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BONCAP INCOME BASED OPTION - afhealth.co.za

Page 45 All claims are paid at the Bonitas Rate, unless otherwise stated. All benefits and limits are per calendar year, unless otherwise stated. Managed Care protocols apply. Benefits are subject to approval from the Council for Medical consultations at 100% - GP referral required for all hospital admissionsHospital network appliesR24 230 per family for blood testsR17 600 per family for blood transfusionsUnlimited ultrasounds & x-rays at 100%MRI & CT scans R11 060 per family in hospital with no co-paymentsUnlimited terminal care benefi tUnlimited GP consultations (call the BONCAP call centre after the 7th consultation for approval)Specialist benefi t if referred by network GPSeparate optical benefi t including contact lensesBasic dentistry benefi t available27 conditions coveredChronic medicine delivery to your doorstepthrough the Designated Service ProviderR1 000 per family for contraceptivesWellness screening Preventative care for pap smears, fl u vaccines & moreChildcare benefi ts including newborn hearing screening, congenital hypothyroidism screening & BabylineContributionsRMain memberAdult dependantChild dependantR0 to R7 500R 9 1 8R 870R 432R7 501 to R12 194R1 1 1 6R1 055R 5 1 2R12 195 to R16 659R1 820R1 620R 689R16 660+R2 235R1 990R 847 This traditional entry-level

Page 45 All claims are paid at the Bonitas Rate, unless otherwise stated. All benefits and limits are per calendar year, unless otherwise stated. Managed Care protocols apply.

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Transcription of BONCAP INCOME BASED OPTION - afhealth.co.za

1 Page 45 All claims are paid at the Bonitas Rate, unless otherwise stated. All benefits and limits are per calendar year, unless otherwise stated. Managed Care protocols apply. Benefits are subject to approval from the Council for Medical consultations at 100% - GP referral required for all hospital admissionsHospital network appliesR24 230 per family for blood testsR17 600 per family for blood transfusionsUnlimited ultrasounds & x-rays at 100%MRI & CT scans R11 060 per family in hospital with no co-paymentsUnlimited terminal care benefi tUnlimited GP consultations (call the BONCAP call centre after the 7th consultation for approval)Specialist benefi t if referred by network GPSeparate optical benefi t including contact lensesBasic dentistry benefi t available27 conditions coveredChronic medicine delivery to your doorstepthrough the Designated Service ProviderR1 000 per family for contraceptivesWellness screening Preventative care for pap smears, fl u vaccines & moreChildcare benefi ts including newborn hearing screening, congenital hypothyroidism screening & BabylineContributionsRMain memberAdult dependantChild dependantR0 to R7 500R 9 1 8R 870R 432R7 501 to R12 194R1 1 1 6R1 055R 5 1 2R12 195 to R16 659R1 820R1 620R 689R16 660+R2 235R1 990R 847 This traditional entry-level plan off ers basic day-to-day benefi ts and hospital cover using a network of doctors.

2 Providers and In-hospitalOut-of-hospitalChronic benefi tsAdditional benefi ts INCOME BASED OPTIONBONCAP I INCOME BASEDPage 46 All claims are paid at the Bonitas Rate, unless otherwise stated. All benefits and limits are per calendar year, unless otherwise stated. Managed Care protocols apply. Benefits are subject to approval from the Council for Medical consultations at 100% - GP referral required for all hospital admissionsHospital network appliesR24 230 per family for blood testsR17 600 per family for blood transfusionsUnlimited ultrasounds & x-rays at 100%MRI & CT scans R11 060 per family in hospital with no co-paymentsUnlimited terminal care benefi tUnlimited GP consultations (call the BONCAP call centre after the 7th consultation for approval)Specialist benefi t if referred by network GPSeparate optical benefi t including contact lensesBasic dentistry benefi t available27 conditions coveredChronic medicine delivery to your doorstepthrough the Designated Service ProviderR1 000 per family for contraceptivesWellness screening Preventative care for pap smears, fl u vaccines & moreChildcare benefi ts including newborn hearing screening, congenital hypothyroidism screening & BabylineContributionsRMain memberAdult dependantChild dependantR0 to R7 500R 9 1 8R 870R 432R7 501 to R12 194R1 1 1 6R1 055R 5 1 2R12 195 to R16 659R1 820R1 620R 689R16 660+R2 235R1 990R 847 This traditional entry-level plan off ers basic day-to-day benefi ts and hospital cover using a network of doctors.

