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September 2011

Necesse

network option

2012

uppe marketing A05803

contact us

General enquiries and benefit option information Medihelp Customer Care Centre

Tel: 086 0100 678 Fax: 012 336 9540 www.medihelp.co.za [email protected]

Pre-authorisation

Prescribed Minimum Benefits (PMB) Tel: 086 0100 678 Fax: 012 336 9540 [email protected] Chronic renal dialysis & oxygen administered at home Tel: 086 0100 678 Fax: 012 336 9540 [email protected] Private nursing and sub-acute care facilities Tel: 086 0100 678 Fax: 012 336 9523 [email protected] HIV/Aids (Optipharm) Tel: 086 0906 090 Emergencies: 083 564 9978 Fax: 086 0064 762 [email protected] Optometric services (PPN) Tel: 086 0103 529 or 086 1101 477 www.ppn.co.za Oncology Tel: 086 0100 678 Fax: 086 0064 762 [email protected]

Chronic medicine (CDL) Tel: 086 0100 678 Fax: 012 334 2466 [email protected] Emergency transport services (Netcare 911) Tel: 082 911 Dental procedures (Denis) Tel: 086 0104 941 Fax: 086 677 0336 [email protected] Hospital admissions Tel: 086 0200 678 MRI and CT scans, prostheses and PMB services (during hospitalisation) Tel: 086 0100 678 Fax: 012 336 9540 [email protected] Council for Medical Schemes Tel: 086 1123 267 [email protected] www.medicalschemes.com Medihelp fraudline and compliance department Tel: 012 334 2428 Fax: 012 336 9538 [email protected]

Medihelp is an authorised financial services provider

contents

Day-to-day benefits Services rendered by your Necesse network general practitioner Medicine prescribed by a Necesse network doctor X-rays and blood tests requested by a Necesse network doctor Eye tests and spectacles or contact lenses Pregnancy benefits Physiotherapy and occupational therapy Basic dental services Scheduled and emergency care Specialist care Emergencies and out-of-network consultations Scheduled care Hospitalisation Prescribed Minimum Benefits (PMB) Monthly contribution Explanation of terms Important information What we don't pay for Dental exclusions 2 2 2 4 4 5 6 6 8 8 9 10 10 12 15 16 17 18 20

Necesse (network option)

This primary care option focuses on making private healthcare services accessible to more South Africans Subscription for this option is based on income · Proof of income must be provided in order to qualify for one of the lower income categories Most healthcare services are provided by specific network doctors or providers Formularies, protocols and a pre-authorisation or registration process apply to most services Benefits are subject to an overall annual limit of R800,000 per family per year, with sub-limits applicable to some services

Day-to-day benefits

· You may only choose a doctor for your day-to-day healthcare needs from a list of general practitioners in the Necesse network Only medicine on the approved Necesse medicine list (formulary) qualifies for benefits Get your medicine from your network doctor or a Medihelp network pharmacy Pre-authorise all chronic medicine for CDL conditions Only medicines on the Necesse chronic medicine list (formulary) qualify for benefits Only basic dental services are covered and only if you visit a network dentist Get your spectacles from a network optometrist

Scheduled and emergency care

· You may only visit a specialist if you are referred by your Necesse network doctor and if the visit is preauthorised Only your network doctor or a specialist may refer you for blood tests or X-rays Before you are admitted to hospital you must first obtain approval You may only be admitted to a Necesse network hospital or else you'll be liable for a 20% co-payment Emergency ambulance services are provided by Netcare 911

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Necesse

Day-to-day benefits

Services rendered by your Necesse network doctor (general practitioner)

Consultations at a Necesse network general practitioner · Choose a specific Necesse network doctor as your general practitioner. Visit Medihelp's website at www.medihelp.co.za or dial *120*6364# on your cell phone for a list of network doctors near you. Pre-authorisation is required from the 9th consultation at your Necesse network doctor per family onwards. Description GENERAL PRACTITIONER SERVICES WITHIN THE NECESSE NETWORK · Consultations Benefit

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100% of the scheme tariff Subject to the overall annual limit

