to provincial facility. Limited to provincial facility.


HOME NURSING 12 Days per family per annum. 100% of Scheme rate.

10 Days per family per annum. 100% of Scheme rate.



Nobenefitexceptinlieuofhospitalisation. Subject to pre-authorisation.

Nobenefitexceptinlieuofhospitalisation. Subject to pre-authorisation.

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Note: Chronic medication,• Should be obtained from a preferred provider.• Is restricted to formularies, clinical entry criteria and disease management protocols where applicable.• Requires a script from a person legally entitled to prescribe and the relevant ICD-10 diagnosis code.• Must be registered by the doctor or pharmacy on 0861 111 778.• Reference pricing and GRP may apply.

Note: • OtherInsuredBenefitsarepro-ratedformemberswhojoinorresignduringtheyear.• AuthorisationmustbeobtainedinadvancefromtheSchemeforallhospitalisationandOtherInsuredBenefits.• Nobenefitsshallbegrantedfor: The replacement of existing external medical appliance items, without satisfactory proof that the existing item is obsolete. Costs of maintenance, spares or accessories.• Hospice,rehabandstepdownfacilitybenefitincludesaccommodationandvisitsbyamedicalpractitioner,exceptwhereinclusiveglobalfeesareapplicable.

OTHER INSURED BENEFITS SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION

HOSPICE, REHAB AND STEP DOwN FACILITy 21 Days per family per annum. 100% of Scheme rate.





Nobenefit.

SPECIALISED RADIOLOGy CT, MRI, PET and Nuclear Medicine scans

R15 900 per family per annum. Subject to Scheme protocols. Co-payment of R1 600 per incident (in and out of hospital).Pre-authorisation required. 100% of Scheme rate.

R12 720 per family per annum. Subject to Scheme protocols. Co-payment of R1 600 per incident (in and out of hospital). Pre-authorisation required.100% of Scheme rate.

R10 600 per family per annum. Subject to Scheme protocols. Co-payment of R1 600 per incident (in and out of hospital).Pre-authorisation required. 100% of Scheme rate.

R8 480 per family per annum. Subject to Scheme protocols. Co-payment of R1 600 per incident (in and out of hospital). Pre-authorisation required. 100% of Scheme rate.

R6 360 per family per annum. Subject to Scheme protocols. Co-payment of R1 600 per incident (in and out of hospital). Pre-authorisation required. 100% of Scheme rate.

Covered at network provider. Subject to Scheme protocols and PMBs. Pre-authorisation required.

VIDEO EEG FOR EPILEPSy SURGERy R13 500 per family per annum.

Nobenefit. Nobenefit. Nobenefit. Nobenefit. Nobenefit.

DIALySIS Unlimited at network provider. Subject to Scheme protocols. Pre-authorisation required.

Covered at network provider. Subject to PMBs and Scheme protocols. Pre-authorisation required.





EMERGENCy EVACUATION AND AMBULANCE SERVICESLimited to Europ Assistance (0861 112 162)

100% of Scheme rate. 100% of Scheme rate. 100% of Scheme rate. 100% of Scheme rate. 100% of Scheme rate. 100% of Scheme rate.

CHRONIC MEDICATION BENEFIT SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION

CHRONIC DISEASES25 CDL conditions + HIV, BPH and HRT

Included. Subject to Supreme Chronic Formulary. Reference and GRP pricing applies.

Included. Subject to Millennium Chronic Formulary. Reference and GRP pricing applies.

Included. Subject to Classic Chronic Formulary. Reference and GRP pricing applies.

Included. Subject to Progressive Flex Chronic Formulary. Reference and GRP pricing applies.

Included. Subject to Hospital Chronic Formulary. Reference and GRP pricing applies.

Included. Subject to registration by a network provider. Subject to Foundation Chronic Formulary. Reference and GRP pricing applies.

ADDITIONAL CHRONIC CONDITIONSPro-rated for members who join during the year.

M R4 650M+ R9 300Benefitssubjecttostatedsub-limits and thereafter to PMB CDLs.

M R2 250M+ R4 500 Benefitssubjecttostatedsub-limits and thereafter PMB CDLs.

M R1 750M+ R3 500 Benefitssubjecttostatedsub-limits and thereafter to PMB CDLs.


