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Necesse (networkoption)

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Necesse is a highly affordable network option that offers access to quality healthcare services rendered by the Medihelp Preferred Provider Network of general practitioners, optometrists, pharmacies and dentists. You also receive comprehensive cover for medical emergencies via Netcare 911, as well as specialist services on referral and hospital benefits.

Major medical benefits

· · · Privateandpublichospitalisation­subjecttotheoverallannuallimit Thediagnosis,treatmentandcarecostsof270PMBconditionsand26chronicillnesses(CDL) Traumarecovery

Emergency medical services

· · EmergencytransportservicesbyroadauthorisedandprovidedbyNetcare911toresidentswithin thebordersofSouthAfrica­subjecttotheoverallannuallimit 24-hourhelplineandRapeCrisisCentre(Netcare911)

Day-to-day benefits

· · AmpleinsuredbenefitsareavailableviayourMedihelpPreferredProviderNetworkwhowilltakecareofyour day-to-dayhealthcareneeds,includingnon-chronicandChronicDiseasesList(CDL)/PMBmedicinedispensed accordingtotheMedihelpformulary. SpecialistconsultationsonreferralfromaMedihelpnetworkgeneralpractitioner(pre-authorisationrequired).

major medical benefits

Overall annual limit of R800,000 per family per year Description HOSPITALISATION Forrelevanthealthservicesprescribedbya networkpractitionerasessentialataprivate orgovernmenthospital Subjecttopre-authorisationandclinical protocols · Intensivecareunitsandhighcarewards · Ward accommodation · Theatrefees · Visits/consultationsbynetworkgeneral practitioners or specialists · Treatmentandwardmedicine · Surgeryandanaesthesia APPLICABLE MEDICINE ON PRESCRIPTION DISPENSED BY THE HOSPITAL ON THE DAY OF DISCHARGE FROM HOSPITAL MAXILLOFACIAL SURGERY DUE TO TRAUMA-RELATED INjURIES ­ PMB ONLY Subjecttopre-authorisation DENTAL SURGERY UNDER GENERAL ANAESTHESIA IN A HOSPITAL/DAY CLINIC ONLY Subjecttopre-authorisation,Denisclinical protocols and referral Surgicalremovalofimpactedwisdomteeth andmultipleadmissionsarenotcovered · Traumacases(PMBonly) · Extensivedentaltreatmentforvery youngchildren SUB-ACUTE AND PRIVATE NURSING SERVICES AS AN ALTERNATIVE TO HOSPITALISATION Subjecttopre-authorisationandcase management Benefit

major medical benefits

Overall annual limit of R800,000 per family per year Description PHYSIOTHERAPY AND OCCUPATIONAL THERAPY Duringhospitalisation Subjecttoreferralbyanetworkservice providerandpre-authorisation PATHOLOGY AND MEDICAL TECHNOLOGY Duringhospitalisation BASIC RADIOLOGY SERVICES Duringhospitalisation SPECIALISED RADIOLOGY Servicesrenderedduringandnotduring hospitalisation Subjecttoreferralbyanetworkpractitioner and pre-authorisation · MRIandCT-scans MATERNITY Subjecttopre-authorisationandclinical protocols · Hospitalisation · Post-natal care · Midwiferyandconfinement/delivery OXYGEN Servicesrenderedduringhospitalisation Benefit 100%oftheschemetariff R6,000perfamilyperyear Subjecttotheoverallannual limit 100%ofthescheme/ contracted tariff R18,500perfamilyperyear Subjecttotheoverallannual limit 100%oftheschemetariff R10,000perfamilyperyear Subjecttotheoverallannual limit

100%ofthescheme/ contractedtariff/ medicine price 10%co-paymentper unauthorisednon-emergency admission Subjecttotheoverallannual limit

100%ofthemedicineprice R240peradmission

100%ofthecontractedtariff R13,500perfamilyperyear Subjecttotheoverallannual limit

