seen by everybody as the No.1 medical fund in South Africa

Transcription

1 Benefi ts

2 seen by everybody as the No.1 medical fund in South Africa At Bonitas Medical Fund we are leading the pack in affordable, quality Anybody may fall ill at any time from dad to John Junior. Which is why medical cover. Which is why we are voted the No. 1 Medical Aid Brand we d like to offer you the peace of mind of knowing that with Bonitas, in South Africa* everybody you love is adequately covered - from head to toe. That is our *Markinor/Sunday focus. It s lovely. Times 0860 Top 002 Brand 108 Survey

3 Bonitas Benefit Structure and Options Our five affordable options provide quality health cover for everybody, from the CEO to the factory worker. Select an option to optimise the balance between affordability and richness of benefits to suit your personal healthcare needs. Major Medical Benefit Covers medical expenses in hospital and major medical events Out of Hospital Benefit Covers out of hospital medical expenses Chronic Benefit Covers medicine for conditions that require medication on an ongoing basis Supplementary Benefit Additional benefi ts, medical expenses incurred in or out of hospital To choose your option, consider your healthcare needs in the three main benefi t categories listed below. Major Medical Benefits Major medical benefi ts cover medical expenses in hospital and major medical events. Hospital accounts are covered in full as per the negotiated rates between Bonitas and the major hospital groups. Hospital admission is subject to pre-authorisation by Hospital Benefi t Management (HBM), except in the case of emergencies. BonComprehensive BonSave Standard Primary BonCap Limit R per family per annum R per family per annum Reimbursement Rate 1 300% Bonitas Rate 150% Bonitas Rate 100% Bonitas Rate 100% Bonitas Rate 100% Bonitas Rate Provider Any hospital Any hospital Any hospital Any hospital Prime Cure Hospital Network Chronic Benefits Chronic benefi ts cover medicine for conditions that require medication on an ongoing basis. Subject to pre-authorisation by Chronic Medicine Management. BonComprehensive BonSave Standard Primary BonCap 63 conditions Comprehensive Formulary Prescribed Minimum Benefi ts only at Designated Service Provider (26 conditions) R6 500 per benefi ciary R per family 44 conditions Comprehensive Formulary Prescribed Minimum Benefi ts only at Designated Service Provider (26 conditions) Prescribed Minimum Benefi ts only at Designated Service Provider (26 conditions) Any Pharmacy or Dispensing GP Pharmacy Direct Any Pharmacy or Dispensing GP up to limit PMBs unlimited at DSP Pharmacy Direct Prime Cure Network Pharmacy Out of Hospital Benefits Out of hospital benefi ts cover day to day medical expenses incurred out of hospital. New Generation Options Traditional Options Low Cost Capitation BonComprehensive BonSave Standard Primary BonCap Savings account enables members to self-insure and manage their own out of hospital medical expenses. Unspent savings are carried forward with interest. An insured threshold benefi t on BonComprehensive provides additional peace of mind for high out of hospital expenses. Out of hospital expenses are insured via a fl exible day to day benefi t. Dental, optical, radiology and pathology benefi ts are provided in addition to the day to day benefi t. Out of hospital expenses are managed without fi nancial limits by the Prime Cure GP. 1 Reimbursement rate of healthcare practitioners in hospital e.g. medical specialists 1

4 BonComprehensive BonComprehensive is a new generation product with a threshold benefi t to provide members with peace of mind. Major medical expenses are covered at 300% of the Bonitas rate. It covers a wide range of chronic diseases at any service provider and unlimited hospitalisation with no hospital network. Major Medical Benefits This benefi t covers medical expenses incurred in hospital, as well as major medical events e.g. oncology. All hospital admissions, oncology treatment plans and renal dialysis require pre-authorisation by Hospital Benefi t Management (HBM) except in the case of emergencies. Overall Annual Limit Benefits payable at 300% of the Bonitas Rate Sub-limits applicable: GP & Specialist Consultations, 300% Bonitas rate Pathology 1 Radiology (Specialised & General) Paramedical/Auxiliary Services e.g. physiotherapy, speech therapy, occupational therapy Oncology Biological drugs e.g. Herceptin Organ Transplants Renal Dialysis Maxillo Facial Surgery Medication to take out (TTO) Physical Rehabilitation, sub-limit of R for medicine R per family, subject to clinical protocols and 10% co-payment, excluding orthognatic surgery R350 per benefi ciary, per admission R per family Chronic Medicine Benefits 2 Covers medication for conditions that require medication on an ongoing basis. cover for 63 diseases, subject to pre-authorisation Biological drugs: R per family, subject to clinical protocols and 10% co-payment This Summary is for information purposes only and does not supersede the Rules of the Fund. In the event of any discrepancy between the Summary and the Rules, the Rules will prevail. 1 Subject to pathology management programme - Pathology programme 2 2 Comprehensive formulary, refer to page 12 for a complete chronic disease list 3 Comprehensive list of dental benefi ts (DENIS) page 13

