2018 - TBMS

1 Tiger Brands Medical Scheme Benefit and member guide 20181 chronic Medicine Benefit Unlimited PMB CDL-ChronicMedicationAnnual Routine Care Benefit (ARCB) for day-to-day expensesGP and Specialist consultationsAcute medication, Radiology & pathology, Basic & specialiseddentistry & optometry Hospitalisation (major medical expenses)Unlimited cover in private hospital of choiceUnlimited cover for Prescribed Minimum BenefitsTiger Brands Medical SchemeTiger Brands Medical Scheme is an affordable scheme which offers four options. Three options with traditional benefits, Level A, B and C and Mzansi which offers medical cover through a Network environment1 Why Tiger Brands Medical Scheme? Member s choice to select an option cover that suits their pocket and their medical needs Generous day-to-day benefits (Annual Routine Care Benefit) Separate chronic medicine benefit Freedom of choice in service provider selection Unlimited overall annual benefit A wellness benefit - including flu vaccines and mammogramsAbbreviationsPMBP rescribed Minimum BenefitARCBA nnual Routine Care BenefitMRPM edicine Reference PriceMMAPM aximum Medical Aid PriceCDLC hronic Disease List*Scheme RateScheme rate 2017 + or **Agreed TariffSAOAS outh African Opthalmology AssociationAuxiliary servicesAssociated Medical Services speech therapyTBMST iger Brands Medical Scheme* Scheme rate.

2 The rules of the Scheme make provision for benefits to be paid at a specific tariff, or rate, known as the Scheme rate . This Scheme rate is in line with the industry benchmark tariff.** Agreed tariff: this is a rate negotiated between the Scheme and certain health care benefitsAll out-of-hospital day-to-day claims, except for authorised chronic medicine, are paid at 100% of the Scheme Rate from the Annual Routine Care Benefit (ARCB). The ARCB limit is based on the level selected. All annual limits specified in this section, are pro-rated if membership commences during the Routine Care Benefit (ARCB)Level ALevel BLevel CMemberR 14 200R 10 800R 7 200 Member + 1R 22 600R 16 900R 11 600 Member + 2R 25 300R 18 600R 12 600 Member + 3R 27 600R 20 400R 13 500 Thereafter add*R 2 400R 1 800R 900* Add this amount to the Member + 3 amount for each additional dependantThe following benefits are payable from the ARCB.

3 Subject to specified sub-limits for: Optical Acute medicine Appliances Radiology Pathology PhysiotherapyDay-to-day services payable from the ARCB, unless otherwise specifiedBENEFITSLIMITSC onsultationsGP consultations100% of Scheme rateSpecialist consultations*100% of Scheme rate* Subject to specialist authorisation (Pg 7)Specialist referral and authorisation processMembers and their beneficiaries are required to obtain a referral from a GP before going to a specialist for a consultation and treatment. This is only for out-of-hospital benefits of this initiative are as follows: It ensures that your GP is in control of your healthcare, co-ordinates your health care and has a holistic view of your health. It ensures that only appropriate, complex cases are referred to specialists for treatment.

4 It ensures that referral to the correct type of specialist takes authorisation process will support the process that is used by your GP. When you obtain the referral letter from your GP, the referral letter should be submitted to Universal Health. Based on the referral letter, an authorisation will be created in the administration system. If a referral has been obtained the claim will be paid, subject to limits and the scheme referral letter can be submitted via: E-mail to Fax to 086 503 8038; The call centre on 0800 002 authorisation will be: Granted for a period of three months in order to give the member a chance to obtain an appointment with a specialist. Limited to one consultation. For the speciality and not a particular following will be excluded from the specialist authorisation requirement process:1.

5 One gynaecologist visit per female, over the age of 16, per annum;2. One urologist visit per male beneficiary, over the age of 40, per annum;3. Paediatrician consultations for children under the age of 3;4. Pregnancies;5. Oncology (will be approved as part of the oncology management programme).6. Ophthalmologist 7. Orthodontists5 BENEFITSLEVEL ALEVEL BLEVEL CCOMMENTO pticalEye testOne per beneficiary, per annumPer beneficiary at IsoLeso Optometrist; FramesLensXtendR 900R 1 500R 820R 1 270R 740R 1 060 Lenses: Single vision OR Bi-focal OR Multi-focal OROne set of lenses every 24 months per beneficiaryMembers can either have glasses or contact lenses, not both Contacts R 3 200 R 2 980 R 2 770 Per annumRadial KeratotomyARCBR 6 000R 6 000R 6 000 Per familyHospital benefitR 6 000R 6 000R 6 000 Per familyAppliancesExternal fixatorR 18 040R 18 040R 18 040BP MonitorR 780R 780R 780 GlucometerR 780R 780R 780 HumidifierR 340R 340R 340 NebulizerR 1 240R 1 240R 1 240 Elastic stockingR 900R 900R 900 Foot arch support3 810R 3 810R 3 810 Elbow crutchR 440R 440R 440 CPAP machine R 11 990R 11 990R 11 990 Foam walkerR 2 240R 2 240R 2 240 WalkerR 390R 390R 390 Braces & CalliperR 780R 780R 780 CommodeR 1 240R 1 240R 1 240 Stocking (thigh)