3 Providers and In-hospitalOut-of-hospitalChronic benefi tsAdditional benefi ts INCOME BASED OPTIONIN-HOSPITAL BENEFITSH ospitalisation is covered at 100% of the Bonitas Rate at all hospitals on the BONCAP Network. You must get pre-authorisation for your hospital admission. You will have to pay a R6 350 co-payment if you use a non-network hospital (except for emergencies) or you do not get pre-authorisation within 48 hours of admission. GP consultationsUnlimited, covered at 100% of the Bonitas RateSpecialist consultationsUnlimited, covered at 100% of the Bonitas RateBlood tests and other laboratory tests R24 230 per familyBlood transfusions R17 600 per familyX-rays and ultrasoundsUnlimited, covered at 100% of the Bonitas RateMRIs and CT scans(specialised radiology)R11 060 per familyPre-authorisation requiredParamedical/Allied medical professionals(such as physiotherapists, occupational therapists)

4 R4 130 per familyYour therapist must have a referral from the doctor treating youSurgical procedures that are not coveredBack and neck surgeryJoint replacement surgeryCaesarean sections done for non-medical reasonsFunctional nasal and sinus surgeryVaricose vein surgeryHernia repair surgeryLaparoscopic or keyhole surgeryGastroscopies, colonoscopies and all other endoscopiesBunion surgeryIn-hospital dental surgeryInternal and external prosthesesPMB onlyManaged Care protocols applyPre-authorisation requiredYou must use a preferred supplierMental health hospitalisation PMB only No cover for physiotherapy for mental health admissionsSubject to using the Designated Service ProviderNeonatal careLimited to R43 220 per family, except for PMBsTake-home medicine R360 per beneficiary, per hospital stayPhysical rehabilitationR47 250 per familyPre-authorisation requiredAlternatives to hospital (hospice, step-down facilities)

5 R13 600 per familyPre-authorisation requiredTerminal careUnlimitedIncluding hospice/private nursing, home oxygen, pain management, psychologist and social worker supportCancer treatmentPMB onlySubject to using the Designated Service ProviderOrgan transplantsPMB onlyPre-authorisation requiredKidney dialysisUnlimitedYou must use a Designated Service Provider, or a 20% co-payment will applyPre-authorisation requiredHIV/AIDSPMB only, if you register on the HIV/AIDS programmeChronic medicine must be obtained from the Designated Service ProviderOUT-OF-HOSPITAL BENEFITS These benefits cover your day-to-day medical expenses at of 100% of the Bonitas GP consultationsUnlimited consultations, using a maximum of 2 network GPs Pre-authorisation is required from the 8th GP consultation per beneficiaryNon-network GP consultations1 out-of-network consultation per beneficiaryMaximum of 2 consultations per family, limited to R1 000 20% co-paymentGP-referred acute medicine, x-rays and blood tests Main member onlyMain member + 1 dependantMain member + 2 dependantsMain member + 3 dependantsMain member + 4 or more dependantsR1 750R2 910R3 490R3 8 1 0R4 230 Specialist consultations (this benefit includes prescribed acute medicine, blood tests, x-rays, MRIs and CT scans)Limited to 3 visits or R2 960 per beneficiary Limited to 5 visits or R4 400 per familySubject to referral from a network GPPre-authorisation required for MRIs and CT scansBONCAP I INCOME BASEDPage 47 All claims are paid at the Bonitas Rate, unless otherwise stated.