Medicine prescribed by a Necesse network doctor

Acute medicine prescribed by a Necesse network doctor · · Acute medicine must be prescribed by your Necesse network doctor. Medicine may only be obtained from your dispensing network doctor or at a pharmacy in the Medihelp Preferred Pharmacy Network. Visit Medihelp's website for a list of network pharmacies. Only medicines on the Necesse medicine list (formulary) qualify for benefits. Description ACUTE MEDICINE PRESCRIBED BY A NECESSE NETWORK DOCTOR Benefit 100% of the contracted tariff Subject to the overall annual limit Co-payments may apply

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Over-the-counter (OTC) medicine · · · OTC medicine can be obtained without a prescription. OTC medicine may only be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network. Limits are applicable. Description OVER THE COUNTER (OTC) MEDICINE Benefit 100% of the scheme tariff R190 per beneficiary per year, maximum of R65 per event Subject to the overall annual limit

Chronic Diseases List (CDL) medicine · · Chronic medicine for CDL conditions must be prescribed by your Necesse network doctor. Chronic medicine for CDL conditions may only be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network. Visit Medihelp's website for a list of preferred pharmacies. All chronic medicine for CDL conditions must first be approved by Medihelp, subject to pre-authorisation and registration protocols. Only chronic medicine used for the treatment of conditions on the CDL qualify for benefits. Description CHRONIC MEDICINE ­ CHRONIC DISEASES LIST (CDL) MEDICINE Oxygen · · Subject to protocols and pre-authorisation. Must be prescribed by a Necesse network doctor. Description OXYGEN Services rendered not during hospitalisation Benefit 100% of the scheme tariff Subject to the overall annual limit 20% co-payment if not pre-authorised Benefit 100% of the Necesse formulary Co-payments may apply

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X-rays and blood tests requested by a Necesse network doctor

· · · These services must be requested by your Necesse network doctor. Blood tests must be performed by either Lancet or Pathcare. Benefits will only be granted for a limited list of approved basic radiology and pathology services. Description Benefit

BASIC RADIOLOGY (X-RAYS) · Black and white X-rays and soft-tissue 100% of the scheme tariff Subject to the overall annual limit ultrasounds BASIC PATHOLOGY (BLOOD TESTS) 100% of the contracted tariff Subject to the overall annual limit Co-payments apply if services are rendered by non-preferred providers

Eye tests and spectacles or contact lenses

· · · · Services must be obtained from a PPN optometrist. PPN must first approve the optical services. Benefits are available in a 24-month cycle per beneficiary. Limits are applicable on the frame and lenses. Description OPTICAL SERVICES (PPN) · Optometric examinations Benefit Benefits are available per 24-month cycle per beneficiary: 1 comprehensive consultation, including refraction test, tonometry and visual fields test

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Description · Spectacles or contact lenses Benefits are limited to either spectacles or contact lenses · Spectacles · Frame · Lenses One pair of standard high-quality clear lenses · Contact lenses

Benefit

R150 (PPN frame) Clear single vision lenses or Clear Aquity bifocal lenses R395 (only PPN optometrists)

Pregnancy benefits

· · · · · Pre- and post-natal care services must be provided by your Necesse network doctor. Midwife services must be rendered by a registered practising nurse and are subject to preauthorisation and treatment guidelines (protocols). Sonars are subject to referral by a network GP or specialist. See page 11 for maternity benefits. Limits are applicable. Description PREGNANCY · Pre- and post-natal care · Midwife services by a registered practising nurse · Network general practitioner services · Gynaecologist services on referral by a network general practitioner · Sonars (2D) Benefit

Subject to the overall annual limit 100% of the scheme tariff

100% of the scheme tariff 2 consultations per beneficiary 20% co-payment if not on referral 100% of the scheme tariff 2 two-dimensional sonars per beneficiary

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Physiotherapy and occupational therapy

· · These services must be requested by your Necesse network doctor. Limits are applicable. Description PHYSIOTHERAPY AND OCCUPATIONAL THERAPY Benefit 100% of the scheme tariff R1,380 per member per year or R2,120 per family per year Subject to the overall annual limit

