Service Book MUSHLAM PLATINUM · Dental care is given in the “Clalit Smile” chain of dental...

Service BookMUSHLAM PLATINUM

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July 2016Esteemed customers

We at Clalit are committed to provide you with the most high quality extensive and cost-effective health plan. The Clalit Mushlam Platinum Plan meets the needs of the whole family, while reducing family health expenses by thousands of ILS.In this booklet and on our website, you will find all the information about the plan’s wide range and diversity of services, including coverages added in recent years, such as:

• Support package for the oncology patient, providing professional escort and counseling, as well as reimbursement for treatments and operations in Israel and abroad

• Private surgery procedures with low deductible rates• Extended pregnancy package of up to 8,000 ILS, tailored to each expecting customer• Didactic or psycho-didactic assessment package for children with low deductible

rates, performed at institutions included in the Clalit arrangement For your convenience, we have launched a highly advanced system on our site, offering fast and easy access to information, plan’s service providers and other personal needs and errands, at mushlam.clalit.co.il For any further information, you may contact us from any phone at our customer service center at *2700.

We are committed to continue to lead the field of health insurances, to provide you with a unique service experience and advanced medicine, and be there for you when it really counts.

To good health,

Peretz GozaHead of health insurances

and Clalit Mushlam division

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What’s in the Booklet?

Support Package for the Oncologic Patient 6

Didactic or Psychodidactic Diagnoses for Children 6

Tests for Diagnosing Attention Deficit Disorder 7

Vaccination for Travelers 7

Dental Care 8

Optics for Children 9

Private Operations in Foreign Countries 10

Private Operations in Israel 11

Extended Pregnancy Basket 12

Pregnancy Tests 12

Egg donation in a Foreign Country 12

Maternal Recovery 13

Aesthetic Operations and Treatments 14

ER Ambulance Transport 15

The New Website 16-17

Platinum Code – Second Layer of 18-55

Receiving a Refund 56-57

* It shall be emphasized that the first part of the book constitutes a general description of services in the plan. The updated and binding text for the purpose of realizing rights is the text of the code that appears in the second part of the book.

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Support Package for the Oncologic Patient

Platinum clients are entitled to a support package for the oncologic patient, including:

• Operations and treatments abroad – 75% monetary refund for the expense and up to ILS 100,000 • Private local operations – 75% monetary refund for the expense and up to ILS 40,000 • Coverage for expenses of disease diagnosis and treatment – 75% monetary refund

and up to ILS 10,000 for expenses such as: medical consult, psychological treatments, complementary medicine and more • Professional consult and escort for a patient and his/her family during treatment – a

team composed of a nurse and a social worker, together with oncologic consultation throughout the stages of treatment, assisting with information and making decisions at critical interface points with excess insurance of ILS 500

Eligibility period: for two years after diagnosis.

Eligibility qualification period: 12 months.

Didactic or Psychodidactic Diagnoses for ChildrenPlatinum clients ages 6-18: With excess insurance of ILS 550 per didactic diagnosis at institutions under the arrangementWith excess insurance of ILS 950 per psychodidactic diagnosis at institutions under the arrangementOne test can be performed once during all membership periods in the plan.


* The binding terms and qualification periods are in accordance with the and Platinum Code.

6 | Didactic diagnosis with excess insurance of ILS 550

Tests for Diagnosing Attention Deficit Disorder

Platinum clients are entitled to MOXO or BRC or TOVA or NEUROTRAX tests with excess insurance of ILS 50 per test at institutions under the arrangement. Two tests can be done during the membership periods (including eligibility with "Mushlam Zahav").

Qualification period: 6 months.

Vaccination for travelersPlatinum clients are entitled to vaccinations for a cost up of up to ILS 20 per vaccination and free consultation at institutions under the arrangement.


| 7 Aaccination for travelers for a cost of uo to ILS 20 per vaccination

Dental Care

Platinum clients benefit from lifelong dental health! We at Clalit Platinum are aware of the heavy expenses involved with family dental care, and provide you with benefits that will help you save thousands of shekels a year.• Platinum clients ages 14 -18 are entitled to free preservative dental treatments, including: fillings, extractions, root canal treatment, fissures sealing and more• Platinum clients over 18 are entitled to preservative dental treatments with a 70% discount• Platinum clients under 18 are entitled to orthodontic dental care – teeth alignment with a 60% discount, and over 18 – 50% discount • All Platinum clients are entitled for prosthetic dental care with a 50% discount,

including: braces, crowns, implants, dentures and more

Dental care is given in the “Clalit Smile” chain of dental clinics, with over 85 clinics deployed nationwide. The discount is given upon service - the client only pays excess insurance. To find a dental clinic near your home, call Clalit Smile at *2829.The full list of treatments is detailed in the booklet, chapter A of the Code, pages 23-48.Eligibility qualification period: • Preservative care for children: 3 months • Preservative care for adults, surgeries, facial pain – occlusion disorder, periodontal

treatment, and first aid: 6 months • Prosthetic treatments – rehabilitation, orthodontics, implants and rehabilitation on

implants: 12 months

Preservative dental treatment ages 14 to 18 free of charge!


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Free eyeglasses every for children under 18

Optics for Children

Children with PLATINUM are entitled to receive free prescription eyeglasses every year until they are 18!The service includes: eyeglasses or contact lenses (non-cosmetic) free of charge for children under the age of 18, once a year. Eyeglasses include a frame, optic lenses and anti-reflex coating. The benefit is worth up to ILS 600.If the price of the eyeglasses or lenses exceeds ILS 600, the client will only pay the difference.The benefit can be used in the “Clalit Optic” chain, nationwide.Clalit Optic” stores meet the field’s highest professional standards.


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Private Operations in a Foreign Country

Platinum clients who wish to under surgery in a foreign country, one that is included in the operations list of or the Health Basket pursuant to the National Health Law, are entitled to significant participation in expenses according to the following specification: • Medical expenses related with an operation in Israel – funding medical expenses up to

200% of the price in the Ministry of Health’s pricelist or the price of a hospitalization day if one does not exist in the pricelist • Medical air transport – refunding expenses of medical air transport for performing an

operation, up to an amount of $10,000 • Expenses of an escort’s stay in a foreign country – a refund of up to $120 per day for

one person accompanying the patient during their stay in the foreign country, whereby the post-op hospitalization period is 11+ days and no more than 45 days (up to $5,400) • Refund of air transport for a body – if the client departed during his stay in a foreign

country, during the hospitalization period of during a period not exceeding 7 days as of his/her release from hospital in a foreign country, his/her family will be eligible to receive a refund for the expenses of air transport for a body up to an amount of $8,000 • Exercising such coverage is subject to receiving an operation approval by Clalit

Mushlam at a time when the Insured was staying in Israel, and possible for operations performed with complete hospitalization only


Participation in expenses for privet opertions abroad


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Operations in private hospitals with excess insurance of up to ILS 2,000

Private surgery in Israel

Platinum customers, who wish to undergo an operation included in the Clalit-Mushlam Agreement list, will be charged an especially low deductible, as set forth bellow:

• For a medical operation in a private hospital, by a privately employed surgeon, we offer a low deductible agreement 25% of the applicable Gold Plan deductible (however, no less than 300 ILS) of up to 2,000 ILS, except in cases of unusual procedures, for which a higher deductible will be charged.

Qualification term for eligibility: 12 months

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Extended Pregnancy Basket up to ILS 8,000

The Platinum plan allows pregnant women to receive a refund of ILS 8,000, up to 75% for expenses of consultation, tests and medical treatments related with pregnancy or labor as per the client’s choice, to all pregnancies during the plan membership period, such as: genetic tests, systems review, amniocenteses, blood tests for locating fetal down syndrome, caesarean section in a private Jerusalem "Sharap", a Doula or labor supporter and more.


Pregnancy Tests

Platinum clients are entitled to perform pregnancy tests with very low excess insurance fees at institutions under the arrangement.

• Systems review – with excess insurance of only ILS 57 • Amniocenteses or chorionic sampling – with excess insurance of only ILS 285

No qualification period.

Egg Donation in a Foreign Country

A Platinum client who is interested in an egg donation in a foreign country, for performing in vitro fertilization in a foreign country for the first and second children, is entitled to a 75% reimbursement for expenses of costs incurred in the fertilization process and up to an amount of ILS 11,962 for all attempts of each child.That is, provided that the Insured’s age does not exceed 52, and the treatment was preapproved by the plan’s medical director. The fertilization process will include the donor’s test, preparation, obtaining the egg and returning it to the donation receiver in a foreign country



Pregnancy Basket up to ILS 8,000 for tests and treatments 12 |

Maternal recovery from the first child

> Maternal Recovery

Platinum clients are entitled to participation in expenses of maternal recovery for the first or second or third child at a recovery institution or facility, up to 75% of the expense and no more than ILS 307/day and up to 3 days for a single child.


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Aesthetic Operations and Treatments

Platinum clients who are interested in undergoing aesthetic operations or therapies that are included in the plan will pay very low excess insurance fees:

Aesthetic operations (example prices):

Operation / Therapy Type Excess Insurance Platinum Client

Nose ILS 6,353

One eyelid ILS 5,504

Two eyelids ILS 9,356

Face or neck stretch ILS 18,480

Stomach stretch ILS 16,170

Breast lift or reduction ILS 10,973

(Breast enlargement (no implants ILS 6,300

Hyperhidrosis therapy – armpit ILS 3,100

Hyperhidrosis therapy – palms ILS 2,888

Hyperhidrosis therapy – feet ILS 3,158

Hair removal (example prices):

Operation / Treatment Type Excess Insurance Platinum Client

Women’s mustache ILS 553

Armpit ILS 609

Groin ILS 753

Back ILS 3,600

Shoulders ILS 1,702

Legs – calf ILS 2,182

Legs ILS 3,600

Eligibility qualification period: 12 months.A list of all operation and treatment types is specified in chapter F of the Code, page 52.

