2018 bonitas broker_cover.indd - your health and actuarial ... one pagers/2018 bonitas broker...

Section A: Why BonitasFact sheet 3How our plans work 4Our plans 5Savings 6Contribution table 7

Section B: Contact details

Queries and escalations 10• General 10• BonCap 10• Pharmacy Direct 11Find a service provider 12

Section C: Membership and admin

Individual underwriting 14Group underwriting 16Application process 17Network service providers 18GP referral process 19PMB treatment plan 20How to claim 2 1Hospital pre-authorisation 22Hospital networks 25Locate a provider 35Exclusions 36

Section D: Benefits and programmes

Chronic medicine 43Register with Pharmacy Direct 45Over-the-counter and acute medicine 46Maternity benefits 47Childcare benefits 48Optical benefits 50Dental benefits 52Radiology benefits 55Cancer programme 56HIV/AIDS programme 58Diabetes management programme 60Back and neck programme 62Hip and knee programme 63Wellness benefits 64Preventative care benefits 65International travel benefit 66Emergency medical services 67

INDEX INDEX

Please note: Product rules, limits, terms and conditions apply. Where there is a discrepancy between the content provided in this brochure, the website and the Scheme Rules, the Scheme Rules will prevail. The Scheme Rules are available on request. Benefits are subject to approval from the Council for Medical Schemes

SECTION A:WHY BONITAS

WHY BONITAS

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 Schemes. PRE-CMS01-V6-07SEP2017.

FACT SHEET

OUR MEMBERS

753 514Principal members

Total benefi ciaries

348 08833Average benefi ciary age

46 per member

Average family size

1.162.2

Pensioner rate (%)

8.32Averageprincipalmember age

Number of dependants

WHY BONITAS

Affordable, quality healthcare for all South Africans

Largest GP network and a specialist network to give more value for money

A wide range of plans including savings, traditional, income based and hospital options

Cover for up to 60 chronic conditions and free medicine delivery

Partnerships with quality service providers and healthcare professionals

Preventative care and wellness benefits paid from risk so benefits last longer

Additional benefits for maternity and children, including access to 24/7 paediatric telephonic advice, 365 days a year

Managed Care programmes to help members manage a range of conditions including cancer, mental health, HIV/AIDS and diabetes

Separate benefits for dentistry and optometry on several options, paid from risk

Simple, easy to use benefits

Affordable, quality healthcare for all South Africans

Largest GP network and a specialist network to give more value for money

A wide range of plans including savings, traditional, income based and hospital options

Cover for up to 60 chronic conditions and free medicine delivery

Partnerships with quality service providers and healthcare professionals

Preventative care and wellness benefits paid from risk so benefits last longer

Additional benefits for maternity and children, including access to 24/7 paediatric telephonic advice, 365 days a year

Managed Care programmes to help members manage a range of conditions including cancer, mental health, HIV/AIDS and diabetes

Separate benefits for dentistry and optometry on several options, paid from risk

Simple, easy to use benefits

24.4%solvency ratio

OUR FINANCES*

R

R

R billion in reservesR3.1 non-healthcare

expenditure

9.53%

657 985call centre calls answered in 2016

claims processed per day

32 034

calls a month54 832

hospital admissions authorisedper day

447OUR HIGHLIGHTS

91%of claims paid within 5 days

334 Wellnessdays held last year

*As per the audited 2016 Annual Financial Statements.

FACT SHEET


HOW OUR PLANS W

ORK

HO

W O

UR

PLA

NS

WO

RK

BONI

TAS

TRAD

ITIO

NAL

OPT

ION

• Sta

ndar

d an

d Pr

imar

y - N

o ho

spita

l net

wor

k• S

tand

ard

Sele

ct -

Hos

pita

l net

wor

k

BONI

TAS

TRAD

ITIO

NAL

OPT

ION

Stan

dard

and

Prim

ary

- No

hosp

ital n

etw

ork

TRAD

ITIO

NAL O

PTIO

N

OUT-

OF-H

OSPI

TAL

Day-

to-d

ay b

enefi

ts

Set b

enefi

t lim

its fo

r dai

ly m

edica

l exp

ense

sDo

es n

ot c

arry

ove

r eac

h ye

ar

Chro

nic b

enefi

ts(in

cludi

ng P

MBs

)

Netw

ork

Non-

netw

ork

IN-H

OSPI

TAL

Unlim

ited,

at B

onita

s Rat

e

BONI

TAS

SAVI

NGS

OPT

ION

• Bon

Com

preh

ensiv

e, B

onCl

assic

, Bon

Com

plet

e an

d Bo

nSav

e -

No

hosp

ital n

etw

ork

• Bon

Fit -

Hos

pita

l net

wor

k• A

bove

thre

shol

d be

nefit

ava

ilabl

e on

Bon

Com

preh

ensiv

e an

d Bo

nCom

plet

e

BONI

TAS

TRAD

ITIO

NAL

OPT

ION

BONI

TAS

SAVI

NGS

OPT

ION

BonC

ompr

ehen

sive

BonC

lass

icBo

nCom

plet

e an

d Bo

nSav

e -

No

hosp

ital n

etw

ork

OUT-

OF-H

OSPI

TAL

Day-

to-d

ay m

edica

l exp

ense

s

Use

as y

ou c

hoos

eCa

rry o

ver e

ach

year

Netw

ork

Non-

netw

ork

IN-H

OSPI

TAL

Unlim

ited,

at B

onita

s Rat

e

Self-

paym

ent g

apAb

ove

thre

shol

d be

nefit

s

SAVI

NGS

OPTI

ON

Addi

tiona

l ben

efits

(givi

ng y

ou m

ore

valu

e, d

oes n

ot affe

ctot

her b

enefi

t lim

its o

r sav

ings

)

- Mat

erni

ty- P

reve

ntat

ive c

are

- Wel

lnes

s- C

hild

care

Chro

nic b

enefi

ts(in

cludi

ng P

MBs

)

BONI

TAS

INCO

ME

BASE

D O

PTIO

N• B

onCa

p - H

ospi

tal n

etw

ork

Plea

se n

ote:

Con

tribu

tions

for B

onC

ap a

re in

com

e-ba

sed.