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OUT-OF-HOSPITAL SERVICES SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION

DAy-TO-DAy LIMITS Principal:R12720Adult : R9 540 Child: R1 340

Asspecified. Principal:R4475Adult: R3 820Child: R1 070

Asspecified. Asspecified. Asspecified.

GENERAL PRACTITIONERSConsultations outside provider networks may incur a co-payment

Unlimited. Non-contracted providers at 100% of Scheme rate. Contracted providers at 100% of contracted rate. CDL PMB consultations covered separately. Subject to disease management protocols and pre-authorisation.

Subject to MSA and ATB. Non-contracted providers at 100% of Scheme rate. Contracted providers at 100% of contracted rate. CDL PMB consultations covered separately. Subject to disease management protocols and pre-authorisation.

Subject to day-to day limits. 2 additional visits forbeneficiariesbetween2 and 12 years of age paid from risk. Non-contracted providers at 100% of Scheme rate. Contracted providers at 100% of contracted rate. CDL PMB consultations covered separately. Subject to disease management protocols and pre-authorisation.

M 4 visits per annum. M+1 7 visits per annum.M+2+ 9 visits per annum.Non-contracted providers at 100% of Scheme rate. Contracted providers at 100% of contracted rate. CDL PMB consultations covered separately. Subject to disease management protocols and pre-authorisation.

Limited to PMBs. Subject to pre-authorisation. Non-contracted providers at 100% of Scheme rate. Contracted providers at 100% of contracted rate.

Limited to a Foundation network provider. Unlimited with authorisation required after 4th visit per beneficiary.Non-contractedproviders at 100% of Scheme rate (limited to 2 out-of-network visits per family). Contracted providers at 100% of contracted rate.

SPECIALISTS• Consultations (consultations outside networks may

incur a co-payment)• Room procedures (require pre-authorisation, limited

to Scheme protocols)


M 4 visits per annum.M+1 5 visits per annum.M+2+ 6 visits per annum.

Additional visits subject to PMBs and pre-authorisation.


Subject to MSA and ATB. Additional visits subject to PMBs and pre-authorisation.


Subject to day-to-day limits. 2 Additional paediatrician visits per beneficiaryyoungerthan2 years paid from risk.



M 2 visits per annum.M+1 3 visits per annum.M+2+ 3 visits per annum.


Limited to PMBs at network providers. Subject to pre-authorisation.

Subject to PMBs and referral by GP provider. Subject to pre-authorisation and limited to specialist network providers.

DENTISTRyConservativedentistrylimits Covered as stated below.


Subject to Scheme protocols, MSA, ATB and sub-limits of:M R5 000M+1 R6 900M+2+ R8 200

Subject to Scheme protocols, day-to-day limits and sub-limits of: M R3 180M+ R6 360

Subject to Scheme protocols and annual limits of:M R2 650M+ R4 250

Nobenefit.Subject to Scheme protocols, network providers and annual limits of:M R1 590M+ R2 650

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Rootcanaltherapy Covered at 100% of Scheme rate.

Covered at 100% of Scheme rate.



Emergency root canal only.Covered at 100% of Scheme rate.

Plasticdentures 1 Set of plastic dentures (upper and lower) per beneficiary.Benefitforplastic dentures granted only once in a 4 year cycle.

1 Set of plastic dentures (upper and lower) per beneficiary.Benefitforplastic dentures granted only once in a 4 year cycle.



Subject to Scheme protocols and network providers. 1 set of plastic dentures (upper and lower) perbeneficiary.Benefitforplastic dentures granted only once in a 4 year cycle.


DENTISTRyConsultations Covered at 100% of

Scheme rate. 2 Annual check-upsperbeneficiaryper annum. 2 Emergency consultations per beneficiaryperannum.

Covered at 100% of Scheme rate. 2 Annual check-upsperbeneficiaryper annum. 2 Emergency consultations per beneficiaryperannum.



Nobenefit.


X-rays Intra-oral: 8perbeneficiaryper annum.Extra-oral: 1perbeneficiaryper annum.

Intra-oral: 8perbeneficiaryper annum.Extra-oral: 1perbeneficiaryper annum.


Intra-oral: 8perbeneficiaryper annum.Extra-oral: 1 perbeneficiaryper annum.


Fillings A treatment plan and X-rays will be requested for treatment plans of more than 5fillings.Benefitsforfillingsareavailablewheresuchfillingsareclinically indicated and will be granted once per tooth in a 1yearbenefitcycle.TherearenobenefitsforAmalgam(silver)fillings,tobe replaced with composite fillings(whitefillingmaterial). Covered at 100% of Scheme rate.