Please find a branche: Clalitaesthetics *2829 ׀ Proportsia *5599 ׀ Care *2273


Aesthetic opertions and treatments with low excess insurance 14 |

Ambulance transport to the ER twice a year

ER Ambulance Transport

Platinum clients who are in urgent need of a licensed ambulance to a public hospital ER (including MICU), are entitled to receive 50% reimbursement for the actual expense up to ILS 300, twice per calendar year. That is provided that the Insured were not hospitalized and are entitled to receive reimbursement pursuant to the National Health Insurance Law.


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The Clalit Mushlam Website also available on your mobile phone

The Clalit Mushlam website, with all of the information it offers on Clalit-Mushlam’s services and suppliers can also be accessed on your mobile phone!

Our website offers the following services:

• Complete information about the Gold and Platinum Plans, and eligibility for each of

the services in them

• List of service providers: physicians, surgeons and suppliers who provide our services

• Direction to a Waze connection to the address of the supplier or the physician

• Chats with our service representatives

• Independently investigating and performing: status of claim, personal eligibility

inquiry, debt repayment and more

• Order home laboratory service

• Applying for the plan

Go to mushlam.clalit.co.il or google Clalit Mushlam

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Platinum Code – Second Layer of Clalit Mushlam

1. Introduction:1.1. This Code indicates that in return for payment of participation fees subject the following terms,

provisions and exceptions, the Associate will be eligible to receive services pursuant to the Code.

1.2. Coverages pursuant to this code are supplementary coverages to the Health Services Basket and services and coverages provided under the plan for additional health services – Clalit Mushlam (herein: ) and subject to the relevant provisions of the National Health Law, 1994 (herein: “Health Insurance Law”). In any case of contradiction between the aforesaid in the Code and the aforesaid in the Health Insurance Law, the Law’s provisions supersede.

1.3. The following are some relevant sections of the Health Insurance Law pertaining to plans of additional health services:

1.3.1. Section 10 (b) (2) of the Health Insurance Law: “The Fund may change, from time to time, Associates’ rights in the plan and Associates’ payments”.

1.3.2. Section 10 (c) of the Health Insurance Law: “(1) A Health Fund shall add to the plan any Insured who seeks to join it, regardless of his/ her health or financial situation, and shall not restrict his/her joining or rights at the time of their joining with any condition, except for reasonable qualification periods that will be determined regarding all Associates in the plan for various services therein, and provided that the aforesaid qualification period will not be determined for services that were included in the services basket and the Fund’s payments; (2) The Fund may determine, in regards to qualification periods as aforesaid in paragraph (1), various provisions in regards to moving from another Fund’s plan”.

1.3.3. Section 10 (d) of the Health Insurance Law: “Subject to the aforesaid in Ss (c), a Health Fund will not discriminate between Associates in the plan, either upon joining it or in providing its services”.

1.3.4. Section 10 (e) of the Health Insurance Law: “The price of the plan will be fixed for any age group, with no regard to the Associate’s membership seniority in the plan or his/her health or financial situation”.

1.3.5. Section 21 of the Health Insurance Law: “(a) A Health Fund will provide any under its responsibility as aforesaid in section 3(c) all of its health services to which he/she is entitled to pursuant to this law, either personally or through service providers, without discrimination and shall not condition the provision of services included in its services basket by joining or being a member of a plan for additional services pursuant to section 10. (b) Non-payment or a delay in the payment of health insurance fees shall not exempt the Health Fund from its obligation to provide the health services included in the Health Services Basket. 2. Definitions In this Code (“the Code”), the following terms shall bear the definitions next to them:

2.1. “Membership Application” – an application to join , requested by the Clalit Insured for him/ her and/or for his/her children or requested by a guardian for the Clalit Insureds under his/ her guardianship.

2.2. “Membership Notice” – a page with the Associate’s details, joining dates, base index, initial participation fees and any other detail that requires mentioning in writing, and also constitutes a membership confirmation form.

2.3. “Clalit” – Clalit Health Services (Clalit Health Fund)

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2.4. “The Plan” or “Mushlam Platinum” – a plan for additional health services, second layer, according to the provisions of this Code, the name of which is “Mushlam Platinum”.

2.5. “Appeals Committee” – a committee appointed by Clalit Health Services. Committee composition will be adapted to the issues before them.

2.6. “Clalit Insured” – an individual who is insured with Clalit pursuant to provisions of the Health Insurance Law.

2.7. “Index” – the Consumer Price Index that includes vegetables and fruit, published by the Central Bureau of Statistics, or in lack of such publication, an index published by another official body in its place.

2.8. “Crediting Case” – a system of facts and circumstances as described in each chapter of the Code, the fulfillment of which grants the Associate a right to additional health services pursuant to the Code.

2.9. “Eligibility Amount” – the maximum amount Clalit will be obligated to pay for a single crediting case.

2.10. “Associate” – an 18+ individual insured with Clalit Health Services who has filled a membership form as required and signed the bank standing order for payment of participation fees, and his/her child (an Associate under 18), and any person appointed as his/her guardian, whose parent is a Clalit Insured and an Associate with, or his/her guardian, who has asked to be add him/her to “Mushlam Platinum” and committed to paying participation fees for him/her.

2.11. “Qualification Period” – a sequential period that is specified in each of the Code chapters and starts for any Associate on the day in which the eligibility of that Associate first started pursuant to this Code and ends upon conclusion of the specified period in each chapter, in regards to a crediting case according to that chapter. The qualification period will apply to every Associate once in sequential periods of eligibility, and will apply again whenever an Associate has re-joined the plan, in non-sequential periods..

2.12. ”Code” – code for additional health services for members of Clalit Health Services. In any section in this Code that includes a reference to the Clalit Mushlam Code for Additional Health Services, it refers to the final approved text that was in effect at the time of the crediting case’s occurrence pursuant to this Code.

2.13. ”Associate” – as the term “Associate” is defined in the Code.

2.14. “Participation Fees” – as defined in section 9 of this Code.

2.15. “Foreign Country” – a country that is registered as a member of the UN organization and has Israeli diplomatic representation in its territory.

3. Adding a Insured to "Mushlam Platinum"3.1. Clalit will add to "Mushlam Platinum" any individual who has met the following terms:

3.1.1. He/she is an Associate in , according to the Code.

3.1.2. He/she has submitted a membership application to Clalit.

3.1.3. He/she has provided Clalit with a commitment to pay the participation fees and also a bank or credit card standing order for payment of the participation fees.

3.2. In the event a Clalit Insured has asked to add his/her child who is an Associate in Clalit Mushlam to the "Mushlam Platinum" plan or a guardian has asked to add a Clalit Mushlam

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Associate under his/her guardianship to "Mushlam Platinum", shall submit a membership application for him/her, a commitment to pay the participation fees, and sign a bank or credit card standing order for payment of the participation fees.

4. General Restrictions to the Liability of CLALIT Clalit Health Services will neither be liable nor obligated to pay for additional health services, wholly or partially, according to one or more of the Code’s chapter, in each of the following cases:

4.1. The health services or medical treatments have been provided prior to the beginning of the eligibility period or thereafter conclusion of the eligibility period.

4.2. The Associate is entitled to compensation for the eligibility case by the power of the following laws:

4.2.1. Compensation of Road Accident Victims Law, 1975.

4.2.2. Remunerations to Victims of Hostilities, 1970.

4.2.3. Chapter E of the National Insurance Law (Consolidated Version), 1995 (Work Injuries Insurance).

4.2.4. Persons with Disabilities Law (Compensation and Rehabilitation), 1959 (Consolidated Version).

4.2.5. Zion Prisoners and Their Families Remunerations Law, 1992.

4.2.6. Victims of Nazi Persecution Law, 1957.

4.2.7. Victims of War with the Nazis Law, 1954.4.3. The aforesaid hereinabove notwithstanding, the Associate will be entitled to the services included

in Chapter C of this Code (participation in the cost of performing a private operation) and section 1 of the table in Chapter D of this Code (consulting with a local specialist) in each of the cases specified in sections 4.2.1 and 4.2.3 hereinabove (road accidents and work injuries).

5. General Terms for Receiving Medical Services:5.1. Clalit Health Services will provide the Associate with the medical services to which he/

she is entitled, as specified in the Code’s chapters.

5.2. In case of medical treatments that are not provided by Clalit as aforesaid, the Associate will be entitled to receive refunds for the treatment, as specified in the Code.

5.3. A medical treatment not through Clalit Health Services and payment of refunds as aforesaid are conditioned by Clalit’s prior approval.

5.4. Clalit Health Services will provide its response to a claim within reasonable time and in any case no later than 60 days after receiving the claim from the Associate. In urgent cases, a response will be given within a shorter period of time and in a manner that would not impact the Associate’s health. It is hereby clarified that managing and clearing claims in relation with the Platinum plan will be performed by Clalit and/or any on its behalf.

6. Payment of Claims:6.1. Clalit may, at its sole discretion, pay for the additional health services, directly to whoever

had provided the Associate with medical service, or pay them to the Associate after he/she has had presented an original invoice from the provider. Payment to the Associate will be executed to the method of payment with which participation fees are paid.

6.2. An Associate is entitled to receive from Clalit Health Services, as per his/her demand, advances or a monetary letter of commitment, which will allow him/her to receive medical service as specified in the Code’s chapters, and provided that his/ her eligibility pursuant to the Code is undisputed.

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6.3. Payments that were meant to finance medical treatments performed outside of Israeli borders will be paid in the currency of the state in which payment must be executed.

6.4. Amounts that are specified in foreign currency and paid in Israel will be paid in ILS according to the (high) transfer and check rate of the aforementioned foreign currency in Bank Hapoalim Ltd. in the day of preparing payment.