6 All benefits and limits are per calendar year, unless otherwise stated. Managed Care protocols apply. Benefits are subject to approval from the Council for Medical careAntenatal consultations are subject to the GP consultations and specialist consultations benefits4 consultations with a midwife after delivery Over-the-counter medicineLimited to R90 per event Maximum of R250 per beneficiary, per yearParamedical/Allied medicalprofessionals(such as physiotherapists, occupational therapists, dieticians and biokineticists)PMB onlyGeneral medical appliances (such as wheelchairs and crutches) R5 180 per family You must use a preferred supplierOptometry You must use the contracted service providerManaged Care protocols applyBasic dentistry You must use a provider on the DENIS networkCovered at the Bonitas Dental TariffManaged Care protocols applyConsultations1 consultation per beneficiary, per yearEmergency consultation1 specific (emergency)

7 Consultation for pain and sepsis per beneficiaryX-rays: Intra-oral4 X-rays per beneficiaryX-rays: Extra-oral1 per beneficiary, in a lifetimeX-rays must be submitted to DENIS for reviewScaling and polishing1 polishOR1 scaling and polishing per beneficiaryFluoride treatments1 treatment for beneficiaries under 16 yearsFissure sealants1 per tooth, once every 3 years for beneficiaries under16 yearsInfection control, instrument sterilisation and local anaesthetic1 set per beneficiary, per visitLaughing gas in dental roomsInhalation sedation limited to extensive dental treatment onlyEmergency root canal therapyFor emergency treatment onlySubject to DENIS treatment protocolsPulp treatmentsFor amputation of pulp of primary teethExtractions(removal of teeth)Subject to DENIS treatment protocolsExtractions and treatment of septic socketsDental fillings4 fillings per beneficiaryBenefit for fillings is granted once per tooth, in 365 daysBenefit for re-treatment of a tooth is subject to Managed Care protocolsPlastic dentures1 set of plastic dentures (an upper and a lower) per family, once every 2 years for beneficiaries 21 years and over 20% co-paymentPre-authorisation requiredA further 20% co-payment will apply if authorisation is applied for after the treatment has been doneDenture rebaseRebase of dentures once per family, for beneficiaries 21 years and over20% co-paymentDenture repairsRepairs to existing dentures twice per family, for beneficiaries 21 years and over20% co-paymentMaxillo-facial surgery in dental chairPMB onlyPlease note.

8 No benefit for Osseo-integrated implants and Orthognathic surgeryAccess to a maxillo-facial specialist by DENIS pre-authorisation ONLYPre-authorisation from DENIS requiredIV conscious sedation in the roomsPMB onlyLimited to extensive dental treatmentPre-authorisation from DENIS requiredHospitalisation(general anaesthetic)Pre-authorisation from DENIS requiredBONCAP I INCOME BASEDPage 48 All claims are paid at the Bonitas Rate, unless otherwise stated. All benefi ts and limits are per calendar year, unless otherwise stated. Managed Care protocols apply. Benefi ts are subject to approval from the Council for Medical BENEFITSBonCap ensures that you are covered for the 27 Prescribed Minimum Benefi ts listed below on the applicable formulary. Pre-authorisation is required. If you do not use the Desginated Service Provider or if you use medicine that is not on the formulary, you will have to pay a 40% co-payment.

9 Prescribed Minimum Benefi ts s s Mood Type Type s Obstructive Pulmonary Renal Artery ColitisADDITIONAL BENEFITS We believe in giving you more value. These additional benefi ts will not aff ect your other benefi t women aged up to 50R1 000 per familyYou must use the Designated Service Provider for pharmacy-dispensed contraceptivesChildcareHearing screeningFor newborns, in or out of hospital Congenital hypothyroidism screeningFor infants under 1 month oldBabylineAccess to telephone helpline for 24/7 medical advice (including weekends and holidays for children under 3 years)Immunisations1 fl u vaccine per childPreventative care General health1 HIV test per benefi ciary1 fl u vaccine per benefi ciaryWomen s health1 pap smear every 3 years, for women between ages 21 and 65 Elderly health1 pneumococcal vaccine every 5 years, for members aged 65 and over1 stool test for colon cancer, for members between ages 50 and 75 Wellness benefi tsWellness screening1 wellness screening per benefi ciary at a participating pharmacy, biokineticist or a Bonitas wellness day Wellness screening includes the following tests: Blood pressure Glucose Cholesterol Body mass index Waist-to-hip ratioBONCAP I INCOME BASED


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