Inco

me

will

be v

erifi

ed o

nce

a ye

ar.

• Bon

Com

preh

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e, B

onCl

assic

, Bon

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nSav

e -

No

hosp

ital n

etw

ork

• Bon

Fit -

Hos

pita

l net

wor

k• A

bove

thre

shol

d be

nefit

ava

ilabl

e on

Bon

Com

preh

ensiv

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d Bo

nCom

plet

e

BONI

TAS

INCO

ME

BASE

D O

PTIO

N• B

onCa

p - H

ospi

tal n

etw

ork

Plea

se n

ote:

Con

tribu

tions

for B

onC

ap a

re in

com

e-ba

sed.

Inco

me

will

be v

erifi

ed o

nce

a ye

ar.

Set b

enefi

t lim

its fo

r dai

ly m

edica

l exp

ense

s

INCO

ME

BASE

D OP

TION

Chro

nic b

enefi

tsFo

r 27

PMBs

Netw

ork

IN-H

OSPI

TAL

Unlim

ited,

at B

onita

s Rat

e

BONI

TAS

HOSP

ITAL

OPT

ION

• Hos

pita

l Plu

s, Ho

spita

l Sta

ndar

d an

d Bo

nEss

esnt

ial -

No

hosp

ital n

etw

ork

• Sta

ndar

d an

d Pr

imar

y - N

o ho

spita

l net

wor

k• S

tand

ard

Sele

ct -

Hos

pita

l net

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k• • • • BO

NITA

S HO

SPIT

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PTIO

NBO

NITA

S HO

SPIT

AL O

PTIO

N• • H

ospi

tal P

lus,

Hosp

ital S

tand

ard

and

BonE

sses

ntia

l - N

o ho

spita

l net

wor

k

N/A

HOSP

ITAL

OPT

ION

Chro

nic b

enefi

tsFo

r 27

PMBs

OUT-

OF-H

OSPI

TAL

OUT-

OF-H

OSPI

TAL

Non-

netw

ork

IN-H

OSPI

TAL

Unlim

ited,

at B

onita

s Rat

e

Addi

tiona

l ben

efits

(givi

ng y

ou m

ore

valu

e, d

oes n

ot affe

ctot

her b

enefi

t lim

its o

r sav

ings

)

- Mat

erni

ty- P

reve

ntat

ive c

are

- Wel

lnes

s- C

hild

care

Addi

tiona

l ben

efits

(givi

ng y

ou m

ore

valu

e, d

oes n

ot affe

ctot

her b

enefi

t lim

its o

r sav

ings

)

- Mat

erni

ty- P

reve

ntat

ive c

are

- Wel

lnes

s- C

hild

care

Addi

tiona

l ben

efits

(givi

ng y

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ore

valu

e, d

oes n

ot affe

ctot

her b

enefi

t lim

its o

r sav

ings

)

- Mat

erni

ty- P

reve

ntat

ive c

are

- Wel

lnes

s- C

hild

care


We offer a range of 12 products that are simple to understand, easy to use and give our members more value for money.

This first-class savings plan offers ample savings, an above threshold benefit and extensive hospital cover.

BONCOMPREHENSIVE

Main member Adult dependant Child dependant

R5 774 R5 446 R1 1 7 5

This generous savings option offers a wide range of medical benefits, in and out of hospital.

BONCLASSIC


R4 009 R3 442 R 990

This savings option offers generous savings, an above threshold benefit and rich hospital cover.

BONCOMPLETE


R3 2 1 2 R2 572 R 873

This savings option offers savings to use as you choose for medical expenses and extensive hospital cover.

BONSAVE


R2 304 R1 785 R 690

This savings plan offers basic cover for day-to-day medical needs and essential hospital cover.

BONFIT


R1 930 R1 495 R 578

This traditional option offers rich day-to-day benefits and comprehensive hospital cover.

STANDARD


R3 265 R2 8 3 1 R 958

This traditional option uses a quality provider network to offer rich day-to-day benefits and hospital cover.

STANDARD SELECT


R2 828 R2 447 R 828

This traditional option offers simple day-to-day benefits and hospital cover.

PRIMARY


R2 076 R1 624 R 6 6 1

This hospital plan offers comprehensive hospital benefits with some value-added benefits.

HOSPITAL PLUS


R2 897 R2 607 R 937

This hospital plan offers extensive hospital benefits with some value-added benefits.

HOSPITAL STANDARD


R1 830 R1 5 4 3 R 696

This hospital plan offers rich hospital benefits with some value-added benefits.

BONESSENTIAL


R1 604 R1 2 2 7 R 470

This traditional entry-level plan offers basic day-to-day benefits and hospital cover using a network of doctors, providers and hospitals.

