major medical benefits

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3 major medical benefits HOSPITALISATION (government and private hospitals and day clinics) Subject to pre-registration, pre-authorisation and case management Intensive and high care wards Ward accommodation Theatre fees Visits, treatment and ward medicine Surgery and anaesthesia ORGAN TRANSPLANT ONCOLOGY (SAOC NETWORK ONCOPRIME PROTOCOLS) Subject to pre-authorisation and pre-registration Surgery and hospitalisation Chemotherapy and radiotherapy (PMB cases) GENERAL RADIOLOGY AND PATHOLOGY During hospitalisation PHYSIOTHERAPY, OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES During hospitalisation OXYGEN During and not during hospitalisation DIALYSIS During and not during hospitalisation Subject to pre-authorisation TECHNOLOGIST SERVICES During and not during hospitalisation APPLICABLE PRESCRIPTION MEDICINE DISPENSED BY THE HOSPITAL ON DISCHARGE FROM THE HOSPITAL (TTO) NECK AND BACK FUSIONS (non-pmb cases) Subject to protocols and pre-authorisation CONFINEMENT HYSTERECTOMY DENTAL PROCEDURES UNDER ANAESTHESIA Subject to Denis protocols and pre-authorisation Hospitalisation General anaesthesia IV conscious sedation in dental rooms for the removal of impacted wisdom teeth only Subject to pre-authorisation and protocols /medicine price R950 co-payment per admission where no other co-payments have been specified (non-pmb cases) 100% of the medicine price R240 per admission R14,170 co-payment per admission R1,650 co-payment per admission R2,560 co-payment per admission 100% of the Medihelp Dental Tariff R1,980 co-payment per admission 100% of the Medihelp Dental Tariff Dentist s account For member s account major medical benefits INTERNALLY IMPLANTED PROSTHESES (non-pmb cases) EVARS prosthesis Subject to pre-authorisation Annual limit per family of R27,600 for all internally implanted prostheses Sub-limits: R20,970 per beneficiary per year Vascular/cardiac prosthesis R20,970 per beneficiary per year Health-essential functional prosthesis Subject to pre-authorisation R13,910 per beneficiary per year Intra-ocular lenses Sub-limit: 2 lenses per beneficiary per year R2,600 per lens Prosthesis with reconstructive or restorative surgery Subject to pre-authorisation during and not during hospitalisation SPECIALISED RADIOLOGY Services rendered during and not during hospitalisation MRI and CT-scanning are subject to pre-authorisation Angiogram PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION Subject to pre-authorisation Professional services rendered during and not during hospitalisation by a psychiatrist General ward accommodation Electroconvulsive therapy Medicine supplied during the period of the treatment in the institution PRIVATE NURSING, HOSPICE SERVICES AND SUB-ACUTE CARE FACILITIES Subject to pre-authorisation and as an alternative to hospitalisation MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES Services rendered during and not during hospitalisation Artificial eyes Speech and hearing aids Artificial limbs Wheelchairs R2,670 per family per year R13,050 per family per year 100% of the contracted/ scheme tariff/medicine price R950 co-payment per admission (non-pmb cases) R11,770 per beneficiary per year (maximum R17,760 per family per year) 100% of the contracted/ scheme tariff/medicine price R3,210 per family per 3-year cycle Stoma components and urine bags ENDOSCOPIC PROCEDURES During hospitalisation R2,000 co-payment per scope In the doctor s rooms R660 co-payment per scope on the doctor s account 10

4 major medical benefits trauma recovery monthly contribution BENEFITS FOR TRAUMA THAT NECESSITATES HOSPITALISATION IN THE CASE OF: Motor vehicle accidents Stab wounds Gunshot wounds Head trauma Burns Near drowning Subject to pre-authorisation and case management POST-EXPOSURE PROPHYLAXIS IN THE EVENT OF SEXUAL ASSAULT (Optipharm) Member Principal member Adult dependant Child dependant younger than 26 years (you pay a monthly contribution for maximum two children) Subscription R888 R726 R270 This is a summary of benefits. In the event of a dispute the registered Rules of Medihelp will apply. If a beneficiary joins during the course of a financial year, the benefits are calculated pro rata according to the remaining number of months per year. major medical benefits prescribed minimum benefits (PMB) DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB CONDITIONS AND 26 CHRONIC ILLNESSES ON THE CHRONIC DISEASES LIST (CDL) Subject to protocols, pre-authorisation, registration and preferred providers (where applicable) 100% of the cost Co-payments may apply emergency medical services EMERGENCY TRANSPORT SERVICES (NETCARE 911) Transport by road or air within the borders of the RSA, Lesotho, Swaziland, Mozambique and Namibia (residents of these countries) 100% of the Outside these borders: Transport by road 100% of the cost R1,280 per case Transport by air 100% of the cost R8,340 per case BLOOD TRANSFUSION SERVICES AND THE TRANSPORT OF BLOOD AND BLOOD PRODUCTS 24-HOUR HELPLINE (NETCARE 911) AND NETCARE 911 RAPE CRISIS CENTRE 100% of the cost Phone for advice in a medical emergency day-to-day benefits GENERAL MEDICAL PRACTITIONERS, SPECIALISTS AND MEDICINE Consultations, follow-up consultations and visits Physiotherapy services Non-chronic medicine, self-medication, homeopathic, herbal, naturopathic and osteopathic medicine dispensed by the Medihelp Preferred Pharmacy Network Overall limit of R1,000 per single member and R1,900 per family per year Sub-limit: R700 per single member and R1,300 per family per year Sub-limit: 80% of the medicine price R600 per single member and R900 per family per year 11

5 Details of dental benefits all benefits are subject to Denis protocols, and pre-authorisation in the case of specialised dentistry Necesse Overall annual limit Dimension Prime 1 Dimension Prime 2 Dimension Prime 3 Dimension Elite Routine examinations (check-ups) Oral hygiene Fillings A treatment plan and X-rays may be required for multiple fillings 1 per beneficiary per year 1 scale and polish treatment per beneficiary per year Limited to Denis item codes 4 fillings per beneficiary per 365-day cycle Limited to Denis item codes 2 per beneficiary per year 2 scale and polish treatments per beneficiary per year 1 filling per tooth per 365-day cycle 2 per beneficiary per year 2 scale and polish treatments per beneficiary per year 1 filling per tooth per 365-day cycle Tooth extractions and root canal treatment in the dentist s chair Plastic dentures (including professional and dental laboratory fees) Partial metal frame dentures Crown and bridge work Orthodontic treatment Fixed braces only one beneficiary per family may begin orthodontic treatment per calender year Periodontal treatment Subject to registration on the Perio Programme X-rays Intra-oral Extra oral Dental procedures under conscious sedation in the dentist s chair (sedation cost) Laughing gas 1 set (upper and lower jaw) per family in a 24-month cycle for patients >21 years Co-payment of 20% on total cost applies For member s account 4 per beneficiary per year 1 per beneficiary in a 3-year cycle Extensive dental treatment only For member s account Removal of impacted wisdom teeth only Available funds in the savings account/for member s account Dentist s account For member s account Savings account Dental surgery under general anaesthesia in a hospital/day clinic only Removal of impacted wisdom teeth under general anaesthesia in a hospital/ day clinic only Trauma cases (PMB only) R1,980 co-payment per admission R1,280 co-payment per admission For member s account For member s account For member s account 1 set (upper and lower jaw) per beneficiary every 4 years 1 partial frame (upper or lower jaw) per beneficiary every 5 years 1 crown per family per year, once per tooth every 5 years R6,000 per beneficiary younger than 18 years per lifetime 1 set (upper and lower jaw) per beneficiary every 4 years 2 partial frames (upper and lower jaw) per beneficiary every 5 years 2 crowns per family per year, once per tooth every 5 years R8,000 per beneficiary younger than 18 years per lifetime 1 per beneficiary in a 3-year cycle Extensive dental treatment only R950 co-payment per admission 1 per beneficiary in a 3-year cycle Extensive dental treatment only R950 co-payment per admission MDT = Medihelp Dental Tariff Please refer to dental exclusions and protocols op p. 26 en p

6 What we don t pay for Medihelp excludes the following from benefits, except in the case of statutory Prescribed Minimum s (PMB): General Services which are not mentioned in the Medihelp Rules as well as services which are not aimed at the generally accepted medical treatment of an actual or a suspected sickness or handicap, which is harmful or threatening to necessary bodily functions (the process of ageing is not considered to be a sickness or handicap). Travelling and accommodation costs, including meals as well as administration costs of a member and/or service provider. Aptitude and intelligence tests. Operations, treatments and procedures of own choice; for cosmetic purposes; and for the treatment of obesity, with the exception of the treatment of obesity which is motivated by a medical specialist as life-threatening and approved beforehand by Medihelp. Treatment of wilfully self-inflicted