Basic dental services

· · · · · You must obtain all dental services from a dentist in the Dental Information Systems (Denis) network. Benefits are only provided for basic conservative dental services that meet specific clinical treatment guidelines (protocols). Services that are excluded from benefits are listed on page 20 to 21, e.g. crowns and bridges. All benefits are subject to Denis protocols and managed care interventions. Acute medicine prescribed by a dentist is for your own account. Description BASIC CONSERVATIVE DENTAL SERVICES (DENIS) · Routine check-ups (full mouth examination) · Oral hygiene Fluoride treatments for children only (Item codes: 8155/8159/8161) Fillings (Item codes: 8341/8342/8343/8344/ 8351/8352/8353/8354) Root canal therapy and extractions Plastic dentures Including associated laboratory costs Benefit

100% of the Medihelp Dental Tariff 1 consultation per beneficiary per year 100% of the Medihelp Dental Tariff 1 scale and polish treatment per beneficiary per year 100% of the Medihelp Dental Tariff 4 fillings per beneficiary per year 100% of the Medihelp Dental Tariff 100% of the Medihelp Dental Tariff 1 set of plastic dentures (an upper and lower set) per family in a 24-month cycle for patients 21 years and older Co-payment of 20% on Medihelp Dental Tariff applies

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Description · Laughing gas in Denis network dentist's rooms · Dental procedures under conscious sedation in the Denis network dentist's chair for extensive dental treatment only Subject to pre-authorisation · · X-rays: Intra-oral X-rays: Extra-oral

Benefit

100% of the Medihelp Dental Tariff

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

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Scheduled and emergency care

Specialist care

· · · · · · You may only visit a specialist if you are referred by your Necesse network general practitioner, otherwise a co-payment will be applicable. The specialist's consultation and follow-up consultations must be pre-authorised by Medihelp. All medicine prescribed by a specialist must be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network. Only chronic medicine used for the treatment of CDL conditions qualify for benefits, if prescribed by a specialist on referral. Pathology services requested by a specialist must be rendered by either Lancet or Pathcare. Limits are applicable. Description SPECIALIST CARE · Specialist consultations · · Surgical and non-surgical procedures Diagnostic endoscopic procedures performed in the specialist's rooms Benefit

ACUTE MEDICINE BASIC RADIOLOGY AND PATHOLOGY CHRONIC CDL MEDICINE PRESCRIBED BY A SPECIALIST ON REFERRAL

100% of the contracted/scheme tariff R2,120 per single member or R3,000 per family per year Subject to the overall annual limit 20% co-payment if not on referral

100% of the Necesse formulary

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Emergencies and out-of-network consultations

Emergency visits (PMB cases)

· · Only emergencies that meet the definition on page 16 qualify for benefits. Emergency consultations must be reported to Medihelp and authorisation obtained within 72 hours after the visit. Description EMERGENCIES (PMB) Benefit 100% of the cost Unlimited ­ in accordance with PMB regulations

Emergency visits (non-PMB cases) and out-of-network consultations

Description EMERGENCY VISITS AND OUT-OFNETWORK CONSULTATIONS · Outpatient and emergency consultations (non-PMB cases) · ·Medicine and services rendered by a non-network general practitioner · Facility fee RADIOLOGY AND PATHOLOGY REQUESTED BY NON-NETWORK DOCTORS Benefit 80% of the scheme tarrif R740 per member per year R1,480 per family per year Subject to the overall annual limit

For member's account For member's account

Emergency transport

· · Emergency transport services are provided and must be pre-authorised by Netcare 911. Netcare 911 also offers support through a 24-hour helpline and a Rape Crisis Centre. Description Benefit

EMERGENCY TRANSPORT SERVICES ­ NETCARE 911 Pre-authorisation by Netcare 911 · Emergency transport services by road 100% of the contracted tariff/cost within the borders of South Africa only · Transport of blood and blood products Phone 082 911 for advice in a medical emergency

24-HOUR HELPLINE (NETCARE 911)

