Schedule of Benefits (REGIONAL-SEHA PRIME Plan_AL DURRA)
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1 Plan Name Annual Benefit Limit Territorial Limit 1 REGIONAL-SEHA PPRIME Plan (AL DURRA) AED 5,000,000 Per Person Per Policy Year MENA Region* Extended to: Worldwide for (a) Emergencies (b) the Non-Elective Medical Conditions arising during business trip and/ or holidays only and (c) Extended in case medical treatment is not available within REGIONAL SEHA PRIME (AL DURRA) Plan network. (Allowing direct billing at designated provider) MENA Pre-existing conditions Fully Covered Inpatient Treatment Non Inpatient & Day Treatment(All Emergency and Non-emergency cases do not require pre-authorization but should be notified to Daman within 24 hours) (including Pre & Post In Hospital Treatment Covered) Accommodation Type-Private Room Hospital Accommodation & Services Consultant s, Surgeon s & Anesthetist s Fees and other fee Ambulance Services (in Medical emergency only, subject to General exclusions) (emergency evacuation while abroad) Parent Accommodation for accompanying an Insured Child under 12 years of age (Maximum limit of AED 500 Per day) Companion Accommodation for Critical Illness (Maximum limit of AED 500 Per day) Non cosmetic reconstructive surgery Organ Transplantation including acquisition and transplant procedures, harvest and storage and post-transplant care (including donor costs) Notes: organ transplantation shall be subject to UAE law Medical Rehabilitation (Inpatient) Acute rehabilitation of non-excluded conditions (AED 500 per day, up to 90 days PPPY, based on DRG) Palliative care for Non excluded medical 9 conditions Bariatric Surgery 6,2 (Based on eligibility criteria) Hearing aids and Cochlear Implants 2 Out-patient Treatment Physician Consultation (Deductible not applicable for follow up within 7 days) Diagnostics (X-Ray, MRI, CT-Scan, PET Scan, Nuclear Medicine, Ultra Sound, (Covered up to a maximum limit of AED 500 per visit) Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 1 of 5
2 etc.), Laboratory including reference lab services (Specialized investigation and scan including but not limited to elective MRI, CT,PET CT and Nuclear Medicines with Pre-authorization only) (AED 10 applicable per procedure) Pharmaceuticals (Long term medications with Pre authorization only in case of Medications exceeding 90 days in Abu Dhabi s Providers (Non SEHA) (No pre-authorization required at SEHA facilities) 12 Physiotherapy 2 (Including Occupational and Speech Therapy) Other Benefits Home healthcare and palliative care 9,2 (Maximum Annual limit AED 10,000 Per Person Per Year) Chemotherapy and Radiotherapy Phototherapy for dermatological conditions 3 Physical, Occupational and speech therapy with pre-authorization Cardiac Rehabilitation 2,10 Pulmonary Rehabilitation 2, 11 Chiropractic Services visits PPPY) Podiatry Services 2 visits PPPY) Dietician 2 consultations PPPY) Preventive Services and infectious diseases; Medical Check-up 2 (Covered up to a Maximum of AED 1,000 PPPY) Hearing Exams Health screening as mandated by HAAD Hormonal Replacement Therapy (Prescribed medically necessary for nonexcluded medical conditions, including growth hormone therapy as per current International guidelines) 12 Dermatological Treatment (Prescribed medically necessary treatment for un-excluded medical conditions including, but not limited to: Warts; Acne; Vitiligo U/V treatment and other non-cosmetic conditions.) 12 Allergy Testing and Treatment( including allergy injections) if medically necessary 9, upon referral only (AED 10 per consultation) 12 Allergy Treatment 2 - Pharmaceuticals Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 2 of 5
3 rules applicable 12 Vitamins, Supplements and Preventive Pharmaceuticals if medically necessary 12 Contraceptive and Birth Control Treatments 12 Medical Nutrition including feeding 12 equipment and supplies Durable Medical Equipment, Prosthetics and orthotics with pre-authorization only) (Covered up to a Maximum of AED 50,000 PPPY) Hepatitis A, B & C 100% Covered Vaccination as per MOH & HAAD (including Hepatitis B vaccination) Psychiatric Treatment 2 (Psychiatric Pharmaceutical shall be covered as per pharmaceutical rules up to the Policy limit) 12 Repatriation of Mortal Remains to country of origin 3 (Maximum limit AED 12,500 Per Person) Diagnostic and treatment services for dental and gum treatment (medical emergency cases) Emergency Treatment Hearing and vision aids, and vision correction by surgeries and laser (medical emergency cases) Healthcare services for work illnesses and injuries as per Federal Law No. 8 of 1980 concerning the Regulation of Work Relations, as amended, and applicable laws in this respect Annual Breast Cancer Screening at designated Providers Not covered (Applicable for females> 35 years) 2,4 Annual Prostate Cancer Screening at designated Providers Not covered (Applicable for males> 45 years) 2,5 Colorectal Cancer Screening at designated providers (applicable for males and females> 50 years) 2,13 Not covered Maternity Maximum annual limit per person (Inpatient & Outpatient Maternity): Within and Outside UAE: 100% Inpatient Maternity 1,2 Including: a) New born care (e.g. incubator) b) New born accommodation c) Birth Defects/ Congenital coverage from date of birth Outpatient Maternity (Deductible not applicable for follow up within 7 days) Outpatient Maternity Service other than Consultation and Pharmaceuticals (Covered up to a maximum limit of AED 500 per visit) Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 3 of 5