injuries, unless it is a Prescribed Minimum. The treatment of infertility, other than the following treatment (according to PMB code 902M), subject to pre-authorisation by Medihelp: Hysterosalpinogram. The following blood tests: Day 3 FSH / LH; Oestradiol; Thyroid function (TSH); Prolactin; Rubella; HIV; VDRL; Chlamydia; and Day 21 progesterone. Laparoscopy. Hysteroscopy. Surgery (uterus and tubal). Manipulation of ovulation defects and deficiencies. Semen analysis (volume, count, mobility, morphology, MAR-test). Basic counselling and advice on sexual behaviour, temperature charts, etc. Treatment of local infections. The artificial insemination of a person as defined in the National Health Act, 2003 (Act No. 61 of 2003). Immunisation (including immunisation procedures and material) which is required by an employer, excluding flu immunisations and standard child immunisations on the Dimension Prime benefit range. Bandages, cotton wool and plasters on prescription that are not used by a supplier of service during a treatment/procedure. Services which are claimable from the Compensation Commissioner, an employer or any other party, subject to the stipulations of rule Treatment of alcoholism and drug abuse as well as services rendered by institutions which are registered in terms of section 21(2) of the Abuse and Dependence-producing Substances and Rehabilitation Centres Act, 1971 (Act No. 41 of 1971) or other institutions whose services are of a similar nature, except in the following instance when alcohol and drug abuse will be considered as a Prescribed Minimum : Code Diagnosis Treatment 182T 910T 910T 910T Abuse or dependance on psychoactive substance, including alchohol Acute delusional mood, anxiety, personality, perception disorder and organic mental disorder caused by drugs Alcohol withdrawal delirium; alcohol intoxication delirium Delirium: amphetamine, cocaine, or other psychoactive substance Hospital-based management up to three weeks per benefit year Hospital-based management up to three weeks per benefit year Hospital-based management up to three days leading to rehabilitation Hospital-based management up to three days Exercise, guidance and rehabilitation programmes. Treatment of impotence. Treatment of occupational diseases. Services rendered by social workers. Completion of medical and other questionnaires not requested by Medihelp. Costs for evidence in a lawsuit. Costs of visits at home and home programmes. Costs exceeding the scheme tariff for a service or the maximum benefit limit to which a member is entitled, subject to Annexure 2 of the Rules. Food substitutes, food supplements and patent food, including baby food. Multivitamin and multi-mineral supplements alone or in combination with stimulants (tonics). Slimming remedies, provided that benefits shall be considered if motivated by a medical specialist as life-essential to be used for a limited period, and if approved beforehand by the Principal Officer. All patent substances, suntan lotions, anabolic steroids, contact lens solutions as well as substances not registered by the South African Medicines Control Council, except in the case of medicine items approved by Medihelp in the following instances medicine items with patient-specific exemptions in terms of section 21 of the Medicines and Related Substances Control Act, 1965 (Act No. 101 of 1965) as amended; homeopathic and naturopathic medicine items that have valid NAPPI codes as well as compounded non-proprietary medicine items dispensed by a homeopath/naturopath; and where well-documented, sound evidence-based proof exists of efficacy and cost-effectiveness. When only accommodation and/or general care services are rendered. The cost of transport with an ambulance/emergency vehicle from a hospital/other institution to a residence; in the event of a self-inflicted injury, unless it is a Prescribed Minimum ; in the event of a visit to friends/family; and to the rooms of a medical practitioner when the objective of the visit/consultation/treatment does not pertain to admission in a hospital. The cost of harvesting and/or preserving human tissues, including, but not limited to, stem cells, for future use thereof to treat a medical condition which has not yet been diagnosed in a beneficiary. Breast augmentation. Breast reduction. Gastroplasty. Gender reversal operations. Lipectomy. Epilation. Otoplasty/reconstruction of the ear. Refractive procedures. Obesity. All biological and other medicine items as per Medihelp s medicine exclusion list. 25