A treatment plan and X-rays will be requested for treatment plans of more than 5fillings.Benefitsforfillingsareavailablewheresuchfillingsareclinically indicated and will be granted once per tooth in a 1 yearbenefitcycle.Therearenobenefitsfor Amalgam (silver) fillings,tobereplacedwithcompositefillings(whitefillingmaterial).Coveredat100% of Scheme rate.

A treatment plan and X-rays will be requested for treatment plans of more than 5fillings.Benefitsforfillingsareavailablewheresuchfillingsareclinically indicated and will be granted once per tooth in a 1yearbenefitcycle.TherearenobenefitsforAmalgam(silver)fillings,tobe replaced with composite fillings(whitefillingmaterial). Covered at 100% of Scheme rate.

A treatment plan and X-rays will be requested for treatment plans of more than 5fillings.Benefitsforfillingsareavailablewheresuchfillingsareclinically indicated and will be granted once per tooth in a 1yearbenefitcycle.TherearenobenefitsforAmalgam(silver)fillings,tobe replaced with composite fillings(whitefillingmaterial). Covered at 100% of Scheme rate.

Subject to Scheme providers. A treatment plan and X-rays will be requested for treatment plans of more than 5 fillings.Benefitsforfillingsareavailablewheresuchfillingsareclinicallyindicated and will be granted once per tooth in a 1yearbenefitcycle.TherearenobenefitsforAmalgam(silver)fillings,tobe replaced with composite fillings(whitefillingmaterial). Covered at 100% of Scheme rate.

Oralhygiene 2 Annual scale and polish treatmentsperbeneficiary.Nobenefitsfororalhygieneinstructions.Nobenefitforadultfluoride.

2 Annual scale and polish treatmentsperbeneficiary.Nobenefitsfororalhygieneinstructions.Nobenefitforadultfluoride.



1 Annual scale and polish treatmentperbeneficiary.Nobenefitsfororalhygieneinstructions.Nobenefitforadultfluoride.

Preventative Fissure sealants programme. Benefitfor1fissuresealant per molar tooth in a 3 year cycle. Limited to individuals younger than 16 years of age.

Fissure sealants programme.Benefitfor1 fissuresealantpermolartooth in a 3 year cycle. Limited to individuals younger than 16 years of age.

Fissure sealants programme.Benefitfor1fissuresealantper molar tooth in a 3 year cycle. Limited to individuals younger than 16 years of age.

Fissure sealants programme. Benefitfor1fissuresealantper molar tooth in a 3 year cycle. Limited to individuals younger than 16 years of age.

Subject to Scheme protocols and network providers. 1 Fluoride treatmentperbeneficiaryyounger than 12 years of age.

Extractions Covered at 100% of Scheme rate.




More than 4 requires pre-authorisation. Covered at 100% of Scheme rate.

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ADVANCED DENTISTRy Sub-limits R9 000 per family per

annum. Pre-authorisation required.

Subject to MSA, ATB and sub-limits of: M R5 000M+1 R6 900M+2+ R8 200Pre-authorisation required.

Subject to day-to-day limits and sub-limits of: M R3 180M+ R6 360Pre-authorisation required.

R4 500 per family per annum. Pre-authorisation required.

As stated below. Pre-authorisation required.

As stated below. Pre-authorisation required.

• Crowns Included. Included. Included. Included.


• Bridges Included. Included. Included. Included.

• Implants Included. Nobenefit. Nobenefit. Nobenefit.

• Partial metal dentures Included. 1Perjawperbeneficiaryevery 3 years.

1Perjawperbeneficiaryevery 3 years.

Nobenefit.

• Periodontics Included. Nobenefit. Nobenefit. Nobenefit.

Orthodontics Fixed braces

Benefitsonpre-authorisation will be applied to cases assessed as treatment mandatory, as per orthodontic indices. Limited to individuals younger than 38 years of age. Orthognathic surgery is not covered.

1 Per lifetime for beneficiariesundertheageof 18 years.

1 Per lifetime for beneficiariesundertheageof 18 years.


SURGERy, DENTAL HOSPITALISATION, ANAESTHETICS AND ASSOCIATED COSTS

Only for impacted wisdom teeth and extensive dental / multiple procedures in children under 5 years of age. Multiple hospital admissions are not covered. Co-payment of R2 120 will apply to all in-hospital dental admissions per protocol. Pre-authorisation is required for certain maxillo-facial procedures that are covered in hospital. Subject to Scheme protocols.