BONCAP

OUR PLANS

2018 Main member

Adult dependant

Child dependant

R0 to R7 500 R 918 R 870 R 432

R7 501 to R12 194 R1 1 1 6 R1 055 R 512

R12 195 to R16 659 R1 820 R1 620 R 689

R16 660+ R2 235 R1 990 R 847

OUR PLANS


SAVINGSThe amount payable towards the member’s PERSONAL MEDICAL SAVINGS ACCOUNT which is included in the total monthly contribution payable by a member

Annual savings

Plans % Main member Adult dependant Child dependant

BonComprehensive * 18.9% R13 068 R12 324 R 2 664BonClassic 14.1% R 6 804 R 5 844 R 1 680BonComplete * 15% R 5 7 7 2 R 4 620 R 1 572BonSave 16% R 4 428 R 3 432 R 1 332BonFit 15% R 3 480 R 2 700 R 1 044

* These plans have an above threshold benefit.

HOW THE BALANCE OF YOUR PERSONAL MEDICAL SAVINGS IS USEDAny amount available in the Personal Medical Savings Account shall be utilised to provide benefits in respect of day-to-day medical expenses. Provided there are actual funds available in a member’s Personal Medical Savings Account, such funds may, in addition to providing for day-to-day benefits, be utilised to pay for services generally or specifically excluded from risk benefits or where the actual costs exceed the benefit payable or available.

ADVANCES OF MEDICAL SAVINGS BENEFITSAt the beginning of each benefit year or on the date of joining the Scheme or this benefit option, each member shall be allocated a medical savings benefit for the year. This benefit shall be deemed to be an advance by the Scheme to the member and shall be equal to 12 (twelve) times the amount, pro-rated in respect of a member who joins the Scheme or this benefit option during the course of the year.

A member whose membership of the Scheme or of an option with a Personal Medical Savings Account is terminated during the course of a benefit year and whose claims exceeded the savings benefit advance, pro-rated on a monthly basis at the date of termination shall be liable to repay the excess / shortfall to the Scheme.

BONCOMPREHENSIVEMain member Adult dependant Child dependant

Savings R13 068 R12 324 R2 664Self-payment gap R 3 8 1 0 R 3 1 5 0 R1 450Threshold level R16 878 R15 474 R4 1 1 4Above threshold benefit Unlimited Unlimited Unlimited

BONCOMPLETEMain member Adult dependant Child dependant

Savings R5 772 R4 620 R1 572Self-payment gap R1 660 R1 400 R 355Threshold level R7 432 R6 020 R1 927Above threshold benefit R4 390 R2 590 R1 1 2 0

CLAIMS ACCUMULATE TO THE THRESHOLD AT 100% OF THE BONITAS RATEPlease refer to Annexure B of the Scheme Rules at www.bonitas.co.za for the full list of claims that accumulate to the threshold.

SAVINGS


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 Schemes. Version 01 - 20August 2017.

BONCOMPREHENSIVE

2018 Main member Adult dependant Child dependant

Risk R4 685 R4 4 19 R 953

Savings R1 089 R1 027 R 222

Total R5 774 R5 446 R1 175

Your 4th and subsequent children will be covered free of charge.

CONTRIBUTION TABLE

BONCLASSIC


Risk R3 442 R2 955 R 850

Savings R 567 R 487 R 140

Total R4 009 R3 442 R 990


BONCOMPLETE


Risk R2 731 R2 187 R 742

Savings R 4 8 1 R 385 R 1 3 1

Total R3 212 R2 572 R 873


BONSAVE


Risk R1 935 R1 499 R 579

Savings R 369 R 286 R 1 1 1

Total R2 304 R1 785 R 690


BONFIT


Risk R1 640 R1 270 R 491

Savings R 290 R 225 R 87

Total R1 930 R1 495 R 578


CONTRIBUTION TABLE



STANDARD SELECT


Total R2 828 R2 447 R 828


PRIMARY


Total R2 076 R1 624 R 661


HOSPITAL PLUS


Total R2 897 R2 607 R 937


HOSPITAL STANDARD


Total R1 830 R1 543 R 696


STANDARD


Total R3 265 R2 831 R 958


BONESSENTIAL


Total R1 604 R1 227 R 470


BONCAP


R0 to R7 500 R 918 R 870 R 432

R7 501 to R12 194 R1 1 1 6 R1 055 R 512

R12 195 to R16 659 R1 820 R1 620 R 689

R16 660+ R2 235 R1 990 R 847

You will pay for all child dependants.

CONTRIBUTION TABLE

SECTION B:CONTACT DETAILS

CONTACT DETAILS


Description Contact details Turnaround time

Broker escalated queries [email protected] 1 day

GENERAL


Chronic medicine authorisations [email protected] 5 to 7 days

Commissions [email protected] 3 days 5 days new broker contract

General queries and customer service [email protected] or 0860 002 108 1 day

Group take-ons [email protected] N/A

Group underwriting requests [email protected] N/A

Individual underwriting review requests [email protected] 5 days

Hospital authorisations [email protected] 1 day

Membership updates [email protected] 3 days

New membership applications [email protected] 1 day

Oncology authorisations [email protected] 3 days

Pre-underwriting requests [email protected] (Subject: Pre-underwriting) 2 days

Submission of claims [email protected] 10 days (including processing and payment)

Processed claims queries [email protected] 7 days

FOR ANY QUERIES THAT DO NOT MEET THE SERVICE LEVEL, PLEASE ESCALATE:


Chronic medicine authorisations [email protected] 5 to 7 days

Hospital authorisations [email protected] 1 day

Income verification [email protected] 3 days

Queries and customer service [email protected] or 0861 239 333 5 days

BONCAP

QUERIES AND ESCALATIONSQUERIES AND ESCALATIONS


PHARMACY DIRECT

1st Level 2nd Level

Customer Service: Escalated queries & general communication

Lead: Senior Fund Account Manager, BonitasArregante Storbeck012 643 3028082 810 [email protected]