6 R 900R 900R 900 Anti-embolic stockingR900R 900R 900 Sling clavicle braceR 220R 220R 220 WigR 2 360R 2 360R 2 360 BraR 1 560R 1 560R 1 560 Medicine1. Pharmacy Advised TherapyR 180R 170R 160 Per Script Subject to acute medicine sub-limit 2. AcuteMRPM emberMember + 1 Member + 2 Member + 3R 3 700R 5 800R 7 200R 8 900R 2 600R 4 200R 4 700R 5 100R 1 600R 2 600R 2 900R 3 1003. Oral contraceptives and devices - femaleR 1 430R 1 430R 1 430 Per beneficiary Subject to acute medicine sub-limitDentistryBasic dentistry100%100%100%of Scheme rateSpecialised dentistryLimited to R 9 500 per beneficiary and R 20 100 per familyof Scheme rateMental health, (including substance abuse) (Out-of-hospital consultations visits)Clinical psychologist100%100%100%of Scheme ratePsychiatry100%100%100%of Scheme rate6 BENEFITSLEVEL ALEVEL BLEVEL CCOMMENTR adiologyBasic RadiologyR 3 300R 2 500R 1 700 Per beneficiaryPathologyBasic PathologyR 3 300R 2 500R 1 700 Per beneficiaryPhysiotherapyPhysiotherapy (in-and-out-of hospital Sub limit)

7 Combined sub-limit with in-hospitalMemberMember + 1 Member + 2 Member + 3R 4 330R 6 240R 7 720R 8 980R 3 300R 4 700R 5 700R 6 700R 2 100R 3 200R 3 800R 4 400 Other benefitsHIV/AIDS100% of Scheme rate, subject to registration with Universal Care HIV/AIDS Disease Management ProgrammeAnte-natal classesR110 per class, maximum of ten classes per member familyHospital emergency room/casualty emergency visits (not requiring admissions, excluding facility fees)100% of Scheme rateAuxiliary services ( speech therapists, social workers and physiotherapists)100% of Scheme rateMaternity ConsultationsConsultations 100% of Scheme rate;Scans limited to two 2D scans per Medicine BenefitThe Scheme offers a separate chronic Medicine Benefit. Once the chronic Medicine Benefit is depleted, your chronic medication will be paid from the ARCB, subject to available benefits.

8 Once the ARCB benefit is depleted, payment of PMB medication by the Scheme is must apply for authorisation for chronic medication benefits by submitting a prescription to or can contact 0860 102 312. Please note with any changes to your chronic medicine, even if it is just the dosage, you need to update the Scheme covers all the PMBs as well as other conditions, as listed below, from the chronic Medicine medicineSubject to approval on the chronic Medicine ProgrammeLevel ALevel BLevel CR 8 500 per beneficiaryR 7 200 per beneficiaryR 5 900 per beneficiaryBiological medicineLimited to R 160 100 per family; Scheme approval required7 Prescribed minimum benefits (PMB)Tiger Brands Medical Scheme offers extensive cover for the 27 listed PMB chronic Disease List (CDL) conditions below.

9 These conditions are medication is subject to the basic formulary and reference pricing. A 20% co-payment is payable for the voluntary use of non-formulary medicinesAll registered PMB CDL chronic medication is unlimited. Once the ARCB limit is reached, the Scheme will continue to pay PMB CDL s diseaseCrohn s diseaseHyperlipidaemiaAsthmaDiabetes mellitus type 1 & 2 HypothyroidismBipolar mood disorderDiabetes insipidusMultiple sclerosisBronchiectasisDysrhythmiasParki nson s diseaseCardiac failureEpilepsyRheumatoid arthritisChronic renal diseaseGlaucomaSchizophreniaChronic obstructive pulmonary disorderHaemophiliaSystemic lupus erythematosusCardiomyopathy diseaseHIVU lcerative colitisCoronary artery diseaseHypertensionCover for non-PMB chronic conditionsTiger Brands Medical Scheme also offers cover for chronic conditions on Level A and B respectively.

10 chronic medication is subject to the basic formulary, reference pricing and a 20% chronic Conditions: Level AAnkylosing spondylitisOsteoarthiritisAttention deficit hyperactivity disorderVertigoAllergic rhinitisGastro-oesophageal reflux diseaseDepressionOsteoarthiritisGoutOste operosisIncontinencePsoriasisMyasthenia gravis Additional chronic Conditions: Level BAttention deficit hyperactivity disorderGastro-oesophageal reflux diseaseAllergic rhinitisOsteoarthiritisDepressionOsteope rosisGoutPsoriasis8In-hospital benefitsAll in-hospital benefits are paid from the Hospital Benefit. Pre-authorisation is required from Universal Care for all hospital admissions. To ensure that beneficiaries receive cost-effective, appropriate care, Universal Care performs pre-authorisation, validation and case management pre-authorisation is not obtained at least 48 hours prior to a non-emergency hospital admission, or if Universal Care is not advised within 24 hours of the emergency admission, a R1 000 co-payment will apply.