6.5. In the event that an Associate has passed away and a debt balance remains to a medical service provider due to medical service that was given to the Associate prior to his/her demise, Clalit Health Services will pay the debt balance as aforesaid to the medical service provider, if the remaining debt balance (for medical service given to an Associate prior to his/ her demise) is personally owed by the Associate who has passed away, Clalit will pay the debt balance as aforesaid to the Associate’s lawful replacement.

6.6. In the event that an Associate also had an indemnification right to a third party because of a crediting case and not by power of an insurance contract, this right will be transferred to Clalit which has paid the Associate and in the amount of compensation that it paid, and without derogating from the Associate’s right to initially collect indemnification from the third party in excess of the amount that he/she had received according to this document. Inasmuch as the Associate has received indemnification from a third party that is deserved by Clalit pursuant to this section, he/she must transfer it to Clalit. The Associate commits to cooperating as much as he/she is required to for the purpose of realizing Clalit’s right as aforesaid.

6.7. Inasmuch as all or some crediting cases have been insured with another insurer (herein: “Double Insurance”), the Associate must notify Clalit Health Services about it. The Associate’s right to receive service or indemnification for it according to this Code, in cases of double insurance, will apply to the proportional share of Clalit out of all plans or policies that apply to the case. The services (or indemnification of it) according to this Code will be wholly given by Clalit, provided that against provision of service (or indemnification) and as a condition thereof the Associate will sign any document that is required and/or useful, according to Clalit’s discretion, to allow Clalit to be paid and / or indemnified and / or reimbursed from other Insurers as aforesaid, and in general, but without derogating from the generality of the aforesaid, the Associate will sign any document by which he/she is transferring and/or assigning his/her aforementioned rights vis-à-vis the other insurers to Clalit and also empowers Clalit or any on its behalf to sue the other insurers in his/her name and on his/her behalf.

7. General Terms of CLALIT’s Liability7.1. A Platinum Associate who is interested in receiving a service that is included in this Code

will notify Clalit about it and provide Clalit with all information and documents required for clarifying its liability, and if he/she does not possess them, he/she must assist Clalit with obtaining them and therefore he/she must, among others, sign a letter of agreement on waiving medical confidentiality and providing instructions to any doctor or medical institutions or national insurance institution and any other authority to provide Clalit with the full medical information regarding the Associate that might impact the regarded claim.

7.2. Clalit may run any test or investigation on its own account, for the purpose of clarifying its liability pursuant to the Code. Clalit will provide its response to the Associate within reasonable time and no later than 60 days after submission of the claim, and provided that the test process does not delay the treatment with a delay that might risk the Insured or his/her health. Clalit’s right to run investigations and tests shall not be impacted if god-forbid the Associate has died.

8. Eligibility Amount:8.1. The maximum amount paid by Clalit Health Services for each chapter will not exceed the

amount specified therein.

8.2. The eligibility amounts specified in USD will be converted to other currencies, including ILS, according to the rules set in section 6 hereinabove.

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8.3. The eligibility amounts specified in ILS will be index-linked, whereby the base index is the index published on 15.7.2016 and the adjustment index is the index known at the time of Clalit Health Services’s execution of payment to the Associate.

9. Participation Fees and Their Method of Payment:9.1. The initial participation fees of each Associate will be determined according to the Associate’s

age upon starting the eligibility period. Participation fees will change according to age groups. The participation fees table, as it exists at the time of publishing this edition of the Code, is attached as Appendix A of the Code. Clalit Health Services may, from time to time, change the participation fees, subject to sections 10 (a) and 10 (b) (2) of the Health Law.

9.2. The participation fees will change every month in accordance with the index known on the day of payment execution by the Association, including a negative index.

9.3. Participation fees will be paid in a bank standing order provided by the Associate to Clalit Health Services upon starting the eligibility period. Clalit will collect the participation fees on the first of every month, or every two or three months in the first half year of the first month of each period as aforesaid.

9.4. Any delay or suspension of the participation fees payment will cause the cancellation of the Associate’s rights pursuant to section 12 of the Code. The amount in arrear will be put to immediate repayment with interest and linkage differentials to the time of its actual payment.

9.5. Clalit Health Services is entitled to deduct the Associate’s participation fees in arrears (including accumulated interest and linkage differentials).

10. Eligibility Period: Subject to the aforesaid in section 12 hereinabove, the eligibility period under this Code is unlimited. Decisions to terminate the plan and arrangements for its termination will be approved by Clalit Health Services’s Board of Directors and are pending the Minister of Health’s approval.

11. Changes to the Code: Clalit may cancel and/or change this Code (entirely and/or certain services and/or coverages included therein), from time to time, by a decision of Clalit Health Services’s Board of Directors and subject to the Minister of Health’s approval, pursuant to the Health Insurance Law.

12. Cancelling Eligibility:12.1. Cancellation by Clalit Health Services:

Clalit may notify an Associate regarding cancellation of eligibility 60 days prior to its cancellation in the following cases:

12.1.1. The Associate is not paying or insurance fees for the Associate were not paid in order, 60 days prior to its cancellation.

12.1.2. The Associate has filed a false payment claim to Clalit with fraudulent intentions.

12.1.3. An Associate who received the aforementioned notice and paid his/her debt (including interest and linkage differentials of 4%) in full within the notice period (60 days), the eligibility cancellation notice will be voided.

12.1.4. An Associate who received the aforementioned notice may appeal it in front of an appeals committee during the 60 days. The cancellation notice will enter into effect only upon the final resolution of the appeals committee or upon 60 days, whichever is late. The Associate may represent himself/herself or be represented by his/her proxy.

12.2. Cancellation by the Associate: eligibility pursuant to this Code can be cancelled at any time by the Associate upon a written notice delivered to Clalit. Eligibility cancellation will enter into effect within 30 days of delivering notice.

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12.3. Automatic cancellation: the Associate’s eligibility will be automatically cancelled whenever the Associate’s eligibility in has been cancelled pursuant to the Clalit Mushlam Code.

13. Appealing a Claim Rejection: In the event an Associate’s payment claim pursuant to this plan has been rejected, the Associate may appeal the rejection in writing in front of an appeals committee. The Associate may be represented in the appeals committee’s hearings by himself/herself or be represented by his/her proxy.

14. Application of Laws: The Health Insurance Law provisions shall apply to this Code as applicable

15. Notifications: The Associate must notify Clalit Health Services on any change in his/her address in a letter sent by registered post. The notification will be considered as delivered by Clalit Health Services to the Associate’s last known address it has as a lawfully delivered notification. Any notification meant for Clalit as well as documents that should be delivered to Clalit Health Services shall be delivered in writing to its main offices at 101st Arlozorv Street, Tel Aviv, or to the Associate’s clinic.

Chapter A: Dental Care1. Medical Service Participation in expenses of dental care performed in S.L.H. – Sherutey Refua Ltd. chain of dental clinics (herein: S.L.H or Clalit Smile).

2. Crediting Case2.1. Performing dental care according to the list that is attached as an appendix to this chapter

(herein: “the List”), as updated from time to time, and subject to a periodic treatment quota as specified in the list.

2.2. Eligibility in this chapter does not include the cost of anesthesia (sedation or general anesthesia), inasmuch as required in the treatments specified in the list.

2.3. Eligibility does not include aesthetic dental care as specified in the list.

2.4. In the event an Associate has started a treatment from the list of treatments as aforesaid in the list prior to starting the eligibility day and has continued it on the day of eligibility or thereafter, will not be eligible to receive coverage for the treatment according to this chapter. In this regard, eligibility day is the day which begins simultaneously with the conclusion of the qualification period according to this chapter.

3. Eligibility3.1. Preservative dental care for Associates over 14:

3.1.1. For Associates who are over 14 years of age and under 18 – “Children Preservative” dental care as defined in the list will be given without excess insurance, subject to the aforesaid in the provisions of this chapter.

3.1.2. For Associates over 18 – “Preservative” dental care as defined in the list – the Associate will pay, directly to the clinic, 30% of the price in the dental care pricelist for Clalit Health Services’s Insured in the S.L.H. chain of dental clinics (herein: “the Pricelist”).

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3.2. In regards to other dental treatments on the list, for all ages – excluding treatments that have been defined in a national health insurance order (addition of dental health services to the second addition to the law), 2010- the Associate will pay 50% of the pricelist price directly to the clinic. The aforesaid notwithstanding, in regards to orthodontic treatments, an Associate under 18 will pay 40% of the pricelist price directly to the clinic.

3.3. The eligibility amount as aforesaid includes the discounts and/or benefits to which the Associate is entitled in the “Mushlam Zahav” plan, and not in addition to them, the aforesaid has no double benefits. The pricelist can be found at S.L.H. clinics, and might be updated from time to time. It shall be clarified that the aforesaid does not derogate from the Associate’s right pursuant to the “Mushlam Zahav” plan.

3.4. In reference to emergency treatments (FA) appearing in the Treatment List appendix in this chapter – an Associate who resides over 45 minutes of drive and no less than 30 KM away from the clinics operated by SLH and/or any on its behalf during nighttime is eligible for reimbursement for such treatments in case he requires emergency treatment and urgent first aid assistance for his teeth during hours of the night in which “night clinics” operate on behalf of SLH, granting first aid in dental treatments. All provided that he had called Clalit’s call center in real time and notified on the need to receive first urgent first aid and received phone confirmation to go and receive first aid by a private doctor due to the distance from the fund’s clinic. The Associate will be eligible for reimbursement in an amount that equals the actual expense and up to a maximum amount no greater than SLH’s tariff for emergency treatments (FA) in accordance with SLH’s price list at the relevant time. Excess insurance fees collected for treatment at clinics under the arrangement will be deducted from the reimbursement amount. The reimbursement is conditioned by a medical letter specifying the treatment that was performed. It is clarified that continued treatment, inasmuch as required, shall be done at arrangement clinics only.