100%ofthecontractedtariff R16,000perconfinement Subjecttotheoverallannual limit 100%oftheschemetariff/cost Subjecttooverallannuallimit 100%oftheschemetariff R13,500perfamilyperyear Subjecttotheoverallannual limit 100%oftheschemetariff R13,500perfamilyperyear Subjecttotheoverallannual limit

100%oftheMedihelpDental Tariff Subjecttotheoverallannual limit 100%ofthecontractedtariff R13,500perfamilyperyear Subjecttotheoverallannual limit 10%co-paymentper unauthorised admission to sub-acute care facilities

BLOOD TRANSFUSION SERVICES AND THE TRANSPORT OF BLOOD AND BLOOD PRODUCTS Servicesrenderedduringandnotduring hospitalisation CLINICAL TECHNOLOGIST SERVICES Servicesrenderedduringhospitalisation

major medical benefits ­ trauma recovery

Description BENEFITS FOR TRAUMA THAT NECESSITATES HOSPITALISATION IN THE CASE OF: · Motorvehicleaccidents · Stabwounds · Gunshotwounds · Headtrauma · Burns · Neardrowning Subjecttopre-authorisationandcase management POST-EXPOSURE PROPHYLAXIS IN THE EVENT OF SEXUAL ASSAULT (Optipharm) Benefit

emergency medical services

Description EMERGENCY TRANSPORT SERVICES NETCARE 911 Pre-authorisation by Netcare 911 · Emergencytransportservicesbyroad withinthebordersofSouthAfricaonly Benefit

100%ofthescheme/ contracted tariff Unlimited

100%ofthecontracted tariff/cost

·

Transportofbloodandbloodproducts Phone082911foradvice inamedicalemergency

24-HOUR HELPLINE (NETCARE 911) NETCARE 911 RAPE CRISIS CENTRE

day-to-day benefits

Description GENERAL PRACTITIONER SERVICES WITHIN THE MEDIHELP NETWORK · Consultations Pre-authorisation must be obtained from the 9th consultation onwards · · Outpatientandemergencyvisits Medicineandservicesrenderedbya on-networkdoctor n Benefit 100%ofthecontractedtariff Subjecttotheoverallannual limit 100%ofthecontractedtarrif R700permemberperyear R1,400perfamilyperyear 20%co-paymentsapply Subjecttotheoverallannual limit 100%oftheschemetariff R2,000permember,toa maximumofR2,800per family per year Subjecttotheoverallannual limit

major medical benefits ­ prescribed minimum benefits (PMB)

Description DIAGNOSIS, CARE AND TREATMENT COSTS OF 270 PMB CONDITIONS AND 26 CHRONIC ILLNESSES ON THE CHRONIC DISEASES LIST (CDL) Subjecttoclinicalprotocols, pre-authorisation,pre-registration, medicineformulariesandpreferredproviders OTHER SERVICES COVERED AS PMB ONLY Subjecttopre-authorisation, pre-registration,clinicalprotocolsand formularies,andmustberenderedby contractedserviceproviders TREATMENT OF A MENTAL HEALTH CONDITION Subjecttopre-authorisation,confirmationof PMBdiagnosis,clinicalprotocolsandservices renderedbypreferredproviders Nobenefitsinrespectofclinicalpsychology andpsychiatricnursingservices 100%ofthescheme/ · Ward accommodation contracted tariff/medicineprice · Medicine and materials supplied or Subjecttotheoverall administeredduringhospitalisation annual limit · Applicablemedicinedispensedby thehospitalonthedayofdischarge from hospital 100%ofthemedicineprice R240peradmission Subjecttotheoverallannuallimit Benefit

100%ofthecost Unlimited Co-payments may apply

SPECIALIST CARE Subjecttoreferralbyyournetworkdoctor, clinical protocols and each consultation must be pre-authorised by Medihelp · Specialistconsultations · Surgicalandnon-surgicalprocedures