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NETCARE 911 RAPE CRISIS CENTRE

Scheduled care

Hospitalisation

· · · · · · · You may be admitted to any of the hospitals in the Necesse network. The list of hospitals is available on Medihelp's website. Your Necesse network doctor or the specialist to whom you've been referred will decide whether you should be admitted to hospital. All hospital admissions must be pre-authorised. In case of an emergency admission after hours the admission must be registered on the first workday after the admission. Hospital benefits are subject to pre-registration, pre-authorisation and clinical treatment guidelines (protocols). A 20% co-payment will apply if your hospital admission is not pre-authorised, except for emergency admissions. A 20% co-payment will apply if you are admitted to a hospital that is not part of the Necesse hospital network, except for emergency admissions. Description HOSPITALISATION · Intensive care units and high care wards · Ward accommodation · Theatre costs · Visits/consultations by network general practitioners or specialists · Treatment and ward medicine · Surgery and anaesthesia APPLICABLE MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON THE DAY OF DISCHARGE FROM HOSPITAL MAXILLOFACIAL SURGERY DUE TO TRAUMA-RELATED INJURIES ­ PMB ONLY Subject to pre-authorisation and clinical protocols Benefit

100% of the contracted/scheme tariff/ medicine price 20% co-payment per unauthorised nonemergency admission or admission to a non-network hospital Subject to the overall annual limit

100% of the medicine price R250 per admission Subject to the overall annual limit

100% of the cost

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Description PHYSIOTHERAPY AND OCCUPATIONAL THERAPY During hospitalisation PATHOLOGY AND MEDICAL TECHNOLOGY During hospitalisation Services should be rendered by Lancet or Pathcare BASIC RADIOLOGY During hospitalisation MATERNITY (non-PMB cases) Subject to pre-authorisation and clinical protocols · Hospitalisation · Midwifery and confinement/delivery · Gynaecologist and anaesthetist OXYGEN Services rendered during hospitalisation BLOOD TRANSFUSION SERVICES AND THE TRANSPORT OF BLOOD AND BLOOD PRODUCTS Services rendered during and not during hospitalisation CLINICAL TECHNOLOGIST SERVICES Services rendered during hospitalisation

Benefit 100% of the scheme tariff R6,360 per family per year Subject to the overall annual limit

100% of the contracted/scheme tariff R19,610 per family per year Subject to the overall annual limit

100% of the contracted tariff R16,960 per confinement Subject to the overall annual limit 20% co-payment per unauthorised nonemergency admission or services rendered by a non-network hospital 100% of the scheme tariff/cost Subject to the overall annual limit 100% of the scheme tariff R14,300 per family per year Subject to the overall annual limit

100% of the scheme tariff R14,300 per family per year Subject to the overall annual limit

Specialised radiology

· · Must be prescribed by your network general practitioner or specialist on referral. You must obtain pre-authorisation for specialised radiology services. Description SPECIALISED RADIOLOGY Services rendered during and not during hospitalisation · MRI and CT scans Benefit 100% of the scheme tariff R10,600 per family per year Subject to the overall annual limit

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Dental surgery under general anaesthesia in a network hospital/day clinic only

· · Benefits are subject to pre-authorisation, Denis clinical protocols, referral and rendered by a Denis network dentist. Services that are excluded from benefits are listed on page 20 and 21. Description DENTAL SURGERY UNDER GENERAL ANAESTHESIA IN A HOSPITAL/DAY CLINIC ONLY · Trauma cases (PMB only) · Extensive dental treatment for very young children Benefit

100% of the cost Subject to the overall annual limit 20% co-payment per unauthorised non-emergency or services rendered by a non-network hospital

Sub-acute and private nursing services as an alternative to hospitalisation

· · Benefits for these services are subject to pre-authorisation and case management. Private nursing benefits exclude general day-to-day services such as bathing and general care. Description SUB-ACUTE AND PRIVATE NURSING SERVICES AS AN ALTERNATIVE TO HOSPITALISATION Benefit 100% of the contracted tariff R14,300 per family per year Subject to the overall annual limit 20% co-payment per unauthorised admission to sub-acute care facilities