4. Qualification Period*Children preservative dental treatments for Associates who are over 14 and under 18 shall have a 3-month eligibility qualification period. For preservative, Surgical, Facial Pain – Occlusion disorders, periodontal treatments and first aid clinic as aforesaid in the list, shall have a 6-month eligibility qualification period pursuant to this chapter. Other dental treatments with prosthetics – rehabilitation, orthodontics and “implants and rehabilitation on top of implants” as aforesaid in the list – shall have a 12-month eligibility qualification period. * Qualification periods for services under this chapter shall not apply to an Associate who joined “Mushlam Platinum” before July 21st, 2009 shall

5. Realizing Eligibility Eligibility for treatments under this chapter is subject to the prior approval of the plan’s medical director, or any on his/her behalf. Clalit will not be obligated to pay the eligibility amounts if the Associate did not seek prior approval for performing any of the treatment types specified in this chapter hereinabove.

6. Exclusion for General Liability Clalit Health Services shall neither be liable nor obligated to participate in paying for any treatments as specified in this chapter hereinabove and in the list in a case where the Associate is entitled to receive the aforesaid treatment as part of a policy issued by the Ministry of Education (herein: “Student Accident Policy”) and covers, among others, dental treatments for children as a result of accidents, as aforesaid in the Student Accident Policy.

24 |

Treatments List Appendix

CN Note CN Description Product Family Description

Qualification Period

Notes

1100 Free basic test Children Preservative 3 months Once every 6 months

1106 Consultation with a specialist for children

Children Preservative 3 months

1107 Test and plan for treatment under general anesthesia


1165 Nitrous Oxide (laughing gas) one session


1166 Using premedication (one session)


1167 Premedication – Dormicum


1202 Bite radiography Children Preservative 3 months According to a Clalit Smile referral

1204 Half status Children Preservative 3 months According to a Clalit Smile referral

1205 Status Children Preservative 3 months According to a Clalit Smile referral

1206 Status of parallels Children Preservative 3 months According to a Clalit Smile referral

1207 Calibrated status of parallels

Children Preservative 3 months According to a Clalit Smile referral

1208 Panoramic radiography Children Preservative 3 months According to a Clalit Smile referral

1209 Occlusive radiography Children Preservative

3 months According to a Clalit Smile referral

1301 F. aid diagnosis and/or drug prescription

Children Preservative

3 months

1305 Emergency care (F. aid) Children Preservative

3 months

1305 Specialist Emergency care (F. aid) - specialist


3 months

1320 Restoration of one surface including polishing


3 months Once per year from all types of restoration in that tooth

*Exception in reegards to aesthetic treament: it is hereby clarified that the entitlement for (white) composite fillilngs according to this appendix does not incluld aesthetic treatment

| 25



Notes

1321 Restoration of two sequential surfaces (II-CL) including polishing



1325 Restoration – up to two surfaces



1330 Restoration of 3 surfaces (MOD) or non-sequential



1340 Restoration from a composite material one surface*



1342 Restoration from a composite material two surfaces*



1345 Restoration – three surfaces and more



1355 Restoration from light-hardened composite material*



1361 Restoration of tooth neck/canal in material based on glass-ionomers



1415 Root canal treatment for a primary tooth (including final radiography)


3 months

1419 Laser addition (endodontic)


3 months

1425 Root canal treatment – one canal


3 months

1425 Specialist Root canal treatment – one canal – specialist


3 months

1435 Root canal treatment –two canals


3 months

1435 Specialist Root canal treatment –two canals – specialist


3 months

1440 Root canal treatment – three canals


3 months

1442 Root canal treatment – four canals


3 months

1444 Root canal treatment of a tooth with abnormal anatomy


3 months

*Exception in reegards to aesthetic treament: it is hereby clarified that the entitlement for (white) composite fillilngs according to this appendix does not incluld aesthetic treatment 26 |



Notes

1445 Root canal treatment – three canals and more


3 months

1446 Bandage in calcium hydroxide between sessions for a dirty tooth


3 months

1447 Root canal treatment for a tooth with endodental history


3 months

1450 Apexification of an open root-end (for each session)


3 months

1460 Root canal treatment renewal – one canal


3 months

1470 Root canal treatment renewal – two canals


3 months

1480 Root canal treatment renewal – three canals


3 months

1485 Treatment with calcium hydroxide fixed tooth apexification/dirty


3 months

1490 Root canal treatment renewal – four canals


3 months

1492 Screw/bracket/silver screw posts extraction (one tooth)


3 months

1493 Microscope-assisted treatment (for a tooth)


3 months

1494 Removing/bypassing broken equipment from the canal with a microscope


3 months

1495 Pulpotomy Children Preservative

3 months

1496 Pulpotomy (excluding external restoration)


3 months

1497 Root-end resection by an Endodontist with a microscope


3 months

1498 MTA treatment Children Preservative

3 months

1515 Extraction Children Preservative

3 months

*Exception in reegards to aesthetic treament: it is hereby clarified that the entitlement for (white) composite fillilngs according to this appendix does not incluld aesthetic treatment | 27




Notes

1515 Extraction – specialist Children Preservative

3 months

1535 Surgical extraction (including stitches)


3 months

1540 (not locked) Wisdom tooth extraction


3 months

1620 Focal treatment with fluorine / dental sensitivity tretment


3 months Once per year

1655 Treatment with fluorine spoons including instructions for dental hygiene



1655 Specialist Treatment with fluorine spoons including instructions for dental hygiene – specialist



1675 Fissures sealing (for each tooth)


3 months Once every two years for each tooth

1800 Aesthetic restoration with a composite material in front teeth CLASS III*


3 months Once per year from all restorations types in that tooth

1801 Aesthetic restoration with a composite material in front teeth CLASS IV*



1802 Composite restoration in front teeth CLASS IV*



1804 Broken tooth restoration(no root canal or bracket)



1804 Specialist Broken tooth restoration(no root canal or bracket) - specialist



1806 Addition for pre-pulperic screw posts



1808 Aesthetic composite restoration in back teethSingle surface-direct*



1810 Aesthetic composite restoration back Direct 2 or 3 surfaces*



1812 Aesthetic restoration TUNNEL Amalgam+Composite*



1816 Aesthetic restoration back, with a composite clinic material*



28 |




Notes

1832 Non-vital brightening (excluding restoration or composite coating)


3 months Once per year in that tooth

2125 Industrial/composite light-hardened crown


3 months

2135 Placeholder on a crown or ring (one side)


3 months

2155 Pulp capping as first aid Children Preservative

3 months

2165 Broken tooth restoration with a composite material*



2175 Returning a tooth that has been extracted in an accident to alveolus, fixing with a composite material*


3 months

2185 Removing fixing (due to post-accident treatment)


3 months

2195 Broken tooth restoration with an industrial anchoring peg



2215 Returning any additional tooth in that session


3 months

2225 Fixing moving teeth Children Preservative

3 months

6030 Hemisection Children Preservative

3 months

6040 Hemisection – root amputation


3 months

6050 Locked tooth extraction operation (wisdom tooth, cuspid)


3 months

6067 Repairing a perforation in the pulp chamber


3 months

6068 Repairing a perforation in the root canal


3 months

6080 Cyst extraction Children Preservative

3 months

9000 Test Children Preservative

3 months

| 29



Notes

9001 Periapical or bite radiography


3 months

9009 Trepanation/Extraction Children Preservative

3 months

9019 MUSHLAM difference – unique clinic


3 months

9020 Regular extraction including radiography


3 months

9021 Surgical extraction excluding radiography


3 months

9022 Extraction of a locked tooth including radiography


3 months

9040 Temporary filling Children Preservative

3 months

1100 Semi-annual test and mapping (excluding radiography)

Preservative 6 months Once every six months

1204 Half status Preservative 6 months According to a Clalit Smile referral

1205 Status Preservative 6 months According to a Clalit Smile referral

1206 Status of parallels Preservative 6 months According to a Clalit Smile referral

1207 Calibrated status of parallels

Preservative 6 months According to a Clalit Smile referral

1208 Panoramic radiography Preservative 6 months According to a Clalit Smile referral

1209 Occlusive radiography Preservative 6 months Once

1300 Emergency care (first aid) Preservative 6 months

1301 F. aid diagnosis and/or drug prescription

Preservative 6 months

1320 Restoration of one surface including polishing

Preservative 6 months Once per year from all restorations types in that tooth

1321 Restoration of two sequential surfaces (II-CL) including polishing


30 |




Notes

1330 Restoration of 3 surfaces (MOD) or non-sequential


1340 Restoration from a composite material one surface*


1342 Restoration from a composite material two surfaces*


1361 Restoration of tooth neck/canal in material based on glass-ionomers


1419 Laser addition (endodontic)




1430 Root canal treatment – two canals


1440 Root canal treatment – three canals


1442 Root canal treatment – four canals


1444 Root canal treatment of a tooth with abnormal anatomy


1446 Bandage in calcium hydroxide between sessions for a dirty tooth


1447 Root canal treatmentfor a tooth with endodental history


1450 Apexification of an open root-end (for each session)


1460 Root canal treatment renewal – one canal


1470 Root canal treatment renewal – two canals


1480 Root canal treatment renewal – three canals


1490 Root canal treatment renewal – four canals


1492 Screw/bracket/silver screw posts extraction (one tooth)


| 31



Notes

1493 Microscope-assisted treatment (for a tooth)


1494 Removing/bypassing broken equipment from the canal with a microscope


1496 Pulpotomy (excluding external restoration)


1497 Root-end resection by an Endodontist witha microscope


1498 MTA treatment Preservative 6 months

1510 Regular Extraction Preservative 6 months

1530 Surgical extraction Preservative 6 months

1540 (not locked) Wisdomtooth extraction


1560 Abscess drainage Preservative 6 months

1603 Scaling and root planning a session of up to 30 minutes with a doctor’s referral

Preservative 6 months 4 per year from all scaling and root planing/gum recession codes

