2019 - CompCare Wellness Website

1 MUMEDCompCare Wellness medical SchemeInformation and Benefit Guide 2018 CompCare Wellness medical Scheme is administered by Universal Healthcare Administrators (Pty) Ltd/ DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / SUCCESS / ENERGY / INSPIRATION / VICTORY / ACTIVE / DYNAMIC / EVOLVING / PROGRESSIVE / CHAMPIONS / WINNING / The MUMED option is a traditional option that offers above average cover, with unlimited hospital cover and day-to-day benefits consisting of flexible risk cover. Additional cover for specified services are available once the flexi risk benefit is Wellness medical SchemeInformation and Benefit Guide 2018 HOSPITAL BENEFIT Unlimited cover for in-hospital and hospital-related servicesACHIEVE YOUR OPTIMAL HEALTHWITH CompCare Wellness medical SCHEMEDAY-TO-DAY BENEFITS ARE SUBJECT TO: Annual Flexi Benefit (AFB)BENEFITS NOT SUBJECT TO AFB Wellness and Preventative Benefits Ambulance Services Netcare911 HospitalisationMembers have full access to all private hospitals throughout South Africa.

2 All hospital accounts are paid in full at a rate agreed between the Scheme and the individual hospital the case of elective admissions, authorisation must be obtained at least 48 hours before a beneficiary is admitted to a hospital or day clinic, failing which a co-payment of R2 000 per admission will apply. Late authorisations will require a R1 000 the event of a medical emergency the Scheme must be notified within one working day following the admission, failing which a co-payment of R500 per admission will apply. CompCare Pre-authorisation / 0860 111 090Co-payments are payable on specified elective procedures (excluding PMBs*) done in a hospital or a day facility. *PMB = Prescribed Minimum Benefit as defined in the medical schemes Act No 131 of 1998. For the co-payment schedule, please refer to related accountsUnless otherwise indicated in-hospital related benefits are unlimited and accounts are paid at 100% of the Scheme rate.

3 These include but are not limited to: General Practitioner visits Radiology Pathology Surgical procedures Blood transfusions Auxiliary services ( physiotherapy) Sports injuriesSpecialist accounts with the exclusion of dental accounts relating to hospital admissions are unlimited and paid at 100% of the scheme in hospital is limited to R6 315 per in hospital medicine is unlimited, medicine prescribed on discharge (Medicine TTO) is limited to a supply of seven days. Non-PMB medicine is subject to the reference agents and specialised medicines are limited to R130 500 per family. A 25% co-payment is applicable. These medicines can only be obtained if Prostheses ( artificial joints, stents, artificial limbs) and electronic/nuclear devices ( pacemaker, defibrillators, nerve stimulators and cochlear implants) are limited to an overall limit of R38 650 per family. Sub-limits per sub-category apply.

4 Sub-limits can be viewed on the CompCare Website or obtained from the CompCare Call radiology includes MRI, CT scans and high resolution PET scans and is limited to R23 150 per family per annum. Pre-authorisation is required for all MRI and CT Scans. High resolution CT Scans/PET Scans are subject to special medical motivation and also requires pre-authorisation. There is no benefit for unauthorised scans, except for PMBs. No benefits are available for screening or investigative purposes. Maternity benefitsExpecting mothers have access to 12 Antenatal consultations with a GP or specialist which are paid from risk (not from the Day-to-Day benefits). Confinements are subject to clinical protocols. Ultrasound pregnancy scans are limited to two 2D mothers are encouraged to register on the maternity programme and receive a baby bag. Please also remember to obtain pre-authorisation for the confinement. CompCare Pre-authorisation / 0860 111 090 Mental health benefitsPsychiatric hospitalisation is limited to 21 days in a psychiatric facility or mental health hospital admissions are limited to R2 105 per , drug dependence and narcotism hospitalisations are only authorised in the case of PMB is required and protocols relating to the following conditions and procedures are covered in full for PMB conditions only: Organ and tissue transplants Renal dialysis PlasmapheresisPre-authorisation is required and protocols following alternatives to hospitalisation are available subject to pre-authorisation and protocols and unlimited unless otherwise specified.

5 Step-down nursing facilities, hospice and rehabilitation Terminal care (Imminent death, regardless of diagnosis) Out-of-hospital surgical procedures Oncology, including chemotherapy and radiotherapy (See limit on biological agents and specialised medicines) Wound care in lieu of hospitalisation Excimer Laser Refractive Surgery limited to the day-to-day optical limitIN-HOSPITAL BENEFITSDAY-TO-DAY BENEFITSCHRONIC CONDITIONSA nnual Flexi Benefit (AFB)We pay your day-to-day medical expenses from the available funds in your AFB is a risk Values for 2018 PACAFBR5 658R3 549R1 408 PMB related benefits will be paid for from your AFB risk AFB will be pro-rated if you join during the course of the CoverWhen you run out of AFB, we will pay for specified healthcare expenses from risk. These include: GP visits (balance of consultations only)The MUMED option provides cover for 36 chronic conditions. These include 26 conditions from the Chronic Disease List (CDL) as published in the medical Scheme Act and 10 chronic conditions not listed as a list of chronic conditions covered in the Mumed option, please refer to and Non-CDL chronic conditions are subject to the AFB.