MEDICINE · Non-chronic medicine · Prescribedbyanetworkdoctor Must be obtained from a dispensingnetworkgeneral practitioner or a pharmacy in the Medihelp Preferred Pharmacy Network · Prescribed by a specialist on referral Can only be obtained from a pharmacy in the Medihelp Preferred PharmacyNetwork · Chronicmedicine­ChronicDiseasesList (CDL)/PMBmedicinesonly Allmedicinebenefitsaresubject to Medihelp's authorisation and registration · Prescribedbyyournetworkgeneral practitioner Must be obtained from your dispensingnetworkgeneral practitioner or a pharmacy in the Medihelp Preferred Pharmacy Network · Prescribed by a specialist on referral Must be obtained from a pharmacy in the Medihelp Preferred PharmacyNetwork · Over-the-counter(OTC)medicine without a prescription obtained from a pharmacy in the Medihelp Preferred PharmacyNetwork

100%ofthecontractedtariff Subjecttotheoverallannual limit

RENAL DIALYSIS - PMB ONLY (acuteandchronic) Subjecttopre-authorisationandenrolment ontherenalmanagementprogramme · Renderedbypublichospitalsand NationalRenalCare ONCOLOGY - PMB ONLY Subjecttopre-authorisationandenrolment ontheoncologymanagementprogramme providedbyICON · Chemotherapy and radiotherapy · Surgery INTERNALLY IMPLANTED PROSTHESES PMB ONLY Subjecttopre-authorisation Servicesrenderedduringandnotduring hospitalisation · Implantedprosthesis · Intra-ocularlenses

100%ofthecontractedtariff Subjecttothelimitapplicable to specialist care Subjecttotheoverallannual limit

100%ofthecontractedtariff Subjecttotheoverallannuallimit

100%ofthecontractedtariff Subjecttotheoverallannuallimit

100%ofthemedicineprice Subjecttotheoverallannual limit

100%oftheschemetariff/cost Subjecttotheoverallannuallimit Sub-limit: 100%oftheschemetariff/cost 2 lenses per beneficiary per year R2,600perlens Subjecttotheoverallannuallimit 100%oftheschemetariff/cost R6,000perfamilyperyear Subjecttotheoverallannuallimit

requiredduringhospitalisation

· External prosthesis ·Surgicalandorthopaedicappliances

100%oftheschemetariff R180perbeneficiaryperyear, maximumofR60perevent Subjecttotheoverallannual limit

HIV/AIDS (Optipharm) Subjecttoclinicalprotocols,treatmentplans andregistrationontheHIV/Aidsdisease managementprogramme · Antiretroviraltherapyandtreatmentby preferredprovider

100%ofthecost Unlimited

day-to-day benefits

Description BASIC RADIOLOGY (X-RAYS) Subjecttoreferralandclinicalprotocols · BlackandwhiteX-raysandsoft-tissue ultrasounds · Requestedbyanetworkgeneral practitioner · Requestedbyaspecialiston referral Benefit

day-to-day benefits

Description · Oralhygiene Fluoridetreatmentsforchildrenonly SubjecttoDenisprotocols 100%oftheschemetariff Subjecttooverallannual limit 100%oftheschemetariff Subjecttothelimit applicable to specialist care Subjecttooverallannuallimit Subjecttooverallannual limit 100%ofthecontractedtariff Co-payments may apply if servicesarerenderedby non-preferredproviders 100%ofthecontractedtariff Subjecttothelimitapplicableto specialist care Co-payments may apply if servicesarerenderedbynonpreferredproviders Subjecttooverallannuallimit 100%oftheschemetariff 100%oftheschemetariff 2 two-dimensional sonars per beneficiary 100%oftheschemetariff 2 consultations per beneficiary 100%oftheschemetariff/cost Subjecttotheoverallannual limit 100%oftheschemetariff R1,300permemberperyear toamaximumofR2,000per family per year Subjecttotheoverallannual limit · Fillings SubjecttoDenisprotocols Benefit 100%oftheMedihelp DentalTariff 1 scale and polish treatment per beneficiary per year 100%oftheMedihelp DentalTariff 4fillingsperbeneficiary per year 100%oftheMedihelp DentalTariff 100%oftheMedihelp DentalTariff 1 set of plastic dentures per family in a 24-month cycle for patients 21 years and older Co-paymentof20%ontotal cost applies