1604 Scaling and root planning a session of 50 minutes with a doctor’s referral

Preservative 6 months 4 per year from all scaling and root planing/gum recession codes

1620 Treatment with concentrated fluorine (Durfort) for the jaw

Preservative 6 months Once per year

1621 Treatment with fluorine spoons including instructions for dental hygiene

Preservative 6 months Once per year

1630 Test – breath Preservative 6 months Once every three years

1640 Review – breath Preservative 6 months Once every three years

6067 Repairing a perforation in the pulp chamber


6068 Repairing a perforation in the root canal


32 |



Notes

6069 Purposeful implanting )Reimplantation)




1420 Specialist Root canal treatment –one canal – specialist


1430 Root canal treatment –two canals


1430 Specialist Root canal treatment –two canals – specialist


1510 Extraction Preservative 6 months

1510 Specialist Extraction – specialist Preservative 6 months

1803 Broken toothrestoration (no canal treatment or bracket)


1560 Specialist Abscess drainage – specialist

Surgery 6 months

1790 Crown lengthening surgery for one tooth

Surgery 6 months

1792 Crown lengthening surgery for two adjacent teeth in one session

Surgery 6 months

1794 Crown lengthening –tooth addition (2-4 teethin one session)

Surgery 6 months

6030 Hemisection Surgery 6 months

6040 Hemisection –root amputation

Surgery 6 months

6050 Locked toothextraction surgery (wisdom tooth, cuspid)

Surgery 6 months

6060 Episectomy of a toothwith 1 root and no retrograde filling

Surgery 6 months

6062 Episectomy of a toothwith 2 roots and no retrograde filling

Surgery 6 months

| 33



Notes

6064 Episectomy of a tooth with 3 roots and no retrograde filling

Surgery 6 months

6066 Back retrograde fillingfor each root

Surgery 6 months

6070 Exposing a locked toothto orthodontic attraction

Surgery 6 months

6080 Cyst extraction Surgery 6 months

6090 Vestibular deepening Surgery 6 months

6100 Pre-prosthetic surgery¼ mouth

Surgery 6 months

6110 Biopsy surgery – add a code for a histo-pathological test

Surgery 6 months

6111 \ Histo-pathological test (including delivery)

Surgery 6 months

6120 Other small surgery Surgery 6 months

6401 Test – occlusion disorders, joints – district referral

Surgery 6 months

6501 Test – dental health – district referral

Surgery 6 months

6510 Payment for a test bya professional dentist (for each quarter)

Surgery 6 months

7010 Test/treatment Facial Pains – Occlusion Disorders

6 months

7011 Test/short treatment Facial Pains – Occlusion Disorders

6 months

7020 Diagnostic/therapeutic splint (hardened)

Facial Pains – Occlusion Disorders

6 months

7030 Diagnostic/therapeutic splint (soft)

Prosthetics - Rehabilitation

6 months

1360 Amalgam crown Prosthetics - Rehabilitation

12 months


34 |




Notes

2000 Veneer crown or unit in veneer races includingthe pirce of gold


12 months Once every 5 years from all crown types in this appendix and in that tooth, except for if required due to a medical problem

2001 Test and treatment plan for oral rehabilitation



2030 Cast non-gold bracket, semi-noble metal


12 months

2031 Cast gold bracket, including gold


12 months

2035 Cast bracket (non-gold) Prosthetics - Rehabilitation

12 months

2040 Bracket performedat the clinic


12 months

2041 Direct bracket from composite material including anchoring peg


12 months

2042 Acrylic crown performed in a lab**



2050 Acrylic crown performed in a clinic**



2050 Specialist Acrylic crown performed in a clinic – specialist**



2054 Adjustment of old fixed braces (after their removal) as temporary braces


12 months

2065 Fabricated acrylic crown performed in a lab**


12 months

2080 Any connector – add lab price



2110 Porcelain crown – joined for semi-noble metal – including the price of metal**



2111 Permanent gluing of a crown/braces


12 months

| 35




Notes

2114 Porcelain crown – chrome cobalt metal**



2130 Complete telescope crown (upper+lower)



2140 Root dome of semi-noble metal



2141 Root dome of chrome cobalt



2142 Root dome of gold Prosthetics - Rehabilitation


2160 Teaching patterns (pair) Prosthetics - Rehabilitation

12 months

2214 Porcelain crown metal chrome cobalt including temporary crown**



2613 Maryland bridge – intermediate part with the approval of a head physician



2614 Maryland bridge – wing with the approval of a head physician



3000 Upper CD, ACRY ROCK teeth pad 6 months as necessary



3001 Upper CD + cast chain (chrome cobalt) ACRY ROCK teeth



3002 Complete upper denture with VIVO DENT teeth



3003 Upper CD cast chain with VIVO DENT teeth



36 |



Notes

3010 Complete lower denture with ACRY ROCK teeth



3011 Lower CD cast chain with ACRY ROCK teeth



3012 Complete lower denture with VIVO DENT teeth



3013 Lower CD cast chain with VIVO DENT teeth



3030 Upper RPD of resin up to 21 ACRY ROCK teeth



3031 Lower RPD of resin up to 21 ACRY ROCK teeth



3032 Upper RPD of resin up to 21 VIVO DENT teeth



3033 Lower RPD of resin up to 21 VIVO DENT teeth



3040 Cast upper RPD ACRY ROCK teeth



3041 Cast lower RPD ACRY ROCK



3042 Cast upper RPD VIVO DENT



3043 Cast lower RPD VIVO DENT teeth


12 months

3050 Special hooks (according to lab charge)


12 months

3060 Industrial beagle attachment (according to lab charge)


12 months

| 37



Notes

3070 Cast beagle attachment Prosthetics - Rehabilitation

12 months

3080 Immediate complete denture (as a temporary denture for a final denture)


12 months

3090 Immediate partial/temporary denture 1-2 teeth


12 months

3092 Partial temporary denture tooth 3-6 + 2 pads within 6 weeks


12 months

3094 Immediate partial/temporary denture over 6 teeth


12 months

3110 Padding performed at the clinic for a new denture up to six months no charge


12 months One lining per year per jaw from all lining types

3600 Occlusive protector (splint) Prosthetics - Rehabilitation

12 months Once every two years

4000 Gluing an old crown Prosthetics - Rehabilitation

12 months

4010 Removal of a single crown Prosthetics - Rehabilitation

12 months

4025 Gluing of old braces (3+ units)


12 months

4025 Specialist Gluing old braces (3+ units) – specialist


12 months

4030 Braces removal Prosthetics - Rehabilitation

12 months

4030 Specialist Braces removal – specialist Prosthetics - Rehabilitation

12 months

4040 Repairing cast scaffolds in a chrome-cobalt denture


12 months

4050 Any repair to a regular denture that requires lab involvement


12 months

4051 Addition of a tooth and/or in addition to section 4050


12 months

4080 Padding a denture in a lab, for a new denture up to six months no charge



38 |



Notes

4090 Denture padding + renewal



4091 Soft padding – lab addition Prosthetics - Rehabilitation

12 months

4092 Doctor’s treatment of an old denture that was not performed by S.L.H


12 months

4093 Denture padding + renewal + chain



4598 Electrosurgery by a prosthetist


12 months

2055 Acrylic crown performed in a lab

Prosthetics – Children


2055 Specialist Acrylic crown performed in a lab – specialist

Prosthetics – Children


1700 Periodontal test and mapping

Periodontal Treatments

6 months

1701 Periodontal test without charting


6 months

1720 One Periodchip / GENGIGEL treatment (including price of material) per tooth


6 months 5 per year

1721 Elisol dab up to a quarter mouth - two sessions (including material)


6 months 4 per year from all Elisol dab codes

1722 Elisol dab quarter mouth and above two sessions (including material)


6 months 4 per year from all Elisol dab codes

1730 Scaling and root planning/gum recession quarter mouth – by a periodontist


6 months 4 per year from all scaling and root planing/gum recession codes defined for one quarter of a mouth (no double codes)

1731 Scaling and root planning/gum recession 1/6 mouth – by a periodontist


6 months 6 per year from all scaling root planing/gum recession codes defined for one sixth a of mouth (no double codes)

1740 Gum resection surgery (up to one quarter a mouth)


6 months 4 treatments every 3 years from all periodontal surgery codes defined for one quarter of a mouth (no double codes)

| 39



Notes

1750 Gum resection surgery (one quarter of a mouth)


6 months 4 treatments every 3 years from all periodontal surgery codes defined for one quarter of a mouth (no double codes)

1752 Gum resection surgery (up to 1/6 of a mouth)


6 months 6 treatments every 3 years from all periodontal surgery codes defined for one sixth of a mouth (no double codes)

1754 Addition for laser (in addition to the surgeries’ treatment codes)


6 months

1760 Short surgery (ferenctomy, amputation, hemisection etc.)


6 months

1761 Short operation supplemental to another gum surgery – same session


6 months

1762 Gum implant Periodontal Treatments

6 months 4 every 3 years

1780 Guided bone regeneration of teeth 1-3 – not including materials



1781 Guided bone regeneration of teeth 4-6 – not including materials



1782 Self-bone implant (in addition to codes 1780 1781)


6 months 2 per year

1789 Bone scraper and collector (in addition to code 1782)


6 months 2 per year

1798 Periodic review Periodontal Treatments


1799 Teeth fixing with a composite material


6 months Once per jaw per year

1210 Full orthodontic set Orthodontics 12 months Once

1211 Cephalometric imaging Orthodontics 12 months Once

1212 Computerized drafting and analysis

Orthodontics 12 months Once

1213 Facial and dental photo Orthodontics 12 months Once

1214 Orthodontic teaching patterns


40 |



Notes

1215 Orthodontic set – non-panoramic


2136 Reduced orthodontic treatment with an incline

Orthodontics 12 months

2235 Resin placeholder – RPD up to 2 teeth


2245 Resin placeholder – RPD 3+ teeth


4900 Preliminary test Orthodontics 12 months

4911 Pre-treatment monitoring Orthodontics 12 months Once per year

4912 Short orthodontic treatment


4920 Partial-orthodontic treatment in one jaw or two – no orthodontic set


4921 Partial treatment – charge per visit, no. of charges per one visit


4930 Partial adult treatment in one or two jaws


4931 Partial adult treatment – charge per visit, no. of charges per one visit


4997 Additional orthodontic visit – upon conclusion of the liability period


4998 Orthodontic visit – special approval


4999 Orthodontic visit no charge


5020 Expanded ortho treatment in one jaw, not including retention and set

Orthodontics 12 months Once from all orthodontics types (once of the following alternative codes: 5050 / 5040 / 5030 / 5020)