7 Hip, knee and shoulder replacements. Hymenectomy and circumcision (applicable to Dimension Prime 1 & Necesse). Removal of impacted wisdom teeth during hospitalisation (applicable to Dimension Prime 2, Dimension Prime 1 and Necesse). Roaccutane and Retin A, or any skin lightening agents (applicable to Dimension Prime 3, Dimension Prime 1 & Necesse). Necesse-specific exclusions Services rendered to beneficiaries outside the Medihelp network, except for those services as listed in Schedule B6 or if voluntarily obtained from a non-designated service provider in the case of a PMB condition. Injuries sustained during participation in a strike, unlawful demonstration, unrest or violent conduct, except in the case of a Prescribed Minimum. Homeopathic and herbal medicine, as well as household remedies or any other miscellaneous household product of a medicinal nature. Dental services Oral hygiene instructions and oral hygiene evaluation. Nutritional and tobacco counselling. Caries susceptibility and microbiological tests. Electrognathographic recordings and other such electronic analyses. Fissure sealants on patients older than 16 years. Replacement of amalgam (silver) fillings with composite (white) fillings. Gold foil restorations. Pulp capping (direct and indirect). Polishing of restorations. Ozone therapy. Metal base to full dentures, including the laboratory cost. Crown and bridge procedures for cosmetic reasons and the associated laboratory costs. Diagnostic dentures and the associated laboratory costs. Provisional crowns and the associated laboratory costs. Emergency crowns that are not placed for the immediate protection in tooth injury, and the associated laboratory costs. Resin bonding for restorations charged as a separate procedure. Dental bleaching. Porcelain veneers and inlays and the associated laboratory costs. Orthodontic treatment for cosmetic reasons. The auto-transplantation of teeth. The closure of an oral-antral opening when claimed during the same visit with impacted teeth. Where the reason for admission to hospital is dental fear or anxiety. Where the only reason for admission to hospital is to acquire a sterile facility. Perio chip. The hospital and anaesthetic claims for the following procedures will not be covered when performed under general anaesthesia: Apisectomies. Dentectomies. Frenectomies. Soft tissue impactions. Conservative dental treatment (fillings, extractions and root canal therapy) in hospital for adults. Professional oral hygiene procedures. Implantology and associated surgical procedures. Surgical tooth exposure for orthodontic reasons. Removal of impacted wisdom teeth unless covered by bone. Orthognathic (jaw correction) surgery and the related hospital cost, and the associated laboratory costs. Sinus lift procedures. Bone augmentations. Bone and other tissue regeneration procedures and the cost of material. Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis. Surgical periodontics which includes gingivectomies, periodontal flap surgery, tissue grafting and hemisection of a tooth. Orthodontic re-treatment and the associated laboratory costs. The cost of dental materials for procedures performed under general anaesthesia. Dolder bars and associated abutments on implants, including the associated laboratory costs. The laboratory costs, where the associated dental treatment is not covered. The laboratory cost associated with mouth guards. The clinical fee will be covered at the Medihelp Dental Tariff where clinical protocols apply. Snoring appliances and the associated laboratory costs. High-impact acrylic. Cost of mineral trioxide. Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments. The cost of gold, precious metal, semi-precious metal and platinum foil. Cost of invisible retainer material. Cost of bone regeneration material. Appointments not kept. Professionally applied topical fluoride in adults. Laboratory delivery fees. Special reports. Dental testimony. Enamel microabrasion. Behaviour management. Intramuscular and subcutaneous injections. Procedures that are defined as unlisted procedures. The clinical fee for the addition of a soft tissue base to new dentures. The laboratory fee will be covered at the Medihelp Dental Tariff where clinical protocols apply. The clinical fee for denture repairs and denture tooth replacements. The laboratory fee will be covered at the Medihelp Dental Tariff where clinical protocols apply. Multiple hospital admissions. Full mouth rehabilitations and the associated laboratory costs. Denis dental protocols Fillings For extensive restorative treatment plans (multiple fillings) a treatment plan and X-rays may be requested. Crowns and bridges s for crowns will be granted once per tooth in a 5-year period. s for crowns/bridges will not be applied toward the following