Only for impacted wisdom teeth and extensive dental / multiple procedures in children under 5 years of age. Multiple hospital admissions are not covered. Co-payment of R2 120 will apply to all in-hospital dental admissions. Scheme protocols apply.



Limited to R3 710 per family per annum for impacted wisdom teeth and associated costs. Co-payment of R2 120 will apply to all in-hospital dental admissions. Multiple hospital admissions are not covered. Scheme protocols apply.

Subject to PMBs only. Pre-authorisation required. Multiple hospital admissions are not covered. Scheme protocols apply.

DENTAL ANAESTHETICS IN ROOMS Laughing gas and IV sedation

Covered at 100% of Scheme rate. Clinical protocols apply.




Nobenefit. Covered at 100% of Scheme rate. Clinical protocols apply.

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Note: • Non-emergencydentaltreatmentperformedinahospitaloperatingtheatreordayclinicundergeneralanaestheticshallbesubjecttopriorpre-authorisationbytheSchemeinordertoqualifyforbenefitsincludingtheatrefees,

anaesthetist fees, ward fees and associated costs, excluding the dental practitioner and procedure costs that shall be subject to the conservative or advanced dentistry limits.• Outofhospitalbenefitsaresubjecttotheformulariesandcase/diseasemanagementprotocols.PMBmanagementalsoincludedinoverallbenefit.Allspecialiseddentistrymustbepre-authorisedat0861743367.Formoredetailson

yourdentalbenefits,opticalbenefitsandexclusionspleasevisitwww.resomed.co.za

PREVENTATIVE CARE LIMIT Excludes consultation

R3 180 per family per annum. Scheme rate applies.


R2 120 per family per annum, Scheme rate applies.


Nobenefit. Asspecified.

• Blood pressure• Blood sugar• Cholesterol• Body Mass Index

R100perbeneficiaryoverthe age of 18 years. Only at pharmacy.




Nobenefit. Included in the Foundation network provider consultation.

HIVtest 1Testperbeneficiaryperannum.

1Testperbeneficiaryperannum.



Nobenefit. 1Testperbeneficiaryperannum.

PREVENTATIVE CARE SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION


OPTOMETRyLimitedtonetworkproviderand24monthbenefitcycleConsultations/examination 1 Consultation per

beneficiary.

Subject to MSA , ATB and sub-limit of R2 250 per beneficiary.

1 Consultation per beneficiary.


Nobenefit.


Spectacles 1 Pair of single vision spectacles. Inclusive of a frame and consultation per beneficiary.LimitedtoR1 780.

Or

1 Pair of single vision spectacles. Inclusive of a frame and consultation per beneficiary.LimitedtoR1 060.

Or

1 Pair of single vision spectacles. Inclusive of a frame and consultation perbeneficiary.LimitedtoR975.

Or

1 Pair of single vision spectacles. Inclusive of a frame and consultation perbeneficiary.LimitedtoR890.

Or

1Pairofflattopbifocalspectacles. Inclusive of a frame and consultation per beneficiary.LimitedtoR2 150.

Or

1 Pair of multifocal spectacles. Inclusive of a frame and consultation per beneficiary.LimitedtoR2 700.

Or

1 Pairofflattopbifocalspectacles. Inclusive of a frame and consultation per beneficiary.LimitedtoR1 645.

Or

1 Pair of multifocal spectacles. Inclusive of a frame and consultation per beneficiary.LimitedtoR1 900.

Or

1 Pairofflattopbifocalspectacles. Inclusive of a frame and consultation perbeneficiary.LimitedtoR1 485.

Or

1 Pair of multifocal spectacles. Inclusive of a frame and consultation perbeneficiary.LimitedtoR1 720.

Or

1 Pairofflattopbifocalspectacles. Inclusive of a frame and consultation per beneficiary.LimitedtoR1 350.

Nobenefitformultifocalspectacles.

Contactlenses Limited to R2 015 per beneficiary.

Limited to R1 060 per beneficiary.

Limited to R975 per beneficiary.

Nobenefit.

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Note: Pro-rated for members who join during the year.

ANNUAL LIMITS M R6 320M+1 R11 080M+2+ R12 030

Subject to MSA and ATB. Subject to day-to-day limits.