4 Dental Dental 2,7 (Maximum Annual limit of AED 15,000 Per Person) 80% covered 80% covered 80% covered Dental Implants 50% covered Not covered Not covered Accidental dental treatment Optical Optical 3 (Limited to 1 vision tests per year and Maximum Annual limit AED 1,000 Per Person including Prescribed Eye glasses/ lens (once a year), Frames (once a year) and /or disposable contact lenses (aggregate) and consultation Lasik surgery 3 (Maximum Annual limit AED 10,000 Per Person) 100% Other services (through designated service providers only) Second Opinion facility for specified conditions (Europ Assistance) International Assistance through Assist America * MENA includes: Algeria, Bahrain, Cyprus, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, Palestine, United Arab Emirates and Yemen 1 Please note: (1) Coverage outside UAE is limited to 180 days per treatment. (2) A single holiday or business trip may not exceed 180 days 2 Pre-authorization required to avail this benefit. All Emergency cases do not require pre-authorization but should be notified to Daman within 24 hours. 3 Available on reimbursement only. Providers covered on re-imbursement only. 4 Includes: a) Clinical Exam b) Mammogram c) Pelvic Sonogram (if medically indicated) d) CA 15.3 (if medically indicated) 5 Includes: a) Clinical exam b) PSA c) Rectal sonogram 6 Eligibility Criteria for the purpose of this Policy: i. A Body Mass Index (BMI) >= 40, or ii. A BMI with at least one clinically significant obesity-related co-morbidity, including but not limited to the following: a. Arthropathy in a weight-bearing joint b. Type 2 diabetes mellitus c. Poorly controlled hypertension (systolic blood pressure at least 140mm Hg or diastolic blood pressure 90 mmhg or despite optimal medical management) d. Major hyperlipidemia e. Coronary heart disease f. Lower extremity lymphatic or venous obstruction g. obstructive sleep apnea h. pulmonary hypertension 7. Following services are covered: a) X-Rays, Anesthesia, assistance; b) Extractions (simple and surgical); c) Amalgam / Composite Fillings; d) Root Canal Treatments; e) Consultations; f) Surgical Interventions; g) Bridgework, h) Crowns i) Tooth Scaling and polishing twice in a year; j) Gum Treatment; k) Dental Implants, l) Prescribed Drugs for the above mentioned services shall be covered as per Pharmaceutical rules and covered up to the policy limit. 8. up to Policy limit if palliative care benefits taken as Inpatient in medical facility Outpatient palliative limit will be applicable if taken at home. 9. Covered Allergy testing procedure includes; a)skin prick test b) Intradermal prick test c) Skin patch d) Photo patch e) Bronchial Inhalation f) Oral challenge g) Radioallergosorbent test RAST covered Immunotherapy procedure include; Immunotherapy, Rapid desensitization procedure (e.g. Insulin, Penicillin, Equine serum) Gamaglobulin; IgA, IgD,IgG,Igm,Ige Gamaglobulin;immunoglobulin subclasses (IgG1,2,3 or 4) Excluded Services include; Leukocyte histamine release (LHR) Ophthalmic mucous membrane tests Direct nasal mucous membrane test Inhalation bronchial challenge testing Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 4 of 5
5 10 Cardiac Rehabilitation coverage include Physician service for cardiac rehabilitation Nutritional counseling, Risk factor management (lipids, hypertensions, weight and diabetes) 11 Pulmonary Rehabilitation covers 1) one PR evaluation for a single diagnosis 2) Medically Necessary goal directed program of PR for a) C/c pulmonary disease b) Impaired pulmonary function due to restricted conditions like thoracic cage abnormalities c) severe respiratory impairment d) pre and post-operative intervention for lung transplantation and lung volume reduction surgery 12 Pharmacy authorization rules applicable 13 Includes: a) FIT (Fecal Immunochemical Test) every 2 years; b) Colonoscopy every 10 years HAAD S Approval number (license number) for this product is (as appearing on the Health Insurance card). SOB REF NO:SOB-US-473-R Package Numbers are 13660&13661 Version No.: 1 Revision No.: 0 Date of Issue: Page No(s).: 5 of 5
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