Support 1:Senior Fund Account Manager, BonitasHansley Kiewiets012 643 3037079 034 [email protected]

Support 2:Senior Fund Account Manager, BonitasNatasha Kroukamp012 643 3090084 216 [email protected]

General Manager:Georgina Schutte012 643 3087082 573 [email protected]

Principal Pharmacist:Ansie van der Merwe012 001 3865079 898 [email protected]

Clinical:Escalated queries & clinical communication

Lead:Business Unit Manager, BonitasSunet Delport012 643 3069084 608 [email protected]

Support:Pharmacist, BonitasAbbe van Wyk012 643 4221072 437 [email protected]

Support:Senior Pharmacist Assistant, BonitasSulize Nel012 643 4241076 424 [email protected]

Principal Pharmacist:Ansie van der Merwe012 001 3865079 898 [email protected]

Broker Support: Malebo Semenya012 643 [email protected]

N/A

Take-on Communication Channels: Member information & prescriptions

086 524 [email protected] N/A

QUERIES AND ESCALATIONSQUERIES AND ESCALATIONS

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 Schemes. PRE-CMS01-V6-07SEP2017.

We’ve partnered with several reputable service providers to ensure that our members receive excellent service and more value for money.

FIND A SERVICE PROVIDERFIND A SERVICE PROVIDER

Dental benefi ts

Call: 0860 336 346Fax: 0866 770 336Email: [email protected]

HIV/AIDS programme

Please call me: 083 410 9078Call: 0860 100 646Fax: 0800 600 773Email: [email protected]

Optical benefi ts

Call: 0861 103 529www.ppn.co.za

Chronic medicine

Call: 0860 027 800Fax: 0866 114 000Email: [email protected]

Optical benefi ts

Call: 011 340 9200Fax: 011 782 5601www.isoleso.co.za

Emergency assistance

Call: 084 124Email: [email protected]: [email protected]

Hip and knee programme

Call: 0861 112 666www.icpservices.co.za

Diabetes programme

Call: 0860 002 108Email: [email protected]

Back and neck programme

Call: 0860 105 104

Wellness Odyssey

www.wellnessodyssey.co.za

Babyline

Call: 0860 999 121

SECTION C:MEMBERSHIP AND ADMIN

MEMBERSHIP AND ADMIN


INDIVIDUAL UNDERWRITINGCATEGORIES FOR INDIVIDUAL UNDERWRITING:

A Members who NEVER belonged to a medical scheme before, or whose break in cover has been MORE than 3 months

UNDERWRITING DECISIONS PER CATEGORY:

B Members who ARE ACTIVE members on a medical scheme and have a break in membership of LESS than 90 days and a previous membership of LESS than 24 months

C Members who ARE ACTIVE members on a medical scheme for MORE than 24 months

ANo cover for more than 90 days

BNo cover for less than 90 days and

previous cover for less than 24 months

C

3-month general waiting period

12-month condition specific

waiting period

Late-joiner penalty

3 12 LJP

NO PMB ELIGIBILITY

12-month condition specific

waiting period

12 LJP

FULL PMB COVER

3-month general waiting period

3 LJP

FULL PMB COVER

Cover for more than 24 months

Ordinary dependants Spouse, common-law spouse (partner), same-sex spouse/partner, fiancée, customary partners, biological children, adopted children, foster children, stepchildren and disabled biological children

Special dependants • Brother, sister, parents, nephew, niece, cousins, grandparents, mother-in-law, father-in-law and grandchildren

• Full underwriting will apply to registration of all special dependants at all times• For the purpose of determining contributions, any special dependant under the age of 21 years will be

regarded as a child dependant and child rates will apply• Special dependants, who are dependants on a membership where the main member is compelled to

resign from a closed scheme due to a change of employment, will be accepted underwriting free if application is made to join Bonitas as a dependant within 3 months after termination at closed scheme (no waiting periods, but late-joiner penalties if applicable)

Grandchildren Grandchildren will ONLY be accepted underwriting free if:The parent (MOTHER OR FATHER of the baby) has been an ACTIVE member on the grandparent’s existing membership BEFORE the start of the pregnancyThe Act stipulates the following:• A medical scheme may not impose a general or a condition-specific waiting period on a child dependant

born during the period of membershipDefinition of a child in the main rules:• “a member’s natural child, or a stepchild or legally adopted child or a foster child or a child who has

been placed in the custody of the member or his/her spouse or partner”• A newborn baby who is the grandchild of a member does not qualify as a child dependant in terms of

the rules and will thus be defined as a special dependant. UNDERWRITING will therefore be applied to any special dependant born into scheme membership

• The relationship of the newborn baby should always be clearly stated on the application form to ensure that the correct underwriting rule is applied

INDIVIDUAL UNDERWRITING

Late-joiner penalty

Late-joiner penalty


Newborns (Ordinary dependants only)

The Scheme must be NOTIFIED within 30 days from date of birth

The main member must register the baby within 3 months from date of birth, with an inception date backdated to the date of birth of the baby for NO UNDERWRITING to apply

Newly-weds If application is made to register the newly-wed within 3 months after marriage, NO UNDERWRITING will apply

Inception date of the newly-wed does not necessarily need to be date of marriage, but should fall within the 3 months that are provided to register the newly-wed

If above criteria is not met, the newly-wed will be seen as a late registration and full underwriting will applyFoster and adopted child dependants

If application is made to register a foster or adopted child dependant within 3 months from date on which fostership or adoption was granted, with an inception date backdated to the date of adoption or fostership of child, NO UNDERWRITING will apply