cases: Laboratory fabricated crowns on primary teeth Fixed prosthodontics (crowns) used to repair teeth damaged due to bruxism (tooth grinding); toothbrush abrasion or attrition; erosion or fluorosis Fixed prosthodontics where a reasonable attempt has not been made to restore/replace the tooth conservatively Fixed prosthodontics where the member s mouth is periodontally compromised Fixed prosthodontics where the tooth has been recently restored to function Fixed prosthodontics (crowns) where the tooth is unopposed/non-functional. Periodontics Periodontal benefits will only be applied to cases assessed as periodontally compromised. Orthodontics s for orthodontic treatment are only available to beneficiaries whose treatment commences before their 18 th birthday. Only one beneficiary per family may commence orthodontic treatment in a calendar year. Maxillo-Facial Surgery and Oral Pathology for Temporo-mandibular Joint (TMJ) therapy is limited to non-surgical intervention/treatments. 26

8 The claims for oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours) will only be covered if supported by a laboratory report that confirms diagnosis. Scheme exclusions: Orthognathic (jaw correction) surgery Bone augmentations Bone and tissue regeneration procedures The cost of bone regeneration material The auto-transplantation of teeth Sinus lifts The closure of an oral-antral opening (currently code 8909) when claimed during the same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion. Hospitalisation (general anaesthetic) General anaesthetic benefits are available for the removal of impacted teeth; benefit will be granted where the teeth are covered by bone. The Hospital and anaesthetist claims for the following procedures will not be covered when performed under general anaesthesia. The payment of the dental procedure will be dependent on available benefits, and payable at MDT: Soft tissue impactions Apicectomies Dentectomies Frenectomies Implantology and associated surgical procedures Conservative dental treatment (fillings, extractions and root canal therapy) for adults Professional oral hygiene procedures Surgical tooth exposures for orthodontic reasons Scheme exclusions: Where the only reason for admission to hospital is dental fear and anxiety Multiple hospital admissions Where the only reason for the admission request is for a sterile facility The cost of dental materials for procedures performed under general anaesthesia Necesse-specific exclusions Specialised dentistry, partial metal frame dentures, crowns and bridges, implants, orthodontics and periodontics. Metal base to full dentures. Explanation of terms The back treatment programme is a non-surgical intervention in lieu of surgery for the management of spinal column disease/conditions/ abnormalities. This new approach to the treatment of back and neck pain is used as an alternative to back surgery, and involves an interdisciplinary team handling the rehabilitation programme, which is individualised for each patient based on the patient s needs and clinical diagnosis. Chronic medicine is medicine used for the long-term treatment (three months or longer) of a chronic condition, and which meets the following requirements: It must be used to prevent and treat a serious medical condition; It must be used for an uninterrupted period of three months or longer; It must be used to sustain life, to delay the progress of a disease, and to repair natural physiology; It must be registered in South Africa for the treatment of the medical condition for which it is prescribed; and It must be the accepted treatment according to local and international treatment protocols and algorithms. MEDICHRON (Medihelp s chronic medicine management division) approves benefits for all chronic medicine. Contracted tariff is the tariff as approved by the Board of Trustees and contractually agreed with service providers, which includes per diem, fixed and global fees. Co-payments are the difference between the cover provided by Medihelp and the cost/tariff charged for the medical service, and are payable directly to the service provider. Members must make copayments in the following cases: When doctors and other providers of medical services charge fees which exceed Medihelp s scheme tariffs, the member is responsible for paying the difference between the amount charged and the amount which Medihelp pays; When Medihelp s benefit allocation is not 100% (e.g. for non-chronic medicine), or where the cost exceeds the limit available for the service (e.g. for medical, surgical and orthopaedic appliances); and When the member chooses not to obtain services from a designated service