Prescribed Minimum Benefits (PMB)

· Prescribed Minimum Benefits (PMB) are 270 conditions for which diagnosis, care and treatment costs are covered. Medicine for the treatment of the additional 26 specific chronic conditions (CDL) qualify for benefits subject to algorithms. If you are diagnosed with a PMB condition by your network doctor, you must submit the doctor's report on the PMB condition to Medihelp to have it authorised. PMB are subject to pre-authorisation, clinical protocols and formularies, and services must be rendered by contracted service providers. If you deviate from the formularies or protocols or are not treated by a contracted service provider, co-payments will be applicable.

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Description DIAGNOSIS, CARE AND TREATMENT COSTS OF 270 PMB AND CHRONIC MEDICINE FOR 26 CDL CONDITIONS

Benefit 100% of the cost Unlimited ­ in accordance with PMB regulations Co-payments may apply

Oncology (PMB cases only) · · Benefits are subject to protocols and pre-authorisation. Benefits are subject to enrolment on the oncology management programme provided by ICON. Description ONCOLOGY ­ PMB ONLY · Chemotherapy and radiotherapy · Surgery Benefit 100% of the cost Unlimited ­ in accordance with PMB regulations Co-payments may apply

HIV/Aids (Optipharm) · · Benefits are subject to clinical protocols and treatment plans. Benefits are subject to registration on the HIV/Aids management programme provided by Optipharm. Description HIV/AIDS (Optipharm) · Antiretroviral therapy and treatment by preferred provider Benefit 100% of the cost Unlimited ­ in accordance with PMB regulations Co-payments may apply

Trauma recovery (PMB cases) · Benefits are subject to pre-authorisation and case management. Description BENEFITS FOR TRAUMA THAT NECESSITATES HOSPITALISATION POST-EXPOSURE PROPHYLAXIS (Optipharm) Benefit 100% of the cost Unlimited ­ in accordance with PMB regulations Co-payments may apply

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Other services covered as PMB only · · · · Benefits are subject to pre-authorisation and admission to a network hospital. 20% co-payment applies for unauthorised admissions. No benefits in respect of clinical psychology and psychiatric nursing services. Renal dialysis is subject to pre-authorisation and enrolment on the renal management programme. Description TREATMENT OF A MENTAL HEALTH CONDITION ­ PMB ONLY · Professional psychiatric services · Ward accommodation · Medicine and materials supplied or administered during hospitalisation · Applicable medicine dispensed and charged by the hospital on the day of discharge from hospital Benefit 100% of the scheme/contracted tariff/ medicine price Subject to the overall annual limit 20% co-payment applies to nonauthorised and non-network hospital admissions 100% of the medicine price R250 per admission

RENAL DIALYSIS ­ PMB ONLY (acute and chronic) · Rendered by a designated service provider PROSTHESES ­ PMB ONLY · Internally implanted prosthesis · External prosthesis SURGICAL AND ORTHOPAEDIC APPLIANCES REQUIRED DURING HOSPITALISATION ­ PMB ONLY

100% of the contracted tariff

100% of the scheme tariff/cost

100% of the scheme tariff/cost R6,360 per family per year

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Monthly contribution

Member Subscription *Gross monthly income of principal member R7,500 or less Principal member Adult dependant Child dependant < 21 years R744 R588 R318 R7,501 to R11,000 R918 R714 R396 R11,001 and more R1,062 R828 R456

* If the member's gross monthly income (before deductions) is more than R11,001, no proof of income is required.