5 Out of Hospital Benefit Covers day to day medical expenses e.g. GP & specialist consultations, acute medication, paramedical/auxiliary services, optometry, radiology, pathology etc. Savings Benefit Per Month Per Annum Principal Member Adult Dependant R 422 R 398 R5 064 R4 776 Child Dependant R 86 R1 032 Threshold Benefit Threshold Self-Funding Gap Principal Member Adult Dependant Child Dependant R6 500 R6 000 R1 700 R1 436 R1 224 R 668 Major Medical 300% Bonitas Rate Out of Hospital Savings & Threshold Plus Basic & Advanced Dentistry Supplementary Benefits Chronic Medication 63 Chronic Conditions at any service provider Supplementary Additional Benefi ts in or out of hospital Acute Medication & Pharmacy Advised Therapy Member Member + 1 Member + 2 Member Subject to savings and/or threshold The following limits apply: R R R R (90% of the Bonitas rate accrues to threshold; 10% co-payment in threshold) GP and Specialists Consultations General Radiology Pathology Paramedical Services/ Auxiliary Services e.g. speech therapy, occupational therapy, physiotherapy Optometry In addition: Dental Benefits Basic Dentistry Advanced Dentistry Subject to savings and/or threshold, unlimited in threshold Subject to savings and/or threshold, unlimited in threshold Subject to savings and/or threshold, unlimited in threshold 1 Subject to savings and/or threshold, limited to R5 500 per family Subject to savings and/or threshold, limited to R2 250 per benefi ciary Subject to clinical protocols & Bonitas Dental Tariff (BDT) 3 Subject to clinical protocols & Bonitas Dental Tariff (BDT) 3 Additional benefi ts, medical expenses incurred in or out of hospital Maternity Care per event hospitalisation (subject to (ante- and postnatal) pre-authorisation) and midwifery services Antenatal classes to the value of R750 and private ward for post-delivery 12 antenatal consultations, 2 X 2D scans and 4 postnatal consultations with midwife Refractive Surgery R per family Subject to pre-authorisation Immune deficiency related to HIV infection Subject to Aid for AIDS (AFA) registration and clinical protocols Mental Health Benefits R per family, subject to pre-authorisation Sub-limit of R for consultations in & out of hospital Specialised Radiology R per family (out of hospital) Subject to pre-authorisation Emergency Transportation, subject to Netcare 911 Endoscopies in practitioners, subject to pre-authorisation. rooms Prostheses Internal R per family Prostheses External R per family Subject to pre-authorisation HIV test and Flu vaccine International cover Free R5 million per trip Appliances General appliances Wheelchairs & large orthopaedic appliances Stoma products & CPAP machines Hearing aids Oxygen: Home ventilation R6 500 per family Included in the general appliance limit May exceed general appliance limit by R3 000 R per family, biennial benefi t, subject to pre-authorisation by HBM WHAT IT WILL COST BonComprehensive Contributions Principal Member Adult Dependant Child Dependant Risk R1 687 R1 591 R343 Savings R 422 R 398 R 86 Total R2 109 R1 989 R429 3

6 BonSave Designed for young executives, professionals and active members. BonSave offers unlimited hospitalisation at 150% of the Bonitas rate at an affordable contribution. The fl exibility of a savings account allows for the payment of out of hospital expenses. Major Medical Benefits This benefi t covers medical expenses incurred in hospital, as well as major medical events e.g. oncology. All hospital admissions, oncology treatment plans and renal dialysis require pre-authorisation by Hospital Benefi t Management (HBM) except in the case of emergencies. Overall Annual Limit Benefits payable at 150% of the Bonitas Rate Sub-limits applicable: GP & Specialist Consultations ; 150% of the Bonitas Rate Pathology 1 Radiology (Specialised & General) Paramedical/Auxiliary Services e.g. physiotherapy speech therapy, occupational therapy Oncology Organ Transplants Renal Dialysis Maxillo Facial Surgery Medication to take out (TTO) Physical Rehabilitation Sub-limit of R for medicines, excluding orthognatic surgery R250 per benefi ciary, per admission R per family R1 000 deductible Colonoscopy Conservative Back Treatment Cystoscopy Flexible sigmoidoscopy Functional Nasal Surgery Gastroscopy Umbilical Hernia Repair Hysteroscopy (but not endometrial ablation) Myringotomy Tonsillectomy and Adenoidectomy (except PMBs) Varicose Vein Surgery R2 500 deductible Arthroscopy Diagnostic Laparoscopy Hysterectomy (except cancer and PMBs) R5 000 deductible Nissen Fundoplication (Refl ux Surgery) Back Surgery including spinal fusion Joint replacements e.g. Hip & Knee replacements (except PMBs) 4 1 Subject to pathology management programme - Pathology programme 2 Restrictive formulary, refer to page 12 for a list of PMBs 3 Comprehensive list of dental benefi ts (DENIS) page 13