If above criteria is not met, foster/adopted child will be seen as a late registration and full underwriting will apply

Dependants transferring from closed schemes and becoming dependants on Bonitas

All dependants who are forced to terminate their membership in accordance with the scheme rules of a closed scheme in the following cases: • Overaged dependants who have reached the maximum age as child dependant of that specific closed

scheme• Spouse that has divorced the main member • Main member has passed away

Will be accepted underwriting free if application is made to join Bonitas as dependants or as main member, within 3 months after termination at closed scheme, irrespective of length of cover at the closed scheme (no waiting periods, but late-joiner penalties if applicable)

All dependants, who are dependants on a membership where the main member is compelled to resign from a closed scheme due to a change of employment, will be accepted underwriting free if application is made to join Bonitas as dependants within 3 months after termination at closed scheme (no waiting periods, but late-joiner penalties if applicable)

Beneficiaries going on pension

When a beneficiary goes on pension and applies to become a new Bonitas member or a new dependant and is forced to resign from their current scheme because they are going on pension, it will be regarded as a change of employment, thus no waiting periods will apply as per the Act, if the break in cover is not greater than 3 months (no waiting periods, but late-joiner penalties may apply)

Local students (SA citizens)

Local students will be accepted underwriting free irrespective of choice of Bonitas option as a main member but only if valid copy of ID, proof of residence and proof of FULL-TIME studentship is submitted along with the application form

Over-aged dependants Dependant 21 to 24 years old (including the last day of the calendar month that the dependant turns 24 years of age) who is a student will be seen as a CHILD DEPENDANT

Students are classified into 3 groups namely: full-time students, part-time students and “in-service training” students – all 3 of these groups qualify as CHILD DEPENDANTS (21 – 24 years old) as long as sufficient proof of studentship is supplied, namely proof of registration or a letter from the applicable institution clearly stating the nature of studentship

Dependant 21 years and older who is not a student will be seen as an ADULT DEPENDANT, except disabled biological children

Child rates will be charged for disabled children of 21 years and older where sufficient proof has been provided that the child is indeed disabled and where application for child rates has been approved by a clinical specialist and Fund Management

Any other dependant can remain on the Scheme as a dependant after age 24 years, but will be seen as an ADULT DEPENDANT

Dependants who turn 21 and 24 will be terminated if no response is received to the notifications sent in respect of the age reviews

Where no response is received for any age review the dependants will be terminated

These terminated over-aged dependants will be accepted underwriting free if application is made to reinstate their membership within 3 months from termination date

If application is made to reinstate these dependants after 3 months from termination date, they will have to reapply for membership and full underwriting will apply

Definition of late-joiner “Late-joiner” means an applicant or the adult dependant of an applicant, who at the time of application for membership or admission as a dependant, as the case may be, is 35 years of age or older, but excludes any beneficiary who enjoyed cover with one or more registered medical schemes in South Africa as from a date preceding 1 April 2001, without a break in cover exceeding three consecutive months since 1 April 2001

Credible coverage • Credible coverage is seen as medical aid cover on a South African registered medical aid scheme• Coverage from age 21 and older only, is seen as credible coverage and must be taken into consideration

when calculating the late joiner penalty• Late joiner penalties are applied from age 36 only in line with the applicable penalty band as stipulated

in the Medical Schemes Act No. 131 of 1998General waiting period A period in which a beneficiary is not entitled to claim any benefitsCondition specific waiting period

A period during which a beneficiary is not entitled to claim benefits in respect of a condition for which medical advice, diagnosis, care or treatment was recommended or received within the twelve-month period ending on the date on which an application for membership was made

INDIVIDUAL UNDERWRITING


Only employer groups of 10 and more employees will be considered for group underwriting.

GROUP UNDERWRITING WILL BE APPLIED IN ONE OF THREE WAYS:• Annual underwriting-free group• Underwriting-free take-on period (1-3 months, depending on group size)• Individual underwriting applied to each individual beneficiary within the group

Determining the status of a particular group will be the responsibility of the Underwriting Department of AfroCentric Distribution Services. In order for the Underwriting Department to consider the underwriting of a group, the group’s demographic information must be submitted in Excel format as well as a business questionnaire and sent to [email protected].

Bonitas reserves the right to review or revoke the underwriting decision should the status of the group change within the first three (3) months of joining the Scheme, or the information on the application forms differs from the information provided on the initial underwriting request.

FREE UNDERWRITING / NO UNDERWRITING AS PER CATEGORY A & B• No condition specific waiting periods• No general waiting periods• No late-joiner penalties

Except:• Employees joining more than 3 months after their permanent employment date (start date) at the company• Ordinary dependants who do not join from exactly the same inception date as the main member during an underwriting free take-on

period, except for newborns and newly-weds who will be accepted underwriting free if they follow the correct procedures as set out above for newly-weds and newborns

• All special dependants, will be fully underwritten at all times

IN THESE CASES INDIVIDUAL UNDERWRITING RULES APPLYDecisions made by: AfroCentric Distribution Services Underwriting Department with the result being one of the following

3 categories:

Category A B CAnnual underwriting-free group Underwriting-free take-on period

of 1-3 monthsIndividual underwriting

RulesNew applications No underwriting for new and

existing employees and their ordinary dependants who join from the same inception date as the main member

No underwriting for new and existing employees and their ordinary dependants who join from the same inception date as the main member

Individual underwriting as per categories set out above for main member and their ordinary dependants during the one month take-on period