provider (e.g. the SAOC network in the case of oncology) or when a pre-determined co-payment is applicable to a specific benefit as indicated per benefit option (e.g. hysterectomy on Dimension Prime 1). Dental Information Systems (Denis) is South Africa s leading dental benefit management company. Medihelp s dental benefits are managed by Denis and granted in accordance with Denis protocols, while Medihelp members obtain services from their regular dentists. In certain cases (particularly for specialised dentistry), benefits are subject to approval by Denis. An emergency medical condition means any sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person s life in serious jeopardy. An emergency medical condition must be certified as such by a medical practitioner. Emergencies qualify for PMB and must therefore also be registered for PMB (see also PMB ). EVARS prostheses shall only be considered where the patient suffers from an abdominal aortic aneurysm with an accompanying high risk for anaesthesia. A formulary is a scientifically compiled list of high-quality, costeffective non-chronic (acute) and chronic medications that are covered in a specific benefit option. A formulary can be based on the active ingredients of the medicine or relate to specific trade names. Gross monthly income means the applicant s gross monthly income before any deductions or, should the applicant not receive a monthly income, such monthly income of the person who pays the subscriptions. Only applicants whose monthly income is less than the highest income category must provide proof of income (applicable to the Necesse benefit option). The health and benefit booster offers benefits for preventative care by means of risk assessment tests, to ensure the early detection of expensive medical conditions in particular, or to assist with the effective management thereof. In the case of the Dimension range of benefit options it also offers benefits for certain day-to-day services. Health-essential functional prostheses necessarily replace a part of the body or a component thereof, or perform an essential function of the body. HIV rapid testing should take place in a controlled clinical environment to determine HIV-status and should include pre- and post-testing counselling. This test may be followed by pathology tests according to Scheme protocols. Hospital benefits refer to benefits for services rendered by a hospital during a patient s stay in hospital. Services include ward accommodation and ward medicine, general radiology and pathology, physiotherapy and other supplementary services rendered during hospitalisation. Hospital benefits are subject to pre-registration and a 10% co-payment (R1,000 in the case of Necesse) will be applicable to the hospital account if the admission is not pre-registered. 27

9 A co-payment per admission is applicable to the Dimension range of benefit options. Emergency admissions must be registered on the first workday following the admission (see also emergency medical condition ). ICON is the Independant Clinical Oncology Network who determines the clinical protocols according to which patients on the Necesse benefit option receive cancer treatment. Standard immunisations are child immunisations in accordance with the guidelines set by the Department of Health on the standard immunisation chart. A limit is the maximum benefit amount which is paid for a specific service, apparatus or appliance, for example in the case of prostheses. Major medical benefits include benefits for hospitalisation, PMB, trauma recovery and benefits that complement care when you need to recover. Co-payments and sub-limits may be applicable in some cases (which may differ per benefit option). Maxillofacial surgery means services pertaining to the jaws and face, particularly with reference to specialised surgery in this region. (In the case of Necesse, maxillofacial surgery pertains to trauma-related injuries only.) Medicine means a substance or mixture of substances which is accepted as being ethical by medical science and which is registered with the South African Medicines Control Council, to be administered or applied for the prevention, treatment or healing of an illness (see also chronic medicine ). Medicine price refers to: The Maximum Medical Aid Price (MMAP) which is the reference price used by Medihelp to determine benefits for non-chronic and chronic medicine. The MMAP is the average price of all the available generic equivalents for an ethical patented medicine item; or The Medihelp Reference Price (MHRP) which is applicable to all pre-authorised PMB medicine. The price is determined according to the most cost-effective