7 Chronic Medicine Benefits 2 Covers medication for conditions that require medication on an ongoing basis. Chronic Disease List (CDL) as per the Prescribed Minimum Benefi ts (PMB), at the Designated Service Provider (DSP), subject to pre-authorisation Major Medical 150% Bonitas Rate Chronic Medication PMBs only at DSP Out of Hospital Benefits Covers day to day medical expenses e.g. GP & specialist consultations, acute medication, paramedical/auxiliary services, optometry, radiology, pathology etc. Savings Benefit Per Month Per Annum Out of Hospital Savings plus Basic & Advanced Dentistry Supplementary Additional Benefi ts in or out of hospital Principal Member Adult Dependant Child Dependant R228 R177 R 69 Acute Medication & Pharmacy Advised Therapy GP & Specialist Consultation General Radiology R2 736 R2 124 R 828 Subject to savings Subject to savings Subject to savings Pathology Subject to savings 1 Optometry Paramedical/Auxiliary Services e.g. speech therapy, occupational therapy, physiotherapy In addition: Dental Benefits Basic Dentistry Advanced Dentistry Subject to savings Subject to savings Subject to clinical protocols and Bonitas Dental Tariff (BDT) 3 Subject to clinical protocols and Bonitas Dental Tariff (BDT) 3 Supplementary Benefits Additional benefi ts; medical expenses incurred in or out of hospital Maternity Care per event hospitalisation (subject to (ante- and postnatal) pre-authorisation) and midwifery services Antenatal classes to the value of R750 and private ward for postdelivery 12 antenatal consultations, 2 X 2D scans and 4 postnatal consultations with midwife Immune deficiency related R per benefi ciary to HIV infection Subject to Aid for AIDS (AFA) registration and clinical protocols Mental Health Benefits R per family, subject to preauthorisation Sub-limit of R for in & out of hospital consultations Specialised Radiology R per family, subject to (out of hospital) pre-authorisation Emergency Transportation, subject to Netcare 911 Endoscopies in practitioners rooms Prostheses Internal and External HIV test and Flu vaccine International cover, subject to preauthorisation R per family, subject to pre-authorisation Free R5 million per trip Appliances This Summary is for information purposes only and does not supersede the Rules of the Fund. In the event of any discrepancy between the Summary and the Rules, the Rules will prevail. General appliances Wheelchairs and large orthopaedic appliances Stoma products and CPAP machines Hearing aids Oxygen: Home ventilation R4 500 per family Included in the general appliance limit May exceed general appliance limit by R4 000 R6 500 per family, biennial benefi t, subject to pre-authorisation by HBM WHAT IT WILL COST BonSave Contributions Principal Member Adult Dependant Child Dependant Risk R685 R531 R206 Savings R228 R177 R 69 Total R913 R708 R275 5

8 Standard The Bonitas Standard option gives complete peace of mind for the whole family. It combines comprehensive cover with generous day to day benefi ts to meet the needs of a growing family. The Standard option has an unlimited overall annual limit and offers substantial chronic medicine benefi ts. Major Medical Benefits This benefi t covers medical expenses incurred in hospital, as well as major medical events e.g. oncology. All hospital admissions, oncology treatment plans and renal dialysis require pre authorisation by Hospital Benefi t Management (HBM) except in the case of emergencies. Overall Annual Limit Benefits payable at 100% of the Bonitas Rate Sub-limits applicable: GP & Specialist Consultations Pathology 1 Radiology (Specialised and General) Paramedical/Auxiliary Services e.g. physiotherapy speech therapy, occupational therapy Oncology Organ Transplants Renal Dialysis Maxillo Facial Surgery Medication to take out (TTO) Physical Rehabilitation R per family R per family R per family, excluding orthognatic surgery R250 per benefi ciary, per admission R per family Chronic Medicine Benefits 2 Covers medication for conditions that require medication on an ongoing basis. Limited to R6 500 per beneficiary and R per family, at any pharmacy or dispensing GP, subject to pre-authorisation. Once limit has been exceeded, PMBs are unlimited at DSP 44 chronic conditions covered This Summary is for information purposes only and does not supersede the Rules of the Fund. In the event of any discrepancy between the Summary and the Rules, the Rules will prevail. 6 1 Subject to pathology management programme - Pathology programme 2 Comprehensive formulary, refer to page 12 for a complete chronic disease list 3 Comprehensive list of dental benefi ts (DENIS) page 13