Dependants Full underwriting for:• Special dependants• Late registration of ordinary

dependants

Full underwriting for:• Special dependants• Late registration of ordinary

dependants

Full underwriting for:• Special dependants• Late registration of ordinary

dependantsPeriod of underwriting status

Underwriting-free groups will be reviewed on an annual basis

1-3 months, unless an extension is granted by the Underwriting DepartmentIf take-on period expires:Underwriting automatically defaults to Individual Underwriting (Group C), unless notification is provided by the Underwriting Department to change underwriting status to that of an annual underwriting-free group

1 monthIf take-on period expires:Underwriting remains on the current Individual Underwriting rule

New employees No underwriting for new employees and their ordinary dependants who join on the same inception date, within 3 months from permanent employment date at group

Special dependants will be fully underwritten at all times

No underwriting for new employees and their ordinary dependants who join on the same inception date, within 3 months from permanent employment date at group


No underwriting for new employees and their ordinary dependants who join on the same inception date, within 3 months from permanent employment date at group


GROUP UNDERWRITINGGROUP UNDERW

RITING


MANDATORY SUPPORTING DOCUMENTS: NEW APPLICATIONSWe require the following with all new applications:• Fully completed application and signed declaration with a copy of the main member’s ID or passport and ID numbers for all

beneficiaries listed on the application form, and• Membership certificates as proof of previous medical scheme cover

In addition, we require:• Proof of income as set out in the application form for individual members for BonCap• A copy of the most recent payslip for Persal members

Where the contribution payer’s details differ from the main member, we require the following:• A copy of a cancelled cheque or bank statement showing the account holder’s details, and • A letter from the contribution payer instructing Bonitas to debit his/her account

Where a company is paying the monthly contributions, we require the following:• A copy of a cancelled cheque or bank statement showing the company’s details, and• A letter from the company (on company letterhead) authorising Bonitas to deduct monthly contributions from the company’s bank

account

WHICH FORM TO USE:

Group take-on application Individual member application

Members joining a new paypoint during an underwriting-free take-on period

All direct paying members

Members joining an existing paypoint during an underwriting-free window period during the year or at year end

Members joining a new paypoint during an individual underwriting take-on period

Members joining an existing annual underwriting-free paypoint Members joining an existing individual underwriting paypointAll new employees joining an existing paypoint after the initial take-on period or a window period and within 3 months from their employment date

If special dependants are added during a take-on or window period of a group, an Indivudual member application form needs to be completed

Name of form To be used for:

Individual member application Direct paying members joining BonitasGroup take-on application Members joining Bonitas from a paypoint or employer groupHealth questionnaire Confirms current health status for members reinstating applicationChange in banking details Updates to banking detailsOption change Changes in optionChange of dependants Addition or termination of a dependantChange in details Updates to personal details, address, contact details and/or

marital statusPrincipal member change Changing a dependant to a main memberTermination of membership Cancellation of membershipBroker application Brokers contracting to sell Bonitas policiesCompany application Companies joining Bonitas as an employer group

APPLICATION PROCESSAPPLICATION PROCESS


We negotiate rates with preferred providers and Designated Service Providers to ensure that they do not charge you more than the agreed rate. This will ensure that your benefits last as long as possible and give you more value for money.

The Scheme reserves the right to charge a member interest (to a maximum of the prevailing mora interest rate) on medical savings benefit advances not settled within 30 (thirty) days of resignation from the Scheme or an option with a savings component.

Please note: Where you are required to use a Designated Service Provider and you do not do so, a significant co-payment will apply.

You can call us on 0860 002 108 or log in to www.bonitas.co.za to view the list of preferred providers and Designated Service Providers.

SPECIALIST NETWORK INCLUDES, BUT IS NOT LIMITED TO, THE FOLLOWING SPECIALISTS:• Cardiology• Cardiothoracic Surgery• Dermatology• Gastroenterology• Neurology• Neurosurgery• Obstetrics and Gynaecology• Ophthalmology• Orthopaedics• Otorhinolaryngology (ENT)• Paediatrics• Plastic and Reconstructive Surgery• Psychiatry• Pulmonology• Rheumatology• Specialist Medicine• Surgery• Urology

SPECIALIST NETWORK TARIFFS APPLY TO IN- AND OUT-OF-HOSPITAL BENEFITS ON:• BonClassic• BonComplete• BonSave• BonFit• Standard• Standard Select• Primary• Hospital Standard• BonEssential

HOW TO ADD A GP TO THE NETWORK

Please encourage your doctor to join the network. You can call 0861 112 666 or email [email protected] and provide the details of your doctor. The healthcare professional contracting team will follow up with the doctor.

NETWORK SERVICE PROVIDERSNETW

ORK SERVICE PROVIDERS


GP REFERRAL PROCESSThere is a growing trend of fragmented care, where a number of our beneficiaries are receiving duplicate treatment from multiple doctors and providers. This leads to poor patient experience and unsatisfactory outcomes. The GP referral process aims to provide safe, appropriate and effective care.

In an effort to enhance the coordination of care, members are required to obtain a referral number from their GP before consulting with certain specialists. From January 2017, claims for specialist consultations without a valid referral number from a GP have been rejected (for member’s own pocket) whenever the specialist consultation is payable from risk.

The following exceptions were approved by Bonitas Medical Fund for all options, except BonCap, where the member doesn’t have to obtain a referral letter:• One gynaecologist consultation or visit per year for female beneficiaries• Maternity consultations• Paediatrician consultations for children under the age of two• Oncology consultations• Ophthalmology consultations

HOW TO REGISTER FOR A SPECIALIST REFERRAL AUTHORISATIONYour GP can contact the Bonitas Healthcare Professional call centre on 0861 112 666 and register an authorisation for you or they can use the online facility.