LimitedtoFlexiBenefit.M R1910perannum.M+R2420perannum.

Nobenefit. Limited to network provider benefits.

ALTERNATIVE HEALTHCARE SERVICES

• Biokineticists• Chiropodists• Chiropractors• Dieticians• Homeopaths• Naturopaths• Occupational Therapists• Osteopaths• Podiatrists• Social workers• Acupuncture

M R2 700M+1 R4 000M+2+ R5 300

100% of Scheme rate. Subject to annual limit.


LimitedtoFlexiBenefit. Nobenefit. Nobenefit.

ADDITIONAL OUT-OF-HOSPITAL BENEFITS SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION

Mammogram(screening) 1 Examination per female beneficiaryperannumoverthe age of 35 years.

1 Examination per female beneficiaryperannumoverthe age of 35 years.



Nobenefit.

NoBenefit.

Papsmears 1Testperbeneficiaryperannum.





PSAtesting 1Testperbeneficiaryperannum over the age of 45 years.

1 Testperbeneficiaryperannum over the age of 45 years.

1Testperbeneficiaryperannum over the age of 45 years.



VaccinationsFlu 1Dosefluvaccinationper

beneficiaryperannum.1Dosefluvaccinationperbeneficiaryperannum.

1Dosefluvaccinationperbeneficiaryperannum.

1Dosefluvaccinationperbeneficiaryperannum.

At discretion of Foundation network provider.

Childhood immunisations Childhood immunisations as recommended by the Department of Health up to 18 months.

Childhood immunisations as recommended by the Department of Health up to 18 months. Subject to limit of R1 590.



At discretion of Foundation network provider.

HPV vaccine (cervical cancer prevention) 1 course (3 doses per registered schedule) per femalebeneficiaryperlifebetween 9 and 46 years of age.

Nobenefit. Nobenefit. Nobenefit. Nobenefit.

Nurse helpline (including Rape Crises Centre) Advice and information regarding any emergency medical condition. Call 086 111 2162.

Advice and information regarding any emergency medical condition. Call 086 111 2162.





Oral contraception R1 272 per female beneficiaryperannum(R106 per month).

R1 272 per female beneficiaryperannum(R106 per month).




PREVENTATIVE CARE SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION

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Note: Pro-rated for proportional annual membership.

ADDITIONAL OUT-OF-HOSPITAL BENEFITS SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION

RADIOLOGy AND PATHOLOGyExcluding specialised radiology

M R2 700 M+1 R3 315M+2+ R4 000100% of Scheme rate. Subject to annual limit.


LimitedtoFlexiBenefit. Nobenefit. Limited to PMBs. Subject to network provider formulary list.

PHySIOTHERAPy R1 180 per family.100% of Scheme rate. Subject to annual limit.


LimitedtoFlexiBenefit. Nobenefit. Limited to PMBs.

PSyCHOLOGy AND PSyCHIATRIC TREATMENT R1 350 per family.100% of Scheme rate. Subject to annual limit.


LimitedtoFlexiBenefit. Limited to PMB at DSP providers.

Limited to PMB at DSP providers.

SPEECH THERAPy AND AUDIOLOGy R1 350 per family.100% of Scheme rate. Subject to annual limit.


LimitedtoFlexiBenefit. Nobenefit. Nobenefit.

ACUTE MEDICATIONSubject to relevant plan formularyReference and GRP pricing may applyBenefitprotocolsapplyUse preferred provider pharmacies

M R6 320 M+1 R11 080 M+2+ R12 030

With a sub-limit on Schedule 0-2 drugs of:M R1 910M+1 R3 285 M+2+ R3 605Subject to annual limit.

Subject to MSA, ATB and sub-limits of:M R5 000M+1 R6 900M+2 R8 200

With a sub-limit on Schedule 0-2 drugs of:M R1 485M+1 R2 070 M+2 R2 440

Subject to day-to-day limits and sub-limits of:M R3 180 M+ R6 360

With a sub-limit on Schedule 0-2 drugs of:M R955 M+ R1 910

Limited to:M R1 910M+ R2 470

With a sub-limit on Schedule 0-2 drugs of:M R530 M+ R742

Nobenefit. Limited to network providers. Scheme protocols and formularies apply. For non-dispensing providers, script limit of R80 per event limited to 4 events per beneficiary.