9 Out of Hospital Benefits Covers day to day medical expenses e.g. GP & specialist consultations, acute medication, paramedical/auxiliary services, optometry, radiology, pathology etc. Day to Day Benefit Major Medical 100% Bonitas Rate Chronic Medication 44 Chronic Conditions R6 500 per benefi ciary R per family Flexible benefi t with no sub-limits that can be used to cover out of hospital benefi ts. e.g. GP & specialist consultations, acute medication, paramedical services and alternative healthcare. Member Member + 1 Member + 2 Member + 3 Member R4 300 R6 400 R7 000 R7 500 R8 000 In addition to the day to day benefit the following is also provided: Basic Dentistry Advanced Dentistry General Radiology Subject to clinical protocols and Bonitas Dental Tariff (BDT) 3 Subject to clinical protocols and Bonitas Dental Tariff (BDT) 3 R2 100 per family Pathology R2 100 per family 1 Optometry Optometric examination Frames & prescription lenses/add-ons Clear Single Vision Clear Aquity Flat-Top Bifocal Clear Aquity Multifocal Contact lenses 2-year benefi t, per benefi ciary 100% of cost at PPN optometrist or to a maximum of R400 at a nonnetwork provider R 600 per benefi ciary R 110 per lens or R 230 per lens or R 420 per lens or R1 200 per benefi ciary Supplementary Benefits Additional benefi ts; medical expenses incurred in or out of hospital Maternity Care per event (ante- and postnatal) Immune deficiency related to HIV infection Mental Health Benefits Specialised Radiology (out of hospital) Out of Hospital Day to Day plus Radiology Pathology Optometry Basic & Advanced Dentistry hospitalisation (subject to pre-authorisation) and midwifery services 12 antenatal consultations, 2 X 2D scans and 4 postnatal consultations with midwife R per benefi ciary Subject to Aid for AIDS (AFA) registration and clinical protocols R per family, subject to pre-authorisation Sub-limit of R for consultations in & out of hospital R per family, subject to pre-authorisation Emergency Transportation, subject to Netcare 911 Endoscopies in practitioners rooms Supplementary Additional Benefi ts in or out of hospital, subject to pre-authorisation Prostheses Internal and External HIV test and Flu vaccine International cover R per family, subject to pre-authorisation Free R5 million per trip Appliances General appliances Wheelchairs and large orthopaedic appliances Stoma products and CPAP machines Hearing aids Oxygen: Home ventilation R5 000 per family Included in the general appliance limit May exceed general appliance limit by R4 000 R per family, biennial benefi t, subject to pre-authorisation by HBM WHAT IT WILL COST Standard Contributions Principal Member Adult Dependant Child Dependant Total R1 318 R1 140 R385 7

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11 leading the pack in affordable, quality medical cover for everybody At Bonitas Medical Fund we are leading the pack in affordable, quality medical cover. Which is why we are voted the No. 1 Medical Aid Brand in South Africa* *Markinor/Sunday Times Top Brand Survey 9

12 Primary The Bonitas Primary option has been designed for members who do not require extensive chronic medicine benefi ts. With an overall annual limit of R , the Primary option provides affordable cover with rich day to day benefi ts. Major Medical Benefits This benefi t covers medical expenses incurred in hospital, as well as major medical events e.g. oncology. All hospital admissions, oncology treatment plans and renal dialysis require pre-authorisation by Hospital Benefi t Management (HBM) except in the case of emergencies. Overall Annual Limit R per family Benefits payable at 100% of the Bonitas Rate Sub-limits applicable: GP & Specialist Consultations Pathology General Radiology Paramedical/Auxiliary Services e.g. physiotherapy, speech therapy, occupational therapy Oncology Organ Transplants Renal Dialysis Maxillo Facial Surgery Medication to take out (TT0) Physical Rehabilitation ; subject to overall annual limit (R ) ; subject to overall annual limit 1, subject to overall annual limit Subject to overall annual limit R per family PMBs at public hospitals only PMBs at public hospitals only, subject to overall annual limit, excluding orthognatic surgery R250 per benefi ciary, per admission R per family Chronic Medicine Benefits 2 Covers medication for conditions that require medication on an ongoing basis. Chronic Disease List (CDL) as per the Prescribed Minimum Benefi ts (PMB), at the Designated Service Provider (DSP), subject to pre-authorisation This Summary is for information purposes only and does not supersede the Rules of the Fund. In the event of any discrepancy between the Summary and the Rules, the Rules will prevail. 8 1 Subject to pathology management programme - Pathology programme 2 Restrictive formulary, refer to page 12 for a list of PMBs 3 Comprehensive list of dental benefi ts (DENIS) page 13