If your GP refuses to obtain a specialist referral authorisation on your behalf, you must obtain a referral letter from the GP stating which specialist you are required to visit. You can then call the call centre on 0860 002 108 and the agent will assist you in obtaining a referral number. The specialist referral authorisations are valid for 6 months per practice type.

On BonCap if you do not obtain a referral from Network GP for a specialist consultation, it will not be covered.

GP REFERRAL PROCESS


There is a separate benefit for tests and consultations for PMB treatment plans (excluding GP consultations). Therefore, this will not affect your day-to-day benefits.

Please see an example of a PMB treatment plan below:

Diagnosis Description Start Date End Date

HYPERLIPIDAEMIA 01-Jan-2017 31-Dec-2017

In terms of the approved treatment guideline for your condition, Bonitas Medical Fund will fund the following benefits as per the Scheme Rules. (Please note that certain of these benefits may only be obtained from a Designated Service Provider and co-payments may apply).

Service Description Extended Description

Tariff Codes Disciplines Allowed No. Per Year

Dietician Consultation 84201, 84202, 84203, 84204, 84205 Dieticians 1ECG Without effort 1232 General Practitioner,

Specialist Family Medicine

1

ECG 127483, 477387, 643064, 432814, 541369, 413345, 433152, 493663, 588415, 494792, 433004, 444610, 406977, 402971, 431188, 432717, 405234

General Practitioner, Specialist Family Medicine

10

GP Consultations 0190, 0191, 0192 General Practitioner, Specialist Family Medicine

2

Pathology Alanine aminotransferase (ALT)

4131 Pathologists 2

Pathology Aspartate aminotransferase

4130 Pathologists 2

Pathology Chol/HDL/LDL/Trig 4025 Pathologists 1Pathology Cholesterol total 4027 Pathologists 1Pathology Creatine kinase (CK) 4132 Pathologists 2Pathology Glucose-Quantitative 4057 Pathologists 1Pathology HDL cholesterol 4028 Pathologists 1Pathology LDL cholesterol-

Chemical4026 Pathologists 1

Pathology Triglyceride 4147 Pathologists 1

PAYMENT OF SERVICES FOR PMB CONDITIONSBonitas will pay for the diagnosis, treatment and care of a number of chronic conditions as per the Prescribed Minimum Benefits (PMB) legislation. To manage the care of these conditions, your Scheme has put a Care Plan in place which assigns a basket of care specific to your PMB condition. Chronic medicine is not included in the Care Plan.

WHAT IS A CARE PLAN?Your Care Plan is a list of the type and number of services that are likely to be needed by a patient with your diagnosis and that your Scheme will cover. It includes out of hospital treatment such as doctor consultations, radiology and pathology tests that are listed on your Care Plan.

HOW WILL THE CARE PLAN BE COVERED?As per legislation, you will be provided, at the very least, with the minimum treatment needed for your PMB condition. Your Scheme will cover the cost of this treatment. Please note that a DSP (Designated Service Provider) may need to be utilised to avoid co-payments. If you have available benefits, this will be utilised until depleted and then treatment will be paid from the Overall Annual Limit, if clinical criteria are met.

WHAT IF I NEED MORE TREATMENT THAN IS LISTED IN MY CARE PLAN?If you need treatment and care in excess of your Care Plan, a clinical motivation must be provided and approved before more services will be covered.

DO I NEED TO DO ANYTHING?No, this letter is proof that a Care Plan has automatically been put in place. Please make sure that every claim you or your doctor send to your Scheme has an ICD-10 code reflected on it so that it can be identified on the system and paid from the correct benefit.

WHERE DO I SEND MY REQUEST?You can email [email protected].

PMB TREATMENT PLANPMB TREATMENT PLAN


HOW TO CLAIMYou must send us your claim within 4 months of receiving treatment or it will not be paid. Send us your claim in one of the following ways.

Post your claim to:Bonitas Claims DepartmentPO Box 74Vereeniging, 1930

OR

Email your claim to [email protected]

OR

Drop off your claim at one of our walk-in centres

TIPS TO GET YOUR CLAIMS PAID QUICKLYEnsure your bank details are correctClaims refunds are only paid into a bank account by electronic funds transfer (EFT). Please call us on 0860 002 108 if you need to update your banking details.

Please ensure that your claim shows the following:• Your name and initials• Your medical aid number• Treatment date• Name of the patient as shown on your membership card• Amount charged• Tariff• ICD-10 code (diagnosis code)• Healthcare provider’s practice number

Please check that prescriptions for medicine show all your details. Also check that the correct amount of medicine dispensed is shown on the claim. If the pharmacy omits any of these details, we will not be able to process your claim.

CHECK THAT YOUR CLAIM HAS BEEN PAIDWe pay claims weekly. A statement showing your claims will be sent to you at the end of the month by post or email. You can also log in to www.bonitas.co.za to view the status of your claims.

HOW TO CLAIM



Your in-hospital benefi ts will depend on the plan you’re on. You must get pre-authorisation for all hospital admissions. This is subject to Scheme Rules and available benefi ts.

HOSPITAL BENEFITSHospital benefi ts off er cover for major medical events that result in a benefi ciary being admitted to hospital. The level of cover you have in hospital depends on the plan you’ve chosen. We encourage all our members to use healthcare providers on our network, as this will ensure that the providers are paid in full.

WHAT ARE HOSPITAL CO-PAYMENTS AND WHEN WILL I HAVE TO PAY THESE?Co-payments are amounts that have to be paid to the hospital directly before admission.