5021 Expanded treatment in one jaw – visit no. of charge for one visit


5030 Expanded ortho treatment for an adult in one jaw, not including retention


5031 Expanded treatment for an adult in one jaw – one visit


| 41



Notes

5040 Expanded ortho treatment in two jaws – not including set and retention


5041 Expanded treatment for two jaws – no. of charges per one visit


5045 Plate for retention Orthodontics 12 months Once per jaw

5050 Expanded ortho treatment for an adult – two jaws – not including retention


5051 Expanded ortho treatment for an adult – two jaws – charge per one visit


5059 Retainer loss Orthodontics 12 months Up to twice

5060 New device Orthodontics 12 months Up to twice

5070 Device repair Orthodontics 12 months Up to twice

5080 Functional-orthopedic treatment – not including retainer treatment


5084 Eruption of a locked tooth – buccal


5085 Eruption of a locked tooth - platal


5086 Treatment for bite lifting (in addition to the orthodontic treatment)


5087 Double-sided placeholder – lingual arch/platal arch

Orthodontics 12 months Once per jaw

5088 Permanent/mobile fixing Orthodontics 12 months Once

5090 Additional visit upon conclusion of the liability period


5098 Start of liability period*Specify liability conclusion date


5099 Liability conclusion date Orthodontics 12 months

42 |



Notes

5300 Addition for 3D treatments – child


5301 Addition for 3D ortho visit Orthodontics 12 months

5310 Addition for 3D treatment – adult


5311 Addition for 3D ortho treatment – adult


4099 Nylon cap for denture ball Implants and Rehabilitation on Implants

12 months

8000 Surgical preparation Implants and Rehabilitation on Implants

12 months

8001 Test – prosthetics Implants and Rehabilitation on Implants

12 months

8002 Period review for rehabilitation on implants

Implants and Rehabilitation on Implants

12 months

8003 Semi-annual review for rehabilitation on implants (free of charge)


12 months

8008 Removal of an implant that is anchored in soft tissue only


12 months

8009 Implant exposure Implants and Rehabilitation on Implants

12 months

8010 Implant Implants and Rehabilitation on Implants

12 months No more than 5 implants per jaw, per 5 years

8011 Crown on top of an implant – glued – semi-noble metal


12 months One per implant. Replacement – at least 5 years after placement

8012 Crown on top of an implant – screwed including bracket casting



8013 Crown on top of an implant – noble metal



8014 Chrome cobalt crown on top of an implant



8015 Bracket on top of a straight/angular implant



| 43



Notes

8016 Cast bracket for an implant (plastic sleeve with GOLD COPPING)



8017 Cast bracket for an implant with plastic sleeve, including screw



8018 Chrome cobalt crown on top an implant, including temporary



8019 Temporary bracket for an implant performed in a clinic



8024 Denture – on top of 2 implants – ball connectors









8027 Denture – on top of 2 implants - locators



8028 Denture – on top of 3 implants – locators



8029 Denture – on top of 4 implants – locators



8033 Denture – on top of a bar – 2 implants















8051 Fixed detachable hybrid denture of acrylic resin



8052 Fixed detachable ceramic hybrid denture with no special parts



44 |



Notes

8053 Screwed crown unit for a fixed detachable



8054 Intermediate unit (pontic/cantilever) for a fixed detachable



8055 Gum denture (acrylic) Implants and Rehabilitation on Implants

12 months

8060 Open sinus lifting (not including the price of bone and membrane)


12 months Once per sinus

8061 Closed sinus lifting for each implant (not including the price of bone and membrane


12 months Twice a year

8062 Autogenic bone harvesting – in addition to codes 8060, 8061



8070 Guided bone regeneration during implant



8080 Plastic sleeve with gold ring for Gold Copping casting



8081 Addition for a denture locator connectorConnectors



8090 Surgical guide for placing implants (stent)


12 months

8095 Extraction of broken screws from inside implants


12 months

8110 AB implant Implants and Rehabilitation on Implants

12 months No more than 5 implants per jaw, per 5 years

8111 Glued crown on top of an implant AB – semi-noble metal



8112 Crown on top of an implant – screwed with casting a bracket AB



8114 Chrome Cobalt crown on top of an implant AB



8115 Bracket on top of a straight/angular implant AB



8116 Cast bracket for implant with titanium ring AB

| 45



Notes

8117 Cast bracket for implant including screw and plastic sleeve AB



8118 Chrome cobalt crown on top of AB implant including temporary



8124 Denture – on top of 2 implants – spherical connectors AB









8133 Denture – on top of a bar – 2 implants AB















8151 Hybrid denture FIXED DETACHABLE acrylic resin AB



8152 Hybrid denture FIXED DETACHABLE ceramic AB



8153 Screwed crown unit for AB FIXED DETACHABLE



8180 Plastic sleeve with titanium ring AB



8310 Implants MIS Implants and Rehabilitation on Implants


8311 Glued crown MIS Implants and Rehabilitation on Implants


8312 Screwed crown MIS Implants and Rehabilitation on Implants


46 |



Notes

8315 Bracket on top of an MIS implant



8316 Plastic sleeve with gold base for casting a bracket



8317 Plastic sleeve with gold ring for casting



8324 Removable denture on top of 2 implants with bar + screw



8325 Removable denture on top of 3 implants with bar + screw



8326 Removable denture ontop of 4 implants withbar + screw






8334 Removable dentureon top of 3 implantswith bar + screw






8336 FIXED-DETACHABLE (Denture)



8337 FIXED-DETACHABLE (Porcelain Braces)



8351 FIXED-DETACHABLE (Denture)



8352 FIXED-DETACHABLE (Porcelain Braces)



8500 Orthodontic Implant Implants and Rehabilitation on Implants


9000 Test First Aid Night Clinic

6 months

9001 Periapical or bite radiography

First Aid Night Clinic

6 months

9009 Trepanation/Extraction First Aid Night Clinic

6 months

| 47



Notes

9011 Abscess drainage First Aid Night Clinic

6 months

9020 Regular extraction (including radiography)


6 months

9021 Surgical extraction including radiography


6 months

9022 Extraction of a locked tooth including radiography


6 months

9030 Gluing/removing crown for a unit according to the number of holding teeth


6 months

9034 Gluing old braces (3+ units)


6 months

9035 Braces removal First Aid Night Clinic

6 months

9040 Temporary filling First Aid Night Clinic

6 months

* Exception regarding aesthetic treatments: it is hereby clarified that eligibility for (white) composite fillings according to this appendix does not include aesthetic treatments* Exception regarding aesthetic treatments: it is hereby clarified that eligibility for crowns according to this appendix does not include aesthetic treatments

Chapter B: Participation in Private Operations in a Foreign Country 1. Definitions In this chapter, the following terms shall have the meaning specified next to them: “Operation” – an operation that is included in ’s list of operations,or another operation in the Services Basket pursuant to the law, performed with complete hospitalization. “Implanted Accessory” – an accessory that was implanted as part of an operation as aforesaid in this chapter, and is an accessory that is included in the Health Services Basket. “Medical Expenses” – the hospitalization expenses of the Associate and his/her care up to 30 days including usage of an operating room, doctor fees, nurses, medical tests, lab services and drugs, and provided that all were spent during hospitalization. “Medical Transport Expenses” – the Associate’s airfare expenses in a regular airliner or a special plane with a medical team that is medically compatible with the Associate’s situation, for an Associate who is transported from Israel to a foreign country or from a foreign country to Israel, provided that according to common medical criteria, which were pre-approved by "Mushlam Platinum"’s medical director, it has been determined that a need might arise for medical involvement during flight. If it has been determined according to common medical criteria, which were pre-approved by "Mushlam Platinum"’s medical director, that a need might arise for medical involvement during the flight, and as a result the Associate has been accompanied in his/her flight by a doctor and/or paramedic, the expenses of the doctor and/or paramedic’s airfare shall also be included. It is clarified that expenses do not include expenses that result from excess baggage of the Associate and/or doctor and/or paramedic or any additional expenses due to the medical escort. “Expenses of Stay” – expenses for hotel accommodations or rent for leasing a residential room in addition to expenses that apply to a tenant (gas, electricity, water) and living expenses (food and drinks).

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2. Crediting Case A crediting case is the performance of an operation, which according to the Associate’s choice will be performed in a foreign country, and provided that the need for the operation’s performance has been pre-approved and recognized by pursuant to chapter C of the code, while the Associate is staying in Israel. The date of the crediting case’s occurrence shall be considered as the date in which the operation was performed.

3. Coverage According to this Chapter3.1. The maximum amount paid by Clalit upon occurrence of a crediting case for medical expenses

incurred by the Associate shall be no more than 200% of the differential price of the Ministry of Health for medical expenses that are related with the performance of such operation in a general hospital in Israel, or in cases in which the operation performed on the Associate was not set a differential price by the Ministry of Health – 200% of the multiplication of the price of one hospitalization day, as determined by the Ministry of Health from time to time, by the number of actual hospitalization days, however no more than the number of hospitalization days approved by ’s medical director.