13 Out of Hospital Benefits Covers day to day medical expenses e.g. GP & specialist consultations, acute medication, paramedical/auxiliary services, optometry, radiology, pathology etc. Day to Day Benefit Major Medical Overall Annual Limit R % Bonitas rate Chronic Medication PMBs only at DSP Flexible benefi t with no sub-limits that can be used to cover out of hospital benefi ts e.g. GP & specialist consultations, acute medication, paramedical services and alternative healthcare. Member Member + 1 Member + 2 Member + 3 Member R2 250 R4 300 R4 800 R5 300 R5 900 In addition to the day to day benefit the following is also provided: Basic Dentistry General Radiology Subject to clinical protocols and Bonitas Dental Tariff (BDT) 3 R1 150 per family Pathology R1 150 per family 1 Optometry Optometric examination Frames & prescription lenses/add-ons Clear Single Vision Clear Aquity Flat-Top Bifocal Clear Aquity Multifocal Contact lenses 2-year benefi t, per benefi ciary 100% of cost at PPN optometrist or to a maximum of R400 at a non-network provider R 550 per benefi ciary R 110 per lens or R 230 per lens or R 230 per lens or R 900 per benefi ciary Supplementary Benefits Additional benefi ts; medical expenses incurred in or out of hospital Maternity Care per event (ante- and postnatal) Immune deficiency related to HIV infection Mental Health Benefits Out of Hospital Day to Day plus Radiology Pathology Optometry Basic Dentistry Specialised Radiology (joint limit in and out of hospital) Supplementary Additional Benefi ts in or out of hospital hospitalisation (subject to pre-authorisation) and midwifery services 12 antenatal consultations, 2 X 2D scans and 4 postnatal consultations with midwife R per benefi ciary Subject to Aid for AIDS (AFA) registration and clinical protocols R per family, sub-limit R6 000 for consultations in & out of hospital, subject to preauthorisation R8 000 per family subject to pre-authorisation Emergency Transportation, subject to Netcare 911 Endoscopies in practitioners rooms Prostheses Internal and External HIV test and Flu vaccine Subject to overall annual limit and pre-authorisation R per family, subject to overall annual limit and pre-authorisation Free Appliances General appliances Wheelchairs and large orthopaedic appliances Stoma products and CPAP machines Hearing aids Oxygen: Home ventilation R4 500 per family Included in the general appliance limit May exceed general appliance limit by R4 000 R6 500 per family, biennial benefi t Subject to overall annual limit (R ) and pre-authorisation by HBM WHAT IT WILL COST Primary Contributions Principal Member Adult Dependant Child Dependant Total R850 R666 R271 9

14 BonCap The Bonitas BonCap option offers substantial benefi ts at an affordable rate. This option is designed for members who require access to affordable cover at a preferred provider and generous major medical benefi ts. This option provides value for money by making use of the Prime Cure Network, with an overall annual limit of R per family. The BonCap option offers extensive hospital cover with generous GP consultations and medicine benefi ts. Members and benefi ciaries can access providers that are contracted to the Prime Cure Network. Major Medical Benefits This benefi ts covers medical expenses incurred when in hospital as well as major medical events e.g. oncology. Pre-authorisation through Prime Cure is compulsory for all hospital admissions (except in the case of emergencies). Overall Annual Limit R per family Benefits payable at 100% of the Bonitas Rate Sub-limits applicable : GP & Specialist Consultations Pathology General Radiology Physiotherapy & Occupational Therapy Oncology Organ Transplants Renal Dialysis Medication to take out (TTO) Physical Rehabilitation ; subject to overall annual limit (R ) and Prime Cure Provider Subject to overall annual limit and Prime Cure Provider, subject to overall annual limit R5 500, subject to overall annual limit and Prime Cure Provider R per family and Prime Cure Provider PMBs only, subject to pre-authorisation and Prime Cure Provider PMBs only, subject to pre-authorisation and Prime Cure Provider 7-days supply per benefi ciary, per admission Subject to pre-authorisation and Prime Cure Provider Chronic Medicine Benefits 2 Covers medication for conditions that require medication on an ongoing basis. Chronic Disease List (CDL) as per the Prescribed Minimum Benefi ts (PMB), at the Designated Service Provider (DSP) i.e. Prime Cure, accredited pharmacies and Medipost Courier Pharmacy. Subject to pre-authorisation and Prime Cure medicine formulary This Summary is for information purposes only and does not supersede the Rules of the Fund. In the event of any discrepancy between the Summary and the Rules, the Rules will prevail Chronic Disease List as per PMBs page 12