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2014 CONTRIBUTIONS SUPREME CLASSIC PROGRESSIVE FLEX HOSPITAL

PrincipalMember R3 035 R1 863 R1 536 R1 117

Adultdependant R2 951 R1 639 R1 414 R941

Childdependant R777 R703 R470 R413

2014 CONTRIBUTIONS: MILLENNIUM OPTION

Risk Saving Total

Principal R2 274 R569 R2 843

AdultDependant R1 865 R466 R2 331

ChildDependant R545 R136 R681

2014 CONTRIBUTIONS: FOUNDATION OPTION

Principal AdultDependant ChildDependant

R0 - R4 150 R639 R639 R192

R4 151 - R6 400 R763 R763 R263

R6 401 - R8 800 R967 R967 R308

R8 801+ R1 461 R1 461 R501

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PROCEDURE CO-PAyMENTS

PROCEDURE SUPREME MILLENNIUM CLASSIC PROGRESSIVE FLEX HOSPITAL FOUNDATION

Arthroscopy R 3 180 R 3 180 R 3 180 R 3 180 R 3 180 Procedures only funded for prior proven PMB conditions, and strictly subject to Scheme rules and protocols. Co-payments will remain applicable for hospitalisation ifbenefitsareappropriatefor out of hospital access, and where an alternative procedure that does not incur the co-payment is available. Applicable co-payments as for Classic option.

Co-payments for circumcision, nailbed excision, hysterectomy, myringotomy, tonsillectomy, adenoidectomy and tympanoplasty per Classic option irrespective of PMB status.

BenefitsrestrictedtoDSPproviders at DSP network hospitals. Additional R3 300 co-payment applicable for non-DSP hospitals. All Scheme rules and protocols remain applicable. All Scheme exclusions, including the additional exclusions for the Foundation option, remain applicable.

Circumcision No co-payment R 2 120 R 2 120 R 2 120 R 2 120

Colonoscopy, sigmoidoscopy, protoscopy

No co-payment R 2 120 R 2 120 R 2 120 R 2 120

Conservative back or spinal treatment

R 3 180 R 3 180 R 3 180 R 3 180 R 3 180

Cystoscopy No co-payment R 2 120 R 2 120 R 2 120 R 2 120

Dental admissions R 2 120 R 2 120 R 2 120 R 2 120 R 2 120

Excision nailbed No co-payment R 1 590 R 1 590 R 1 590 R 1 590

Gastroscopy No co-payment R 2 120 R 2 120 R 2 120 R 2 120

Gynaecological laparoscopy, endometrial ablation

R 3 180 R 3 180 R 3 180 R 3 180 R 3 180

Hernia repair No co-payment R 3 180 R 3 180 R 3 180 R 3 180

Hysterectomy No co-payment R 3 180 R 3 180 R 3 180 R 3 180

Hysteroscopy R 2 385 R 2 385 R 2 385 R 2 385 R 2 385

Joint replacements R 6 065 R 6 065 R 12 000 R 6 065* R 6 065*

Laparoscopic procedures R 3 180 R 3 180 R 3 180 R 3 180 R 3 180

Myringotomy No co-payment R 1 855 R 500 R 1 855 R 1 855

Nasal surgery (including endoscopy)

No co-payment R 4 770 R 4 770 R 4 770 R 4 770

Refluxsurgery R 9 115 R 9 115 R 9 115 R 9 115 R 9 115

Rotatorcuffsurgery R 6 065 R 6 065 R 6 065 R 6 065 R 6 065

Skin lesions No co-payment R 1 590 R 1 590 R 1 590 R 1 590

Spinal surgery R 6 625 R 6 625 R 12 000 R 6 625* R 6 625*

Tonsillectomy and adenoidectomy

R 1 855 R 1 855 R 500 R 1 855 R 1 855

Tympanoplasty R 1 590 R 1 590 R 500 R 1 590 R 1 590

Urinary incontinence repair R 3 180 R 3 180 R 3 180 R 3 180 R 3 180

Varicose veins R 3 180 R 3 180 R 3 180 R 3 180 R 3 180

*Subject to PMBs only.

Note:• Subject to Scheme rules, policies and protocols.• These co-payments are per incident or event.• Procedurespecificco-paymentsstillapply,evenforPMBs,ifalternativetoendoscopicorlaparoscopicsurgeryisavailable.