6 Once the benefit is depleted, CDL medicines are benefits for CDL chronic conditions (PMBs) are unlimited and initially paid from the member s available AFB with no levy or co-payment if the medicine forms part of the Scheme s formulary and the price of the medicine is equal or less than the reference price for the product. Thereafter medicines are unlimited. Non-CDL chronic medicines are paid from the member s available are required to register for all CDL and non-CDL applicable covered chronic to registration on the chronic programme, only the first prescription will be paid from the acute medicine limit. Formularies and reference pricing applies. A 25% co-payment is payable for the voluntary use of non-formulary medicine. CompCare Chronic Registrations / 0860 111 900 DAY-TO-DAY BENEFITS SUBJECT TO AFBAll benefits are paid at 100% of the Scheme rate unless otherwise paid from available AFB where no sub-limits are applicableSub-limits while AFB funds are availableGP Consultations, procedures and materialsM: 6 visits;M+1: 8 visits:M+2: 10 visits:M+3+: 11 visitsSpecialist Consultations, procedures and materialsPaid at 100% of the Scheme rateA referral from a GP is required before seeking treatment from a specialist, failure which will result in a 30% co-payment.

7 No referral required for services provided by an ophthalmologist, gynaecologist, oncologist or urologist (for beneficiaries over the age of 40) and a paediatrician in respect of children under the age of 2 years or where multiple visits to a specialist are authorisedAcute medicines Prescription medicines - Schedule 3 and higherA 25% co-payment is applicable to non-generic products. Reference Pricing applies to medicines where a generic product is available and might result in a co-paymentOver the counter medicine (OTC) and homeopathic medicineR160 per event, R560 per beneficiary per annum and R1 000 per family per annumBasic radiology Including black and white X-rays and ultrasoundSpecialised radiology MRI, CT, High resolution CT and PET scansCombined in-and-out of hospital benefit, limited to R23 150 from in-hospital benefitPathology Subject to AFB, combined in-and-out of hospital benefit, limited to R28 940 per familyDentistryConservative and restorativeSpecialised dentistry Dentures, crowns, bridgework, metal fillings and inlays, orthodontics, prosthodontics, periodontics, Osseo integrated implants including the cost of the appliances and prosthesis, maxillofacial and oral surgerySub-limit of R1 950 per beneficiaryOptometryConsultationsOne test per beneficiary every second yearOptometryLenses.

8 Contact lenses and disposable lensesR1 520 per beneficiary and R4 340 per family every second yearOptometryFramesR765 per beneficiary every second year, included in lenses limit Auxiliary services Including audiologist (to be recommended by a medical practitioner), chiropractors, Dieticians, homeopaths (Consultations), Naturopaths (Consultations), Speech and Occupational therapists, Chiropody/ Podiatry, Social workers, Physiotherapy and BiokineticistsR1 895 per beneficiary and R3 000 per familyMental Health - Clinical psychologistsR1 575 per familyMental Health - PsychiatryR4 000 per familyOxygen-home ventilationPrivate nursing homesLimited to 60 days per familyAnte-natal classes12 ante-natal classes, limited to R715 per pregnancySurgical and medical appliancesWheelchairs, crutches, glucometers, hearing aids, artificial eyes and external fixatorsEmergenciesAmbulance services - Emergency roadside assistance and ambulance transportation.

9 NETCARE: 082 911In the case of non-emergency cases, authorisation must be obtained from Netcare911 at the time of transportation or within 24 hours thereof, failing which will result in a 25% emergency room / Casualty emergency visits not requiring admission are paid from and limited to the member s emergency room / Casualty emergency visits resulting in a hospital admission will be paid from the in-hospital emergency room / Casualty emergency visits as a result of physical injury caused by an external force will be paid in emergency benefit - If the AFB is depleted members will have access to one additional visit to an emergency facility per child younger than 6 years per annum. Limited to R1 050 per counselling benefitUnlimited telephonic counselling sessions with a psychologist or social worker with the option of referral for one-on-one sessions with qualified psychologists or social workers to a maximum of 3 sessions per beneficiary per relates to psychosocial counselling related to substance abuse, emotional stress, major life events birth, accidents and death, separation and loss, health care concerns, family or personal relationship issues, concerns about eldercare, childcare, parenting issues, family violence, harassment, work related stress, balancing work and family, provided by DSP Network of psychologists and social workers.

10 CompCare Care Counsellors / 0800 390 003 DAY-TO-DAY BENEFITS PAID FROM RISKAll Wellness and preventative benefits are paid from AND PREVENTATIVE BENEFITSPREVENTATIVE BENEFITSHEALTHY LIFESTYLE BENEFITSV accinations and immunisations Flu vaccinations - one dose per beneficiary per annum. HPV (cervical cancer) vaccine - one course (3 doses per registered schedule) per female beneficiary between ages 12 and 18 years. Adult pneumococcal vaccine (Pneumonia) as required. Childhood pneumococcal vaccine as required. Tetanus vaccine - one injection when required. Childhood immunisations as recommended by the Department of Health up to 12 years. Fitness assessment and exercise prescription members have access to the Universal Network of biokineticists for an annual fitness assessment, exercise prescription and regular monitoring benefits. Pre-authorisation is required and protocols apply. Fitness assessment for pregnant women members have access to one fitness assessment per pregnancy.