15 Out of Hospital Benefits Covers day to day medical expenses e.g. GP & specialist consultations, acute medication, paramedical/auxiliary services, optometry, radiology, pathology etc. Day to Day Benefit Major Medical Overall Annual Limit R Hospital Network 100% Bonitas rate Chronic Medication PMBs through Network Provider These benefi ts cover out of hospital expenses which are accessed through the Prime Cure Network providers and are listed below. GP Consultations Subject to Prime Cure network Out of Area I visit per benefi ciary or 2 visits per family to a / Emergency maximum of R650 and 20% co-payment Consultations Acute Medication Prime Cure or accredited pharmacy and subject to medicine formulary Out of Hospital Supplementary GP Additional Benefi ts in Consultations through or out of hospital Prime Cure Network Supplementary Benefits Additional benefi ts; medical expenses incurred in or out of hospital Over the Counter Medication Specialist Consultation Occupational Therapy & Physiotherapy General Radiology Pathology Basic Dentistry Emergency Dentistry Plastic Dentures Specialised Dentistry Optometry Examination / Consultation Frame Lens Contact Lenses R165 per benefi ciary, per annum maximum of R55 per event 3 visits or R1 800 per benefi ciary, up to 5 visits or R2 450 per family R1 200 per benefi ciary up to R1 800 per family Subject to case management and approved black and white X-rays at network providers Subject to case management and a list of approved tests at a Network Provider List of approved codes, subject to Prime Cure Provider limited to: One consultation per benefi ciary, per annum One preventative treatment per benefi ciary per annum e.g. cleaning, polishing, fi llings, extractions, pain and sepsis treatment, X-rays and emergency root canal treatment 1 episode per benefi ciary, per annum One set of dentures per family over a 24-month period applicable over the age of 21 20% co-payment No benefi t One pair of spectacles every 24 months, subject to network provider One optometric examination per benefi ciary Range of approved frames; 1 per benefi ciary Single vision or bifocal lens No benefi ts Maternity Care per event Network provider (ante- and postnatal) Neonatal Care R per family Immune deficiency related Clinical protocol and subject to to HIV infection HIV Disease Management Programme Mental Health Benefits R5 500 per family, subject to (in and out of hospital) pre-authorisation by contracted provider and registration on disease management programme Specialised Radiology R8 000 per family, subject to pre- (joint limit in and out of hospital) authorisation Emergency Transportation, subject to Netcare 911 Prostheses Internal R per family, subject to preauthorisation External No benefi t Appliances R3 000 per family (Includes general appliances, wheelchairs, stoma products, CPAP, hearing aids) Oxygen Therapy & Home Ventilation Subject to overall annual limit (R ) and pre-authorisation by Prime Cure WHAT IT WILL COST BonCap Income Band Principal Member Adult Dependant Child Dependant R0 - R4 000 R371 R352 R175 R R6 600 R450 R426 R206 R R945 R842 R358 11

16 PMBs as per Chronic Disease List Chronic Disease Lists 25 PMBs BonComprehensive Standard In addition to the 25 PMB conditions the following 38 diseases are covered: In addition to the 25 PMB conditions the following 19 diseases are covered: 1 Addison s Disease 2 Asthma 3 Bipolar Mood Disorder 4 Bronchiectasis 5 Cardiac Failure 6 Cardiomyopathy 7 Chronic Renal Disease 8 Chronic Obstructive Pulmonary Disease 9 Coronary Artery Disease 10 Crohn s Disease 11 Diabetes Insipidus 12 Diabetes Mellitus Type1&2 13 Dysrhythmias 14 Epilepsy 15 Glaucoma 16 Haemophilia 17 Hyperlipidaemia 18 Hypertension 19 Hypothyroidism 20 Multiple Sclerosis 21 Parkinson s Disease 22 Rheumatoid Arthritis 23 Schizophrenia 24 Systemic Lupus Erythematosus 25 Ulcerative Colitis 1 Acne 2 Allergic Rhinitis 3 Ankylosing Spondylitis 4 Anorexia Nervosa* 5 Attention Defi cit Disorder 6 Behcet s Disease 7 Barrett s Oesophagus 8 Bulimia Nervosa* 9 Cushing s Disease* 10 Depression* 11 Dermatitis 12 Eczema 13 Generalized Anxiety Disorder 14 Gastro-Oesophageal Refl ux (GORD) 15 Gout 16 Huntington s Disease 17 Hyperthyroidism* 18 Hypoparathyroidism 19 Menopause* 20 Myaesthenia Gravis 21 Narcolepsy 22 Neuropathies 23 Obsessive Compulsive Disorder 24 Osteoporosis 25 Paget s Disease 26 Panic Disorder 27 Paraplegia* 28 Pemphigus 29 Polyarteritis Nordosa 30 Post-Traumatic Stress Syndrome 31 Pulmonary Interstitial Fibrosis 32 Quadriplegia* 33 Stroke* 34 Systemic Sclerosis 35 Tourette s Syndrome 36 Thrombocytopaenic Purpura* 37 Valvular Heart Disease* 38 Zollinger-Ellison Syndrome 1 Acne 2 Allergic Rhinitis 3 Ankylosing Spondylitis 4 Attention Defi cit Disorder 5 Barrett s Oesophagus 6 Behcet s Disease 7 Depression* 8 Dermatitis 9 Eczema 10 Gastro-Oesaphageal Refl ux (GORD) 11 Gout 12 Menopause* 13 Narcolepsy 14 Obsessive Compulsive Disorder 15 Panic Disorder 16 Post-Traumatic Stress Syndrome 17 Tourette s Syndrome 18 Valvular Heart Disease* 19 Zollinger-Ellison Syndrome Chronic Medicine Management To apply for chronic authorisation phone Chronic Medicine Management ( ) and request an application form or visit the website ( and download an application form. Designated Service Provider for chronic medication - Pharmacy Direct To apply for the delivery of chronic medication, phone Pharmacy Direct ( ) or visit the website ( and request an application form. 12 * Prescribed Minimum Benefi t conditions