· ·

Rootcanaltherapyandextractions SubjecttoDenisprotocols Plastic dentures SubjecttoDenisprotocols

BASIC PATHOLOGY (BLOOD TESTS) Subjecttoreferralbyadoctor,preferred providersLancetandPathcareandclinical protocols · Requestedbyageneralpractitioner

·

Requestedbyaspecialistonreferral

· ·

Laughinggasindentist'srooms Denis protocols apply Dental procedures under conscious sedation in the dentist's chair for extensivedentaltreatmentonly Subjecttopre-authorisationandDenis protocols X-rays:Intra-oral Subjecttoprotocols X-rays:Extra-oral 100%oftheMedihelp DentalTariff

PREGNANCY ServicesprovidedwithintheMedihelp networkofgeneralpractitioners · Pre- and post-natal care · · Sonars(2D) Subjecttoreferralbyanetworkdoctor Specialistconsultationsonreferral

· ·

4 per beneficiary per year 1 in a 3-year cycle

medihelp preferred pharmacy network

Necesse members can obtain their non-chronic (acute) medicine from their selecteddoctorifthedoctordispensesmedicine.Shouldthedoctornotdispense medicine,itisimportanttoobtainthemedicinefromapharmacyintheMedihelp PreferredPharmacyNetwork,whichalsoincludescertaincourierpharmacies,as onlyclaimsfromthesepharmacieswillqualifyforbenefits.Thisnetworkoffers Medihelpmembersthemostcost-effectivepricingstructureforprescriptionmedicine. Allchronic medicinemustbeobtainedfromanetworkpharmacy.Itisimportant to obtain your medicine only from pharmacies in the Medihelp Preferred Pharmacy Network,asbenefitswillnotbegrantedonmedicinedispensedbypharmacies thatarenotpartofthenetwork. You can find an updated list of these pharmacies on Medihelp's website at www.medihelp.co.zaorphoneourCustomerCarecentreon0860100678.

OXYGEN Subjecttopre-authorisation · Homeoxygen Designatedserviceprovidersonly PHYSIOTHERAPY AND OCCUPATIONAL THERAPY Subjecttoreferralbyyournetworkdoctor

OPTICAL SERVICES PPNprovider Alloptometrybenefitsaresubjectto pre-authorisationbyPPNandservicesshould beobtainedfromaPPNprovider · · Optometric examinations

Benefits per beneficiary are availableper24-monthcycle 1comprehensiveconsultation, includingrefractiontest, tonometryandvisualfieldstest

monthly contribution

Member R7,500 or less Principal member R684 R540 R294 Adultdependant Child dependant < 21 years Subscription Gross monthly income of principal member: More than R7,500 R822 R642 R354

Spectaclesorcontactlenses Benefits are limited to either spectacles orcontactlenses: · Spectacles: ·Frames

R150(PPNFrame)/R150 (towardscostofalternative frame) Clearsinglevisionlenses or ClearAquitybifocallenses R395(onlyPPNprovider)

· Lenses One pair of standard high-qualityclearlenses · Contact lenses BASIC CONSERVATIVE DENTAL SERVICES Allbenefitsaresubjecttoclinicalprotocols determined by Denis Seeexclusionsonpage25-26 · Routinecheck-ups (fullmouthexamination)

*Ifyourgrossmonthlyincome(beforedeductions)ismorethanR7,500,no proofofincomeisrequired. ThisisasummaryoftheNecessebenefitoption.Inthecaseofadispute,the registeredRulesofMedihelpwillapply.Alllimitsarevalidforoneyear, unlessotherwiseindicated.Ifabeneficiaryjoinsduringthecourseofa financialyear,thelimitsarecalculatedprorataaccordingtotheremaining numberofmonthsperyear.

100%oftheMedihelp DentalTariff 1consultation(fullmouth examination)perbeneficiary per year

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