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DEFINITIONS

AIDS - AcquiredImmuneDeficiencySyndromeorAcquiredImmunodeficiencySyndrome.

ATB - AboveThresholdBenefit(Millennium option).

Benefitrate - Therateatwhichprovidersarefundedasspecifiedinthebenefitschedule.Thebenefitratereferstothecontracted(individual)rateorapercentageoftheSchemerate.

BHF - Board of Healthcare Funders.

BPH - Benign Prostatic Hypertrophy.

CAT/CTscan - Computerised Axial Tomography scan.

CDL - ChronicDiseaseList.Diagnoses,medicalmanagementandmedicationtotheextentthatthisisprovidedforbywayofatherapeuticalgorithmforspecifiedconditions,publishedbytheMinisterbynoticeintheGazette.

CMS - Council for Medical Schemes

Contracted rate - The fee or rate at which providers contracted to the Scheme are funded.

DSP - Designated Service Provider.

Exclusions - TheScheme’sgeneralandoption-specificlistofconditionandprocedureexclusions.

GP - General Practitioner.

GRP - Generic Reference Price. The price the Scheme funds as a representative price for identical active medication ingredients. All medication above the GRP is subject to a co-payment.

HIV - HumanImmunodeficiencyVirus.

HRT - Hormone Replacement Therapy for female menopause.

ICON - Independent Clinical Oncology Network.

MAV - MaximumAllowedValue.TheMaximumAllowedValuereferstomedicineswithanequallyeffective,lesscostlyalternativeonthemedicineformulary.Thepricecanbereferencedoneitheragenericortherapeuticsubstitute.ReimbursementforitemswithanMAVislimitedtothelistedprice,andmemberswillhaveaco-paymentforproductsabovethisprice.Thispricingstructureallowsmoreflexibleandindividualpatientpreference.

MRIscan - Magnetic Resonance Imaging scan.

MSA - Medical Savings Account (Millenniumoption).Atthebeginningofeachyear,asetRandamountwillbeallocatedtotheMSA.Thefundsallocatedcanbeusedthroughoutthebenefityearwithremainingamountscarriedovertothenextyear.

Networkprovider - A healthcare provider or group of providers selected by the Scheme as designated or preferred providers for diagnosis, treatment and care.

OTC - Over-the-counter medicine, i.e. schedule 0, 1 or 2 medication.

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PMB - PrescribedMinimumBenefits.Alistof271conditionsthatallmedicalschemeshavetocoverintermsoftheMedicalSchemesAct.Toviewthislist,visittheCMSwebsiteatwww.medicalschemes.com

Pro-ratedbenefits - Benefitentitlementcalculatedaccordingtothedurationofmembershipduringabenefityear.

PSA - ProstateSpecificAntigen.

Regulation 8 (3) - Regulation 8 (3) in terms of the Medical Schemes Act, No.131 of 1998.

ResoBaby - Maternitybenefitprogramme.

RPL - Reference Price List.

Schemeprotocols - Documentation that determines the Scheme’s funding.

Schemerate - ThereferencebaseratetheSchemeallocatesforaspecifictarifforrelevanthealthservice.ThisamountiscalculatedbasedonhistoricfeestructuresintheSchemeandisadjustedannually,boundbyCPI.

AllproviderswillbefundedatSchemeratesunlessthespecificprovideriscontractedtodeliverservicesatacontractedfee.Suchcontractswillgovernthecontractofservicesandthereforenoco-paymentsoradministrationfeesmaybechargedto members.

The Scheme rate or contracted rates govern all funding, including PMBs, except in true emergencies which require immediate treatment without any delay, or involuntary admissions, which will be limited to 300% of Scheme rate for non-contracted providers. Otherwise, additional fees charged by non-contracted providers are for the member’s account and CMS regulations will apply.

Feescanbeviewedonlyaftermemberloginonwww.resomed.co.zawithmembernumberandspecificprocedureand/ortariffcodes.Toavoidpossibleco-paymentsandlevies,membersareurgedtoutilisecontractedproviderswhicharelistedonwww.resomed.co.za.

SEP - Single Exit Price. The industry reference price for medication.

SPG - Self Payment Gap (Millennium option). The gap between accumulated savings and the threshold amount.

TTO - To take out. Medicines received on discharge from hospital.

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Notes:

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Notes:

Resolution Health Comparison Brochure 2014

Health & Medicine

Transcript of Resolution Health Comparison Brochure 2014