Proof of income

If the member's gross monthly income (before deductions) is less than R11,001, proof of income is required. Provide proof of income from: Source Full-time employment Basic salary, overtime, commission Bonuses (all types, e.g. 13th cheque, production bonus etc.) Allowances (all types, e.g. car/travelling, cell phone etc.) Fringe benefits (e.g. company car) Investments Interest Dividends Rental income Acceptable proof of income

Past three months' official pay slips Latest tax assessment ­ ITA 34 IRP 5 of previous tax year

Letter of auditor/accountant/tax adviser Latest tax assessment ­ ITA 34 IT3(a) and past three months' bank statements* Rental income ­ rental agreement and/or past three months' bank statements* Latest tax assessment ­ ITA 34 Letter of auditor/ accountant Latest tax assessment ­ ITA 34 Past three months' bank statements* indicating deposits

Self-employment Income from vocation/profession Total income from business Trusts Income from trusts

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Source Unemployment Individuals who earn no income from a vocation/profession/business

Acceptable proof of income UIF payments and bank statements* Income of person paying the subscriptions Maintenance payments and past three months' bank statements* All other sources of income from which subscriptions are paid Latest tax assessment ­ ITA 34 Past three months' bank statements* indicating the pension deposits Past three months' pension payment advices

Pensions and annuities Income from pensions or annuities

*Only bank statements indicating the account holder's initials and surname will be accepted. This guide provides a summary of the Necesse benefit option. In the case of a dispute, the registered Rules of Medihelp will apply, subject to approval by the Registrar of Medical Schemes. All limits are valid for one year, unless otherwise indicated. If a beneficiary joins during the course of a financial year, the benefits (limits) are calculated pro rata according to the remaining number of months per year.

explanation of terms

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 co-payments in the following cases, amongst others: · 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% or where the cost exceeds the limit available for the service; and · When the member chooses not to obtain services from a designated service provider (e.g. the ICON network in the case of oncology) or when a pre-determined co-payment is applicable to a specific benefit as indicated. 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 Denis network dentist. In certain cases 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 authorised for PMB (also see "PMB"). A formulary is a scientifically compiled list of cost-effective medications for the treatment of the 26 conditions on the Chronic Diseases List (CDL).

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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. Hospital benefits refer to benefits for services rendered by a network hospital during a patient's stay in hospital. Hospital benefits are subject to pre-registration and a 20% co-payment will be applicable to the hospital account if the admission is not pre-registered, or if the hospital is not part of the network. ICON is the Independent Clinical Oncology Network who determines the clinical protocols according to which patients on the Necesse benefit option receive cancer treatment from ICON network doctors. A limit is the maximum benefit amount which is paid for a specific service, apparatus or appliance. Maxillofacial surgery pertains to trauma-related injuries only. Medicine price refers to the applicable price of medicine listed on the Necesse formularies for acute and chronic medicine. 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, 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. 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 and hospitalisation by a network of hospitals. Members must make use of the network to qualify for benefits. Optipharm is the preferred provider for the rendering of HIV/Aids-related services and post-exposure prophylaxis in the case of sexual assault. An overall annual limit of R800,000 per family per year 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. All limits are valid for a year unless otherwise indicated. 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. Benefits will be paid according to the PPN tariffs and a copayment may be applicable should the costs exceed the benefit amount (also see "Co-payments"). Prescribed Minimum Benefits (PMB) are paid for 26 chronic illnesses on the 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, protocols, and the utilisation of designated service providers, where applicable. 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. Scheme tariff is the tariff for services as approved by the Board of Trustees.

important information

Doctors' visits You must visit your nominated general practitioner (GP) in the Necesse network. Your network GP will refer you to a physiotherapist, specialist and other medical practitioners if required. Please remember to obtain pre-authorisation from Medihelp from your ninth consultation (the family's visits combined) onwards at your network GP. About your claims Your network GP and other medical practitioners will submit claims directly to Medihelp. If you have paid the account