17 Dental Benefits (DENIS) All dental benefi ts are paid at the Bonitas Dental Tariff (BDT). All specialised dentistry and hospitalisation must be pre-authorised*. Scheme exclusions and clinical protocols can be found in the member information. BonComprehensive Option Standard and BonSave Options Primary Option CONSERVATIVE DENTISTRY SPECIALISED DENTISTRY HOSPITAL AND ANAESTHETICS Consultations Fillings 2 annual checkups per beneficiary. A treatment plan and X-rays will be requested for treatment plans of more than 5 fillings. Benefit for fillings is available where such fillings are clinically indicated and will be granted once per tooth in a 3-year period. There is no benefit for Amalgam (silver) fillings to be replaced with Composite (white filling material). Covered at the BDT Oral Hygiene 2 annual scale and polish treatments per beneficiary. No benefit for oral hygiene instructions. No benefit for professionally applied topical fl uoride in adults Extractions Root canal therapy Plastic Dentures One set of plastic dentures (an upper and a lower) per beneficiary in a 4-year period 2 annual checkups per beneficiary. A treatment plan and X-rays will be requested for treatment plans of more than 5 fillings. Benefit for fillings is available where such fillings are clinically indicated and will be granted once per tooth in a 3-year period. There is no benefit for Amalgam (silver) fillings to be replaced with Composite (white filling material). Covered at the BDT 2 annual scale and polish treatments per beneficiary. No benefit for oral hygiene instructions. No benefit for professionally applied topical fl uoride in adults 2 annual checkups per beneficiary. A treatment plan and X-rays will be requested for treatment plans of more than 5 fillings. Benefit for fillings is available where such fillings are clinically indicated and will be granted once per tooth in a 3-year period. There is no benefit for Amalgam (silver) fillings to be replaced with Composite (white filling material). Covered at the BDT 2 annual scale and polish treatments per beneficiary. No benefit for oral hygiene instructions. No benefit for professionally applied topical fl uoride in adults Covered at the BDT Covered at the BDT Covered at the BDT One set of plastic dentures (an upper and a lower) per beneficiary in a 4-year period Crowns* No benefit 2 crowns per family per year Pre-authorisation is required Benefits for crowns are granted once per tooth in a 5-year period Covered at BDT Partial metal frame dentures No benefit One partial frame (an upper or a lower) per beneficiary in a 5-year period Full metal dentures are not covered Orthodontics* No benefit Benefit on pre-authorisation will be applied to cases assessed as treatment mandatory, as per an orthodontic index A 25% co-payment of the BDT applies Limited to individuals younger than 18 years Orthognathic surgery is not covered Periodontics* No benefit Benefit is limited to conservative, nonsurgical therapy only (root planing) This benefit will be applied to members who are registered on the Perio Programme Surgical periodontics is a scheme exclusion One set of plastic dentures (an upper and a lower) per beneficiary in a 4-year period 3 crowns per family per year Pre-authorisation is required Benefits for crowns are granted once per tooth in a 5-year period Covered at BDT Two partial frames (an upper and a lower) per beneficiary in a 5-year period Full metal dentures are not covered Benefi t on pre-authorisation will be applied to cases assessed as treatment mandatory, as per an orthodontic index Limited to individuals younger than 18 years Orthognathic surgery is not covered Benefit is limited to conservative, nonsurgical therapy only (root planing) This benefit will be applied to members who are registered on the Perio Programme Surgical periodontics is scheme exclusion Implants No benefit No benefi t Benefit on pre-authorisation 2 implants per beneficiary, in a 5-year period. Cost of implant components is limited to R1 500 per implant Surgery Hospitalisation (general anaesthetic)* Laughing gas in dental rooms IV conscious sedation in rooms* Surgery in the dental chair: Covered at the BDT See Surgery Exclusion Summary Surgery in hospital: See Hospitalisation Pre-authorisation is required Admission protocols apply Impacted teeth removals only Multiple hospital admissions are not covered Surgery in the dental chair: Covered at the BDT See Surgery Exclusion Summary Surgery in hospital: See Hospitalisation Pre-authorisation is required Certain Maxillo-Facial procedures are covered in-hospital, subject to admission protocols. See Exclusion Summary General anaesthetic benefits are available for very young children for extensive dental treatment Multiple hospital admissions are not covered Surgery in the dental chair: Covered at the BDT See Surgery Exclusion Summary Surgery in hospital: See Hospitalisation Covered at the BDT Covered at the BDT Covered at the BDT Pre-authorisation required Covered at the BDT Clinical protocols apply Pre-authorisation required Covered at the BDT Clinical protocols apply Pre-authorisation is required Certain Maxillo-Facial procedures are covered in-hospital, subject to admission protocols. See Exclusion Summary General anaesthetic benefits are available for very young children for extensive dental treatment Multiple hospital admissions are not covered Pre-authorisation required Covered at the BDT Clinical protocols apply Bonitas Dental Tariff (BDT) 13