3.2. An Associate who has underwent surgery pursuant to this chapter and requires medical air transport or performing the operation, shall be entitled to a reimbursement in the amount of the medical air transport expenses, but in any case no more than $10,000 in total.

3.3. An Associate who has underwent surgery pursuant to this chapter and requires an implanted accessory for performing the operation, shall be entitled to a reimbursement of the direct expenses that he/she had incurred due to the device, and no more than $5,000.

3.4. An Associate who has underwent surgery pursuant to this chapter will be entitled to the reimbursement of stay expenses in a foreign country for one person who accompanies him/her during their stay in a foreign company, and that is provided that the post-op hospitalization period exceeds 10 days. Clalit will cover the stay expenses of one escort, for the hospitalization’s duration from the 11th hospitalization day and so forth. Clalit’s participation amount as aforesaid shall not exceed $120 per day, and that is for a period of up to 45 days. (And in total - $5,400).

3.5. If god forbid the Associate had departed during his/her stay in a foreign country, during the hospitalization period or during a period that does not exceed 7 days as of his/her release from hospital in a foreign country, his/her family shall be entitled to a reimbursement of the body’s transport expenses. Clalit’s participation amount for the expenses of transporting the body shall not exceed $8,000. It is hereby clarified that no expenses spent in Israel in relation with bringing the body will be covered.

3.6. It is hereby clarified that the total of all reimbursements pursuant to this chapter and/or other sources shall not in any case exceed the actual expenses incurred by the Associate.

4. Special Exceptions for Eligibility According to this Chapter An Associate of the plan will not be eligible to receive payment according to this chapter in each of the following cases:

4.1. Any operation that is directly related to an aesthetic purpose.4.2. An operation performed as part of a clinical trial.4.3. Organ transplant.4.4. Other treatments that are not included in the definition of Operation as specified hereinabove,

including radiations, chemotherapy or oncologic treatments, hypothermic treatment, shots, dabs, imaging test/s and procedures such as: CT and MRI, whereby these are not part of the hospitalization’s duration, during operation.

4.5. Operations related with teeth and gums.

4.6. Treatments and operations related with sterility, fertility, infertility, voluntary castration and labor.

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5. Precondition of CLALIT’s Liability According to this Chapter Clalit Health Services shall be liable to execute payments pursuant to this chapter provided that performance of the operation has been pre-approved by the plan’s medical director.

6. Qualification Period: The qualification period for eligibility pursuant to this chapter is 24 months.

Chapter C: Private surgery in Israel

1. Unless otherwise specifically determined, all terms in this chapter will have the meaning assigned to them in section 1 of chapter C of the Clalit Mushlam’s set of rules and regulations.

2. Entitling event

as defined in the Clalit Mushlam’s set of rules and regulations. For convenience purposes, we include here the exact wording:

An entitling event is when the planholder’s health condition, entitling them to an operation under the Health Law, which the planholder has elected to have privately as part of the arrangement, in a private hospital within the state lines of the State of Israel. The deciding text is the one in the Clalit Mushlam’s set of rules and regulations as - under these rules and regulations and the law - amended from time to time. The entitling event’s date will be the date of the actual performance of the operation

3. A prerequisite to Clalit liability under this chapter:

Clalit Health Services will be responsible to make the payments in accordance with this chapter, if the performance of the operation has been pre-approved by the plan’s medical director. This includes the use of transplanted items and/or technology, if and as much as deemed necessary as part of said operation

4. Planholder’s rights under this chapter:

4.1 Having an operation in a private hospital, performed by a privately employed surgeon under the arrangement, within the state lines of the State of Israel, and in accordance with the list of procedures and surgeons authorized to perform them; all for a sum constituting 25% of the deductible paid for the same procedure at Clalit Mushlam, except in operations listed on the Clalit Mushlam website, for which a different deductible might be charged. The foregoing notwithstanding, the amount of deductible paid by the planholder under this chapter will not be less than 300 ILS. The deductible will be paid by the planholder directly to the private hospital where the procedure was performed. The sum of deductible for each procedure will be as set forth in the list of procedures and surgeons authorized to perform them, which will be published in the Clalit Mushlam website.

4.2 Clalit Health Services will not help pay for an operation unless it is included in the list of procedures and surgeons authorized to perform them, and has been performed by a private surgeon who is listed in the arrangement, and in a private hospital

4.3 Coverage under section 4.1 above will include the entirety of the services offered by the hospital as part of hospitalization, including a hospitalization in another ward in a private hospital; the use of an operating room, anesthetizing services (including the anesthetist); transplanted items, private surgeon’s fees under the arrangement; as well as lab tests, imaging procedures and medications needed during operation. The planholder will not be required to pay any additional sums for the operation, other than the deductible.

5 Qualification term for eligibility: 12 months

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Chapter D: Package for Pregnant Women1. Crediting Case A crediting case is a situation in which a pregnant woman who is an Associate of the “Mushlam Platinum” plan (as the term “Associate” is defined in this Code) requires consultation, performing a test and/or medical treatment (and all in relation with her pregnancy and/or expected labor and/or post-labor), which are not included in the basic health basket and/or the Clalit Mushlam plan, and provided that this does not regard unconventional consultation/test/treatment (including homeopathic therapies and/or alternative medicine). The aforesaid notwithstanding, the Associate will be entitled to reimbursement pursuant to this chapter for services that she had acquired from a non-arrangement vendor, entitling her to a reimbursement from, and that is in excess of the reimbursement amount which she deserves to receive from .

2. Coverage According to this Chapter The maximum amount to which an Associate will be entitled for the occurrence of each of the cases that apply to the definition of a crediting case, is a total of 75% of the total expenses that the Associate had actually incurred, up to a cumulative ceiling of ILS 8,000 for all membership periods in the plan. In this regard, “actual expense” means an expenses incurred by the Associate out of her pocket with the deduction of any refund/participation that the Associate has received or is entitled to receive from the plan. In all matters related with labor and up to 6 months thereafter, the package will include the following issues only: Doula / labor supporter, cord blood preservation, caesarian section in a "Sharap" – private medical service in a public Jerusalem hospital only (Hadassah, Shaarei Zedek and Bikur Holim hospitals only) as defined in chapter C section 1.3 of the “Mushlam Platinum” Code.

3. Eligibility Exhaustion To remove any doubt, it is hereby clarified that eligibility for coverage pursuant to this chapter shall be upon exhaustion of eligibility in the plan.

4. Qualification Period The qualification period for eligibility pursuant to this chapter is 9 months.

Chapter E: Egg Donation in a Foreign Country1. Crediting Case A crediting case is one where obtaining an egg donation in a foreign country for the purpose of performing in vitro fertilization for the first and second child in a foreign country, including testing the donor, preparing the egg obtainment and returning it to the donation receiver in a foreign country, and all provided that the Associate is under 52 years of age upon occurrence of the Crediting Case, as specified hereinbelow, and provided that terms of the People’s Health regulations (In Vitro Fertilization), 1987 have been met. The date of occurrence of the Crediting Case shall be considered as the date of performing the fertilization in a foreign country.

2. Coverage According to this Chapter The maximum eligibility amount paid by Clalit for a Crediting Case pursuant to this chapter is in total of 75% of the actual expense, but no more than ILS 11,962 for all attempts for each child.

3. Precondition of ClaliT’s Liability According to this Chapter CLALIT HEALTH SERVICES shall be liable to execute payments pursuant to this chapter provided that performance of the operation has been pre-approved by the plan’s medical director.


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Chapter F: Participation in costs of Aesthetic Operations and Treatments

1. Definitions In this chapter, the following terms shall have the meaning specified next to them: “Clinics under the Agreement” – hospitals, clinics or institutions with which Clalit has contracted or will contract in an agreement to provide services pursuant to this chapter. The list of clinics as aforesaid shall be updated from time to time by Clalit.

2. Crediting Case A crediting case is the performance of an aesthetic operation or treatment, to which the Associate is not entitled pursuant to the Health Insurance Law and is included in the list of operations and treatments specified in section 3 herein and provided that it was performed in clinics under the arrangements. The date of occurrence of the crediting case shall be considered as the day on which the operation or treatment was performed.

3. Coverage According to this Chapter The following are types of aesthetic operations and/or treatments that are included in the coverage pursuant to this chapter. The Associate will directly pay the clinic under the agreement the excess insurance according to the agreement. The list of excess insurances will be distributed to Clalit clinics and to clinics under the agreement. Type of Operation: Nose, one eyelid, two eyelids, face or neck lift, stomach lift, small liposuction, large liposuction, breast lift/reduction, breast enlargement (no implants), hyperhidrosis treatment – armpit, hyperhidrosis treatment – palms/feet. Hair Removal: Face, armpit/crotch, hands – forearm, hands – arm, hands – palm, back – lower, back – upper, legs – calf, legs – thigh, legs – foot, neck rear, stomach, chest.


Chapter G: Participation in costs of ambulance1. Crediting Case A crediting case is the urgent evacuation of an Associate to the ER via ambulance (including MICU) which has been approved by the Ministry of Health, to a public hospital, and the case did not conclude with the Associate’s hospitalization. The date of occurrence for the crediting case shall be considered as the day on which evacuation by ambulance was performed.

2. Coverage According to this Chapter The maximum amount paid by Clalit for a crediting case pursuant to this chapter is 50% of the actual expense and no more than ILS 299, and twice per calendar year at most. In this regard “actual expense” means an expense incurred by the Associate out of his/her pocket with the deduction of any reimbursement/participation that the Associate had received or is entitled to receive pursuant to the Health Insurance Law or the National Insurance Law [Consolidated Version], 1995.


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Chapter H: Specification of Medical ServicesMedical Service Crediting Case Eligibility Qualification

Period

1 Tests for pregnant women: 1. Systems review for pregnant women at an arrangement institution. Once for each pregnancy in excess of the basic basket eligibility and the eligibility for a test that is defined in the “Mushlam Zahav” Code

Performing a systems review (the refund includes the consult given as part of performing the systems review).

