Benefit summary 2018 - afhealth.co.za

1 Pace2. Benefit summary 2018. personally yours Method of Benefit payment Pace2 On the Pace2 option, in-hospital services are paid from the Scheme risk. Some out-of-hospital services are paid from the annual savings first and once depleted will be paid from the day-to-day Benefit . Once the day-to-day Benefit is depleted, services can be paid from the available vested savings. Some preventative care services are available from the Scheme risk Benefit . PACE2 OPTION COMPREHENSIVE COVER. (IN AND OUT-OF-HOSPITAL). Recommended for? You are an established family in need of extensive day-to-day cover with freedom of choice when it comes to hospitals, doctors and specialists. You can enjoy peace of mind that the Pace2 option will take great care of you and your family's healthcare needs. Contribution range R4 677 (Principal member). R4 586 (Adult dependant). R1 031 (Child dependant).

2 Savings account / Savings account available. Day-to-day benefits Day-to-day benefits are available. Value benefits No co-payment or automatic self-payment gaps. FP and Specialist consultations. Optometry. Dentistry. We are a Scheme Maternity benefits. managed by Over-the-counter Available. members, for medicine members and will never compromise Not recommended Families looking for more comprehensive and on quality service for? speciality cover. Pace3 and 4 are the ideal to you. options for you. In-hospital benefits In-hospital benefits Note: MEDICAL EVENT SCHEME Benefit . All in-hospital benefits referred to in the section below require pre-authorisation. Please contact 080 022 0106 to obtain a Prosthesis External Limited to R23 000 per family. pre-authorisation number. Orthopaedic and 100% Scheme tariff. Clinical protocols,preferred providers, designated service providers (DSPs), medical appliances formularies, funding guidelines and the Mediscor Reference Price (MRP).

3 May apply. Pathology 100% Scheme tariff. Diagnostic imaging 100% Scheme tariff. MEDICAL EVENT SCHEME Benefit . Specialised 100% Scheme tariff. Accommodation (hospital 100% Scheme tariff. diagnostic imaging stay) and theatre fees Oncology Oncology programme. Take-home medicine 100% Scheme tariff. 100% Scheme tariff. Limited to 7 days' medicine. Peritoneal dialysis 100% Scheme tariff. Treatment in mental 100% Scheme tariff. and haemodialysis health clinics Limited to 21 days per beneficiary. Confinements 100% Scheme tariff. Treatment of chemical 100% Scheme tariff. Refractive surgery 100% Scheme tariff. and substance abuse Limited to 21 days or R27 200 Limited to R7 900 per eye. per beneficiary. Subject to Midwife-assisted births 100% Scheme tariff. network facilities. Consultations and procedures 100% Scheme tariff. Supplementary services 100% Scheme tariff. Surgical procedures 100% Scheme tariff.

4 Alternatives to 100% Scheme tariff. and anaesthetics hospitalisation Organ transplants 100% Scheme tariff. Emergency evacuation 100% Scheme tariff. Pre-authorised and rendered by ER24. Major medical maxillo-facial 100% Scheme tariff. surgery strictly related to certain conditions Dental and oral surgery Limited to R11 300 per family. (This limit applies to both in- and out- of-hospital benefits). Prosthesis 100% Scheme tariff. (Subject to preferred Limited to R97 600 per family. provider, otherwise limits and co-payments apply). Prosthesis Internal Sub-limits per beneficiary: Note: Sub-limit subject to the *Functional limited to R14 850. above prosthesis limit. Vascular R36 600. *Functional: Items utilised Pacemaker (dual chamber) R52 750. towards treating or supporting Spinal R36 600. a bodily function. Artificial disk R16 000. Drug-eluting stents R16 000. Mesh R16 000.

5 Gynaecology/Urology R11 950. Lens implants R10 260 per lens We always Joint replacements: strive to 1. Hip replacement and other major exceed your joints R43 950 expectations. 2. Knee replacement R51 000. 3. Minor joints R18 950. Out-of-hospital benefits Out-of-hospital benefits Note: MEDICAL EVENT SCHEME Benefit . Some indicated benefits are paid from the annual savings at 100% Scheme tariff. Optometry Benefit Optometry services are obtained (PPN capitation provider) from and paid by PPN at 100% of cost Once the annual savings account is depleted, benefits will be paid from per beneficiary every 24 months.*. Scheme risk at 100% Scheme tariff (limits apply). For services rendered by a non- Should you not use all of the funds available in your medical savings network provider, the following account, these funds will be transferred into a vested medical savings maximum amounts per beneficiary account at the beginning of the following financial year.