18 Visit us at any of the following walk-in branches Monday to Friday, 08h30 to 16h00 Bloemfontein Suite 13, Westdene Offi ce Park, President Reitz Avenue, Westdene, Bloemfontein Cape Town Durban East London Ellisras Johannesburg Kathu Kimberley Mafikeng Nelspruit Port Elizabeth Polokwane Pretoria Roodepoort Secunda Vereeniging Windhoek Medscheme House, Park Lane, Pinelands 3rd Floor, 67 Old Fort Road, Durban Medscheme House, 39 Balfour Road, Vincent, East London Onverwacht Business, Mienie Building, Block C, Walter Sisulu Avenue, Ellisras Offi ce No.1, Vusa House, Mezzanine Floor, Ghandi Square, Johannesburg 6 Rietbok Street, Kathu, Northern Cape Ground Floor, Trust Bank Building, George Street, Kimberley Shop No. 5, Capital Place, Victoria Street, Mafi keng The Upper Ground Floor, Colfi n House, 11 Ferreira Street, Nelspruit Block 6, Greenacres Offi ce Park, 2nd Avenue, Newton Park, Port Elizabeth Ground Floor, Bonitas House, 22 Hans van Rensburg Street, Polokwane Ground Floor, Benstra Building, 473B Church Street, Arcadia, Pretoria 37 Conrad Road, Florida North, Roodepoort Shop 1, Sanlam Plaza, Horwood Street, Secunda 2nd Floor, 36 Merriman Avenue, Vereeniging First Floor, Hidas Centre, 21 Nelson Mandela Avenue, Windhoek, Namibia 14

19 Bonitas Customer Service: Web: Postal Address: Physical Address: Fraud Hotline Hospital Benefi t Management: Fax: Mon-Fri 08h30-16h00 This 0860 number is charged at local rates wherever you are in South Africa bonitas@medscheme.co.za Bonitas Medical Fund, PO Box 1101 Florida Glen, Conrad Drive, Florida North, Mon-Fri 08h00-16h (authorisations only) authorisations.jhb@medscheme.co.za Chronic Medicine Management: Fax: Members: Doctors & Pharmacists: Postal Address: Aid for Aids Patient Care Line: Doctor & Pharmacist Line: Cape Town Offi ce Line: Fax: Web: SMS (call me): Oncology Management: Fax: Web: Mon-Fri 08h30-17h /680 cmm@medscheme.co.za mml@medscheme.co.za PO Box Pinelands Mon-Fri 08h30-17h afa@afadm.co.za Mon-Fri 08h00-16h cancerinfo@medscheme.co.za Pharmacy Direct: Fax: Web: Mon-Fri 07h30-17h /1/2/3 or care@pharmacydirect.co.za Preferred Provider Network (PPN): Web: Mon-Fri 08h00-17h00 info@ppn.co.za Dental Management Programme (DENIS): Perio Programme: Fax: Web: Mon-Fri 08h00-16h30 perio@denis.co.za Prime Cure: Fax: Web: Netcare 911: Medical Advice Line: Rape Crisis Centres: International Travel: International Travel Fax: Centre for Diabetes and Endocrinology (CDE): Fax: Web: / Mon-Fri 08h00-17h00 customerservice@primecure.co.za assist@netcare.co.za Mon-Fri 08h30-17h members@cdecentre.co.za

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