ACTIVE - lahealth.co.za

1 ACTIVE 2020. ABOUT THIS BENEFIT OPTION. Reasons why the LA ACTIVE Option is the best choice for you This Option has a Major medical Benefit for all in-hospital and large expenses. It provides cover for medicine for Chronic Disease List conditions that form part of the Prescribed Minimum Benefits. It also pays for day-to-day expenses from a medical Savings Account. Additional cover for specific disciplines is provided through the Extended Day-to-day Benefit (GPs, specialists, dentist, acute medicine, radiology, pathology and optical benefits). All planned procedures must be preauthorised. preauthorisation from the Scheme for from the available funds in your medical any planned procedures.

2 (You will have a Savings Account or from the Extended Day- deductible (upfront payment) if you do not to-day Benefit at 100% of the LA Health Rate preauthorise your planned treatment). for medicine on the preferred medicine list and at 90% for medicine on the non-preferred We pay these costs from the Major medical Prescribed Minimum Benefits medicine list. Benefit up to 100% of the LA Health Rate. are paid at cost, subject to The Scheme pays for the completion of the clinical criteria and the use of Chronic Illness Benefit application form by You can enjoy the best your doctor, if the condition is approved. the services of the Scheme's of care during your pregnancy Designated Service Providers.

3 We pay for certain preventive No overall limit applies when you're admitted to hospital as long as you get screening tests or vaccines Non-PMB Benefits are paid preauthorisation for the admission. We pay The Major medical Benefit provides cover for: up to 100% of the Scheme certain out-of-hospital benefits for the mother and baby from the Major medical Benefit, A screening test (to check your blood Rate, subject to clinical criteria, if the mother registers on the Scheme's glucose, blood pressure, cholesterol and the use of the Scheme's body mass index), or a flu vaccination at Maternity Programme. If not registered, all Designated Providers and one of the Scheme's designated service pregnancy-related benefits will be paid from applicable limits.

4 The available benefits in the medical Savings providers or a network pharmacy. Account or Extended Day-to-day Benefit. We also pay for certain screening tests for children. Cover for chronic One specific pneumococcal We cover you in an emergency vaccination in a beneficiary's lifetime and acute medicine LA ACTIVE covers you for emergency for qualifying members. transport. We pay for this service from the You have medicine cover for all approved Pap-smears, mammograms and Major medical Benefit and there is no overall Prescribed Minimum Benefit Chronic Disease prostate-specific antigen tests, subject limit. Call Discovery 911 for authorisation. List conditions, paid in full from the Major to clinical criteria.

5 medical Benefit up to the LA Health Medicine Rate for listed medicine. Medicine that is not We pay for the consultation and other related Cover for GPs and specialists on the Scheme's medicine list is paid up to a costs from your medical Savings Account. in- and out-of-hospital If these are needed as part of Prescribed Chronic Drug Amount. When you're admitted to a hospital, there is no Minimum Benefit, we pay the costs from the Prescribed, acute medicine on the preferred overall limit that applies to GP and specialist Major medical Benefit. medicine list are paid from the available funds visits. We pay up to 100% of the LA Health in your medical Savings Account or from the We pay these costs from the Major medical Rate from the Major medical Benefit.

6 Extended Day-to-day Benefit at 100% of the Benefit up to 100% of the LA Health Rate. e pay for out-of-hospital GP and specialist W LA Health Rate for medicine and those on the visits from the medical Savings Account or non-preferred medicine list are paid at 90%. the Extended Day-to-day Benefit. You also have cover for over-the-counter . (schedule 0, 1 and 2) medicine bought We cover you when at a pharmacy at 100% of the cost you have to go to hospital from the available funds in your medical Savings Account or from the Extended Hospitalisation, theatre fees and costs for Day-to-day Benefit. intensive and high care at private hospitals When you are discharged from hospital after have no overall limit, but you must obtain an admission, we pay for take-home medicine SCHEDULE OF BENEFITS.

7 Hospital No overall limit Overall Member Spouse/adult Child (max 3). annual limits Extended Day-to-day Benefit R4 818 R3 367 R 971. medical Savings Account R6 660 R4 812 R2 760. Emergency transport Paid from Major medical Benefit, up to 100% of the LA Health Rate subject to authorisation. Ambulance No overall limit services Blood transfusions and blood products Subject to Prescribed Minimum Benefits. Paid from Major medical Benefit. No overall limit and blood products Blood transfusions Maxillo-facial procedures: certain severe infections, Subject to Prescribed Minimum Benefits. Paid from Major medical Benefit. No overall limit jaw- joint replacements, cancer-related and certain trauma- related surgery, cleft-lip and palate repair Specialised dentistry Members will have to make an upfront payment (deductible).

8 Hospital Younger than 13 years R2 030. Older than 13 years R5 140. Day Clinics Younger than 13 years R1 000. Older than 13 years R3 370. Hospital and related accounts paid from the Major medical Benefit, up to 100% of the LA Health Rate. Related, non-hospital accounts (for dentists, anaesthetists, etc), subject to a limit of R22 680 per person per year Basic dentistry Members will have to make an upfront payment (deductible). Hospital Younger than 13 years R2 030. Older than 13 years R5 140. Day Clinics Younger than 13 years R1 000. Older than 13 years R3 370. In-hospital Hospital account paid from the Major medical Benefit, up to 100% of the LA Health Rate.

9 Related, non-hospital accounts (for dentists, anaesthetists, etc), paid from and limited to available funds in the medical Savings Account and the Extended Day-to-day Benefit Dentistry Specialised dentistry Paid from and limited to funds in medical Savings Account and Extended Day-to-day Benefit Out-of-hospital Basic dentistry First R3 680 per family per year paid from Major medical Benefit. Thereafter, paid from and limited to funds in medical Savings Account and Extended Day-to-day Benefit Paid from Major medical Benefit up to 100% of the LA Health Rate. No overall limit In-hospital GP and specialist visits in doctor's rooms, hospital Paid from medical Savings Account or Extended Day-to-day Benefit GPs and specialists emergency room visits and virtual GP consultations Virtual paediatrician consultations for children aged 14 Paid from the Major medical Benefit once the medical Savings Account and Extended Day-to- years and younger from a network paediatrician consulted day Benefits are depleted.

10 Subject to criteria. in the six months before the virtual consultation Out-of-hospital Trauma-related casualty visits for children when normal Two trauma-related casualty visits (from the Hospital Benefit) for children aged 10 and under, day-to-day benefits are exhausted once the medical Savings Account and Extended Day-to-day Benefit have been depleted. This includes the cost of the consultation, facility fees and all consumables International clinical review consultations Paid from the Major medical Benefit to a maximum of 50% of the cost of the consultation. Subject to preauthorisation HIV prophylaxis (rape or mother-to-child transmission) Prescribed Minimum Benefits.