6 Apply every 24 months: Any vested credit in your vested medical savings account may be Consultation R365. used for out-of-hospital expenses that are not covered by the Scheme, or Frame R550 AND. should you, for instance, have reached your out-of-hospital or Single-vision lenses R175 OR. day-to-day overall annual limit or the sub-limits as indicated in your Bifocal lenses R380 OR. Benefit guide. Multifocal lenses R695. Unused funds in your vested medical savings account at the end of the Contact lenses R1 420**. financial year will be carried over to the credit of your vested medical sav- Diagnostic imaging Savings first. ings account for the next year. and pathology Limited to M = R2 750, M1+ = R5 500. Clinical funding protocols, preferred providers, designated service provid- (Subject to overall day-to-day limit). ers (DSPs), formularies, funding guidelines and the Mediscor Reference Price (MRP) may apply.

7 Maternity benefits 100% Scheme tariff. 2 sonars and up to 12. antenatal consultations. MEDICAL EVENT SCHEME Benefit . Specialised diagnostic imaging MRI/CT scans: Maximum of 3 scans Overall day-to-day limit M = R12 960, M1+ = R25 920. per beneficiary. FP and specialist consultations Savings first. PET scan: 1 scan per beneficiary. Limited to M = R3 700, M1+ = R7 500. Rehabilitation services 100% Scheme tariff. (Subject to overall day-to-day limit) after trauma Basic and specialised dentistry Savings first. Oncology Oncology programme. Basic: Preventative Benefit or savings 100% Scheme tariff. account. Limit once savings exceeded. Specialised: Savings account then limit. Peritoneal dialysis Subject to pre-authorisation Orthodontic: Subject to pre- and haemodialysis and DSPs. authorisation. Limited to M = R5 700, M1+ = R11 400. *This means that the Benefit is limited to only those products and services negotiated by (Subject to overall day-to-day limit) PPN and only those frames specified by PPN.

8 Medical aids, apparatus Savings first. **Preferred Provider Negotiators (PPN) will pay a maximum amount of R1 420 towards and appliances including Limited to R8 800 per family. the cost for contact lenses per beneficiary every 24 months, irrespective of whether the wheelchairs and hearing aids (Subject to overall day-to-day limit) beneficiary utilised the services of PPN or a non network provider. Limit on wheelchairs of R11 900 per family per 48 months. Limit on hearing aids of R24 250. per beneficiary per 24 months. Supplementary services Savings first. Limited to M = R4 650, M1+ = R9 350. (Subject to overall day-to-day limit). Wound care Benefit Savings first. (incl. dressings, negative Limited to R5 800 per family. pressure wound therapy (Subject to overall day-to-day limit). treatment and related nursing services - out of-hospital). Chronic conditions list CDL.

9 CDL 1 Addison's disease CDL 2 Asthma CDL 3 Bipolar mood disorder CDL 4 Bronchiectasis CDL 5 Cardiomyopathy Want your medicine CDL 6 Chronic renal disease benefits to last longer? CDL 7 Chronic obstructive pulmonary disease (COPD). Ask your doctor to CDL 8 Cardiac failure prescribe generic medicines. Generics CDL 9 Coronary artery disease have the same quality, CDL 10 Crohn's disease safety and efficacy as the original brand CDL 11 Diabetes insipidus medicine. CDL 12 Diabetes mellitus type 1. CDL 13 Diabetes mellitus type 2. Medicine CDL 14. CDL 15. Dysrhythmias Epilepsy - severe Note: CDL 16 Glaucoma All benefits below may be subject to pre-authorisation, clinical protocols, CDL 17 Haemophilia formularies, funding guidelines and the Mediscor Reference Price (MRP). CDL 18 Hyperlipidaemia * Please note that approved CDL, PMB and non-CDL chronic medicine costs will be CDL 19 Hypertension paid from the non-CDL limit first.

10 Thereafter, approved CDL and PMB chronic medicine CDL 20 Hypothyroidism costs will continue to be paid (unlimited) from Scheme risk. CDL 21 Multiple sclerosis Benefit DESCRIPTION SCHEME Benefit CDL 22 Parkinson's disease CDL & PMB chronic medicine* 100% Scheme tariff. Co-payment of CDL 23 Rheumatoid arthritis 30% for non-formulary medicine. CDL 24 Schizophrenia Non-CDL chronic medicine* 18 conditions. 85% Scheme tariff. CDL 25 Systemic lupus erythematosus (SLE). Limited to M = R7 700, CDL 26 Ulcerative colitis M1+ = R15 400. Non-CDL. Co-payment of 30% for non-formulary medicine. Non-CDL 1 Acne - severe Biologicals and other Limited to R140 000 per beneficiary. Non-CDL 2 Attention deficit disorder/Attention deficit high-cost medicine hyperactivity disorder (ADD/ADHD). Acute medicine Savings first. Non-CDL 3 Allergic rhinitis Limited to M = R4 100, M1 + = R8 200. Non-CDL 4 Eczema - severe (Subject to overall day-to-day limit).