50% of the excess insurance paid as part of “Mushlam Zahav” (meaning, excess insurance in total of ILS 57 instead of ILS 114 per fetus), and that is as part of exhausting eligibility according to “Mushlam Zahav”.

None

2. Amniocenteses or chorionic villus sampling for pregnant women over 35. Once for each pregnancy in excess of the basic basket eligibility and the eligibility for a test that is defined in the “Mushlam Zahav” Code

Performing an amniocenteses or chorionic villus sampling for a pregnant Associate including a chromosome test for preventing down syndrome, trisomy 18 and AFP (refund includes the consult given as part of performing the test).

50% of the excess insurance paid as part of “Mushlam Zahav” (meaning, excess insurance in total of ILS 285 instead of ILS 570 at arrangement institutions), and that is as part of exhausting eligibility according to “Mushlam Zahav”.

None

2 Maternal Recovery: participation in recovery expenses of a post-labor Associate after the birth of the first or second or third child. Can be used for one child only.

Leaving to recovery in a institution nor institute that is meant for post-labor recovery, within 30 days of labor.

An amount equaling 75% of the actual expense and no more than ILS 307 per day.For a maximum period of 3 days.

9 months

3 Didactic or psycho-didactic diagnosis not included psychological diagnoses. At arrangement institutions only.

Diagnoses for children ages 6-17 (inclusive) with learning difficulties. Diagnoses will only be performed by diagnosticians who were approved by at arrangement institutions only. A referral by one of the following doctors of Clalit Health Services or doctors approved by is required: family doctor, pediatrician, neurologist, a psychiatrist.

Excess insurance of ILS 550 for a didactic diagnosis. Excess insurance of ILS 950 for a psychodidactic diagnosis. Eligibility once for all membership periods in the plan, for each of the aforementioned tests. However, the eligibility of Clalit Platinum and cannot be used in the same test.

6 months

4 A TOVA, BRC, MOXO or NEUROTRAX test at arrangement institutions. According to a neurologist’s demand.

Associates in need of a TOVA, BRX, MOXO or NEUROTRAX test for diagnosing Attention Deficit Disorder.

Excess insurance of ILS 50 per test. The tests will take place at arrangement institutions only. Eligibility is for two tests only for all membership periods in the plan. This eligibility replaces the eligibility pursuant to “”, so that an Insured cannot perform more than two tests according to both plans together in all membership periods of the plan.

6 months

5 Eyeglasses or optic (non-cosmetic) contact lenses in models approved by* Including eye exam, for an Associate under 18 at arrangement vendors who were approved by.

An Associate under 18, who requires eyeglasses or contact lenses in accordance with an exam at arrangement vendors.

A ILS 600 discount, but in any case no more than the price of the eyeglasses or contact lenses. The Associate will directly pay the arrangement vendor upon deduction of the eligibility amount.Eligibility: once per calendar year.

3 months

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Medical Service Crediting Case Eligibility Qualification Period

6 Vaccines for travelers at arrangement institutions only: participation in expenses of performing vaccinations for travelers abroad.

The trip of an Associate to foreign countries which requires, according to a directive of the Israeli Ministry of Health, vaccinations to prevent catching diseases that exist in such foreign countries.

Excess insurance of up to ILS 20 per vaccination and no more than 25% of the price of any vaccination at arrangement institutions only. Consultation for the vaccinations will also be given at arrangement institutions only for no pay. This coverage is alternative to the coverage under.

3 months

* A list of models approved by will be published in the Fund’s website. To remove any doubt- the inclusion of a model in the list does not necessarily mean that it would be offered by all or some vendors.

Chapter I: Support Package for Cancer Patients1. Definitions

“Specialist” – an MD with a valid Israeli Ministry of Health license to practice medicine, and a valid specialist certificate of the Ministry of Health, who has been recognized as a specialist in the field of oncology, hematology, or children’s hematology by the Israeli health authorities. “Disease” – a malignant tumor disease that was diagnosed in a pathological test, not including: skin infections that require local amputation (except for melanoma) and not including tumors diagnosed as pre-malignant, including cervical. “Eligibility Period” – two years after initial diagnosis. In a case where cells of the disease appear in other organs, it will not be considered as a diagnosis of another disease, and the eligibility period will not restart. In a case where the disease is also diagnosed in other organs (in a manner that diagnoses other cells from the cells that were initially diagnosed in any organ), or in a case where the disease is in remission upon two years after its initial diagnosis – and will again be diagnosed – it will be considered as diagnosing an additional disease and the eligibility period count will restart. “Actual Expense” – an expense that the Associate had actually incurred during the eligibility period, with the deduction of any reimbursement received by the Associate from any funding factor that is not the "Mushlam Zahav" or "Mushlam Platinum" plans. It is clarified that payment of excess insurance that was paid by the Associate as part of each of the aforementioned plans or the health basket will not be considered in any case as an expense.

2. Crediting CaseA situation in which an Associate has been diagnosed by a specialist as a patient of the disease (the Clalit may require documents from the Associate to prove the disease including qualified pathological or cytological tests).

3. Coverage The maximum amount of reimbursement to which the Associate will be entitled for the occurrence of the crediting case (cumulative) according to Clalit Mushlam and "Mushlam Platinum" plans, including according to this chapter, is at a rate of 75% of the actual expenses incurred by the Associate, and provided that it was incurred during the eligibility period but in any case no sooner than day 1.5.13, and that is for all crediting cases in all membership periods of the plan, and up to a ceiling of each of the amounts specified in sections (3.1), (3.2) and (3.3) hereinbelow, where the amounts of ceilings as aforesaid shall be calculated in aggregate. In addition, the Associate will be entitled to the coverage specified in section (d) hereinbelow upon occurrence of the crediting case.a. ILS 40,232 for participation in the cost of an operation and/or other medical treatments that

are required for treating the Associate’s disease in a foreign country (as this term is defined in this Code).

b. ILS 100,579 for participation in the cost of surgery and/or other medical treatments that are required for treating the Associate’s disease in a foreign country (as this term is defined in this Code).

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c. ILS 10,058 for covering various expenses for the purpose of diagnosing and treating the disease as aforesaid hereinbelow:

• Medical consultation – reimbursement for consulting with a specialist, be it a consultation as part of the crediting quote in a reimbursement of the plan, or another consultation in excess of the crediting quote is part of;

• Reimbursement for a private purchase of consultations and psychological treatments and nutritional consultation;

• Reimbursement for purchasing complementary medical services not at arrangement clinics;• Reimbursement for watching a patient by a private caregiver who is not a family member;• Supporting accessories for the house according to a list, in cases where there is no eligibility

to receive them as part of the national health basket;• Reimbursement of cab or ambulance fare for treatments that have eligibility in the basic

basket or for treatments bearing reimbursement eligibility for the Associate according to this chapter.

d. Provision of guidance services to the patient in regards to his/her rights, and a general multi-professional consultation on issues related to treating the disease, and that is via arrangement vendors subject to excess insurance of ILS 500.

4. Eligibility Exhaustion To remove any doubt, it is hereby clarified that eligibility for coverage pursuant to this chapter shall be upon exhaustion of eligibility in the and Clalit Platinum plans, and in addition thereto, and without reimbursement for excess insurance in one of the plans or the health basket.


Appendix A – Table of "Mushlam Platinum" Prices( Tariffs are in addition to the Zahav tariffs)

Associate’s Age Monthly Payment

0-17 16.65

18 14.48

19-30 40.26

31-39 47.59

40-49 49.75

50-59 57.52

60-64 70.77

65-69 90.02

70+ 94.18

Monthly payment as of July 2016, according to the index published on day 15.6.2016, and is index-linked.

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Receiving a Refund

To request reimbursement for the medical services offered in the plan, attach the specified documents in accordance with the required chapter:

Private Operations in a Foreign Country: • Original invoices • Medical report from the hospital in a foreign country indicating the operation or

treatment’s performance • Ensure that the invoices and reports are in English or officially translated to either

English or Hebrew • Claim submission forms that include: demographic information, additional insurances

statement form and medical confidentially waiver form

Package for pregnant women: • Tax invoices + original - receipt – ensure that the receipt specifies the type of treatment

Maternal Recovery: • Tax invoice + original receipt and dates of stay • Hospital hospitalization report with the dates of labor and release • Visible copy of ID annex

Egg Donation in a Foreign Country: • Original invoices on obtaining the donation in a foreign country • Visible copy of ID annex • Hospital release report • Recommendation of a local fertility specialist, approving the need for treatment • Confirmation by the competent authority in the country where the center is located

(Ministry of Health), confirming that the center is lawfully registered and that it is allowed to perform the egg reception and return of the fetuses, the confirmation can be received from the director of the medical center in that foreign country, ensure that the documents specified above are in English or officially translated to either English or Hebrew

Ambulance Ride to the ER: • Original receipt • ER release report

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Supporting Service Package to the Oncologic Patient:Realizing coverage is only after one year of membership in the Platinum plan, provided that two years did not pass since the day of diagnosing the disease and thus, each address should be attached with a medical information summary that specifies the type of disease and diagnosis day (pathology report). Reimbursements are given against the provision of a tax invoice + original receipt and additional required documents as specified: • Supporting accessories (according to a list that is on the Clalit website) medical

recommendation confirming the need for the accessory • Cab or ambulance far expenses – tax invoice + original receipt or copy of tax invoice

+ original receipt + confirmation of Clalit Health Services on reimbursement, and treatment report by the physician / hospital / caregiver performed the treatment for which the Associate has travelled • Watch under any qualified factor (non-family member) – medical certificate

All documents should be sent to the address:2nd B.S.R Towers, 1st Ben Gurion St., Bnei-Brak, PO 2265, Zipcode 5112201

Receiving a Refund

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2016

Jul

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