treatment based on evidence-based principles. The MHRP will differ for the different benefit options and is subject to change (e.g. when new generic equivalents are introduced to the market). Please visit Medihelp s website at for the latest MHRP. You are advised to consult your doctor when using PMB medicine to make sure you use medicine on the MHRP where possible and so prevent or reduce co-payments. Medihelp Dental Tariff means the benefits for dentistry in accordance with the dental schedule of the Scheme as agreed between Medihelp and its contracted dental managed healthcare organisation. Medihelp Preferred Pharmacy Network refers to pharmacies offering Medihelp the most cost-effective professional fee structure for prescribed medicine. While standard co-payments on medicine still apply as set out in the rules of the benefit options, members who make use of network pharmacies will not have to pay any excess amounts in respect of higher professional fees charged by pharmacies to dispense medicine items. National Renal Care is the preferred provider for the rendering of renal dialysis services (chronic, peritoneal and acute dialysis) to patients suffering from renal failure. Optipharm is the preferred provider for the rendering of HIV/Aidsrelated services and post-exposure prophylaxis in the case of sexual assault. An overall annual limit of R800,000 is applicable in the case of the Necesse benefit option. It means that benefits for services rendered during a particular year are subject to an overall annual maximum benefit amount and various sub-limits, where applicable. Per year means from 1 January to 31 December of a year. Should a beneficiary enrol within a financial year, benefit amounts will be prorated according to the remaining number of months of the year. All limits are valid for a year unless otherwise indicated, e.g. for spectacles which are available per 24-month cycle. Pre-authorisation means benefits for a service must be authorised before it is rendered. The Preferred Provider Negotiators (PPN) optical providers manage Medihelp s optical benefits. More than 2,000 optometrists across South Africa are part of the PPN network. Although Medihelp members may visit any optometrist, benefits will be paid according to the PPN tariffs and a co-payment may be applicable should the costs exceed the benefit amount (also see co-payments ). Prescribed Minimum s (PMB) are paid for 26 chronic illnesses on the Chronic Diseases List (CDL) and 270 medical conditions with their treatments as published in the Regulations of the Medical Schemes Act, 1998 (Act No. 131 of 1998). In terms of these Regulations, medical schemes are compelled to grant benefits for the diagnosis, treatment and care costs of any of these conditions as well as emergency medical conditions (that meet the published definition) without imposing any limits. PMB are subject to pre-authorisation, pre-registration, protocols, and the utilisation of designated service providers, where applicable (e.g. the South African Oncology Consortium for cancer treatment). Protocols are clinical guidelines compiled by experts in the field of a specific medical condition for the treatment of that condition based on best practice principles. The SAOC is the South African Oncology Consortium, the professional affiliation of South African oncologists who determine the guidelines according to which patients receive cancer treatment. A savings account offers members of the Dimension Prime 2 benefit option the opportunity to save funds for unexpected medical expenses, especially medical services rendered out of hospital or not covered by the benefit option. The savings account contribution is a fixed monthly amount which is included in the member s monthly contribution, and a credit facility is immediately available at enrolment. Scheme tariff is the tariff for services as approved by the Board of Trustees. Trauma care includes benefits for trauma in the case of motor vehicle accidents, stab and gunshot wounds that require hospitalisation, as well as prophylaxis in the event of sexual assault, and benefits for head trauma, burns and near drowning. Vascular/cardiac prostheses include artificial aortic valves, pacemakers and related or connected functional appliances. Network benefit options offer benefits to members in collaboration with a medical provider network. In the case of the Necesse benefit option, day-to-day services are rendered by a network of general practitioners. Members must make use of the network to qualify for benefits. 28 The content of this brochure is subject to the approval of the Medihelp Rules by the Registrar of Medical Schemes