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yourself, you can submit the claim to Medihelp for a refund, should the claim qualify for benefits. Please post, fax or e-mail the following to Medihelp: · The detailed account · A copy of your proof of payment · The authorisation/referral number for the consultation (in the case of a specialist or medical practitioner on referral). Emergencies Please remember that only emergencies which meet the definition of an emergency on this brochure (see "Explanation of terms") will qualify for Prescribed Minimum Benefits (PMB) and must be registered as such with Medihelp. Acute medicine Should you require medicine, your network GP will provide you with the medicine if he/she is a dispensing doctor, or he/ she will provide you with a prescription for medicine listed on the Necesse formulary. Medicine on prescription must be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network. Chronic medicine Only chronic medicine which forms part of the Chronic Diseases List (CDL) will qualify for benefits. Chronic medicine must be registered with MEDICHRON (Medihelp's medicine benefit management division) according to authorisation protocols. Once your network GP has diagnosed you or your dependants with a chronic illness, he/she will complete an application form to register the chronic medicine with MEDICHRON. As soon as you have received a schedule from MEDICHRON indicating which medicine items have been authorised, you have the choice of either obtaining the authorised chronic medicine on a monthly basis from a pharmacy in the Medihelp Preferred Pharmacy Network, or from a courier pharmacy in the network who will deliver the medicine to an address of your choice. Specialist referral process Your network GP will refer you to a specialist if required. This entails that your network GP completes a specialist referral form which will be used to obtain pre-authorisation for the specialist visit from Medihelp. Pre-authorisation can be obtained by e-mailing the form to [email protected], faxing it to 012 336 9540 or phoning 086 0100 678 prior to visiting the specialist. The referral number must be indicated on the specialist's account. Other referrals Your network GP or specialist on referral will also refer you to a physiotherapist, occupational therapist, pathologist, radiologist or other medical practitioner if required. Hospital admissions Your network GP or the specialist to whom you were referred will decide whether you should be admitted to hospital. You may only be admitted to a Necesse network hospital. If not, a 20% co-payment on the hospital account will apply. All hospital admissions, including for psychiatric admissions, must be pre-registered (and emergency admissions on the first workday following the admission). Phone Medihelp on 086 0200 678 with the following information: · Your membership number · The patient's name and date of birth · Your contact details · The reason for admission (procedure and diagnostic codes ­ your doctor can provide these) · The date of the admission · The doctor/specialist's name and practice number · The hospital's details

what we don't pay for

Medihelp excludes the following from benefits, except in the case of statutory Prescribed Minimum Benefits (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 ­

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· ·

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· 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 Benefit. The treatment of infertility, other than the following treatment (according to PMB code 902M), subject to preauthorisation by Medihelp: · Hysterosalpinogram. · The following blood tests: · Day 3 FSH / LH; · Prolactin; · VDRL; · Oestradiol; · Rubella; · Chlamydia; and · Thyroid function (TSH); · HIV; · 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. 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 15.4. 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 Benefit:

Code 182T 910T 910T 910T Diagnosis

Abuse or dependence on psychoactive substance, including alcohol 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

Treatment

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

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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 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 and contact lens solutions. 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; 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 ­

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· · · · · · · · · · · · · · · · · · · · · · · · · · ·

from a hospital/other institution to a residence; in the event of a self-inflicted injury, unless it is a Prescribed Minimum Benefit; 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. All biological and other medicine items as per Medihelp's medicine exclusion list. Hip, knee and shoulder replacements. Hymenectomy and circumcision. Removal of impacted wisdom teeth during hospitalisation. Roaccutane and Retin A, or any skin lightening agents. 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 Benefit. Homeopathic and herbal medicine, as well as household remedies or any other miscellaneous household product of a medicinal nature. Insulin pumps and related consumables. Back and neck fusion procedures, subject to PMB. Facility fees. Standard immunisation. Contraceptive agents. Sclerotherapy. Hearing aids and services rendered by audiologists and accousticians. Appliances such as blood pressure apparatus, mattrasses and magnifying readers. HIgh technology treatment modalities, surgical devices and medication. Services rendered outside the borders of the Republic of South Africa.

· · · ·

dental exclusions

· · · · · · · · · · · · · · · · · · · · · · Oral hygiene instructions and evaluations. 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 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 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.

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· · · · ·

· · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · ·

Medicine prescribed by a dentist. Tooth-coloured fillings on molars and premolars. 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: · Apicectomies. · 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. 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. Root canal therapy on primary (milk) teeth. Provisional dentures and associated laboratory costs. Treatment plan completed (code 8120). Implants.

denis dental protocols

Denis dental protocols are available on request.

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notes

notes

Information

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