Co-payments will apply in hospital in the following instances:• If you are required to use a specifi c network of hospitals and you choose

not to• If you are required to use a Designated Service Provider or preferred

provider and you choose not to• There is a list of procedures for which your plan requires you to pay a

co-payment on BonSave, BonFit, Primary, Hospital Plus, Hospital Standard and BonEssential. These are shown in the table below:

R1 380 co-payment R3 500 co-payment R6 900 co-payment

1. Colonoscopy 1. Arthroscopy 1. Back Surgery including Spinal Fusion

2. Conservative Back Treatment 2. Diagnostic Laparoscopy 2. Joint Replacements

3. Cystoscopy 3. Laparoscopic Hysterectomy 3. Laparoscopic Pyeloplasty

4. Facet Joint Injections 4. Laparoscopic Appendectomy 4. Laparoscopic Radical Prostatectomy

5. Flexible Sigmoidoscopy 5. Percutaneous Radiofrequency Ablations (Percutaneous Rhizotomies)

5. Nissen Fundoplication (Refl ux Surgery)

6. Functional Nasal Surgery

7. Gastroscopy

8. Hysteroscopy (not Endometrial Ablation)

9. Myringotomy

10. Tonsillectomy and Adenoidectomy

11. Umbilical Hernia Repair

12. Varicose Vein Surgery

Please note: • On Hospital Plus, the R6 900 co-payment will not apply when a hip or knee replacement is performed by a provider contracted to ICPS

or JointCare• A R5 650 co-payment will apply if spinal surgery is performed without an assessment and/or intervention by DBC on BonClassic,

BonComplete, Standard and Standard Select• If you do not use the preferred provider for hip and knee replacements, you will have to pay a R5 650 co-payment on BonClassic,

BonComplete and Standard• If you do not use the Designated Service Provider for hip and knee replacements on Standard Select, the procedure will not be covered

HOW DO I FIND A HOSPITAL ON THE NETWORK?Simply call us on 0860 002 108 and we will assist you, or log in to www.bonitas.co.za and use the Find a Network Provider tool.

We negotiate extensively with hospitals to ensure the best possible value for our members. As a result, we’ve partnered with strategically selected private hospital groups to help further our aim of making quality healthcare more aff ordable and accessible.

HOSPITAL PRE-AUTHORISATION

PLEASE NOTE:

A 30% co-payment will apply to non-network admissions on Standard Select and BonFit. A R6 350 co-payment will apply to non-network admissions on BonCap. This will not apply to emergency admissions.

All hospital admissions must be pre-authorised.




Members have access to all private hospitals countrywide; however, a 30% co-payment may apply at the following hospitals:• Rosepark Hospital• Bedford Gardens Private Hospital• Brenthurst Clinic• Carstenhof Clinic• Flora Clinic• Genesis Clinic (Saxonwold)• Wilgeheuwel Private Hospital• Eugene Marais Hospital• Faerie Glen Hospital• Little Company of Mary Hospital• Wilgers Hospital• Hilton Life Private Hospital• Kingsbury Hospital• Vincent Pallotti Hospital

Please note: This does not apply to Standard Select and BonFit, which make use of specifi c hospital networks.

PRE-AUTHORISATIONAll hospital stays (including emergencies) must be pre-authorised to ensure that your hospital stay is covered. It is best to do this at least two days before you go to hospital. If you do not get pre-authorisation, you will be liable for the full hospital account.

How do I get pre-authorisation?

Step 1:Have the following information ready:• Membership number• Benefi ciary name and date of birth • Date of admission and proposed date of the operation• Name of the doctor, his/her telephone number and practice number• Name of the hospital, the telephone number and practice number• All the relevant procedure and associated medical diagnosis codes (your doctor can assist you with this)

Step 2: Call us on 0860 002 108 orEmail the information in Step 1 to us at [email protected]

Step 3:Once your procedure has been authorised, you will receive a letter confi rming pre-authorisation by email or post. This letter contains important information about your hospital stay. Please make sure that you read and understand the contents of the letter, as it explains how your procedure will be covered. If you are unsure of anything, please discuss the letter with your doctor.

Please note the following pre-authorisation information provided in the letter:• The unique pre-authorisation number• The initial approved length of stay• The status of all the codes (whether approved or rejected in accordance with the Scheme Rules)

WHAT ABOUT EMERGENCIES? Emergencies must be pre-authorised within 48 hours of admission to hospital or on the fi rst working day after a weekend or public holiday. No account will be paid unless pre-authorisation is obtained.

WHAT OTHER TREATMENTS OR PROCEDURES REQUIRE PRE-AUTHORISATION?You will also need pre-authorisation for the following:• Renal clinic admissions for dialysis• Procedures in the doctors rooms instead of hospitalisation• Physical rehabilitation care in rehabilitation facilities• Drug and alcohol rehabilitation in specifi c facilities• Hospice admissions• Oxygen therapy at home• All specialised radiology (such as MRIs and CT scans)




WHY ARE SOME REQUESTS FOR PRE-AUTHORISATION DECLINED?Pre-authorisation requests may be declined if:• The planned procedure is not covered by your benefi t option as specifi ed in the Scheme Rules• The planned procedure is not in line with the acceptable treatment standards for a particular condition• The appropriate clinical information has not been received• Your Bonitas membership is inactive

FOR HOSPITAL PRE-AUTHORISATIONCall: 0860 002 108Email: [email protected]

THE ROLE OF HOSPITAL CASE MANAGERSWhile you are in hospital, case managers ensure that the appropriate care is provided at all times and that the appropriate discharge planning takes place where clinically indicated and where benefi ts are available. This takes place according to the Scheme Rules, clinical protocols and funding guidelines.

When extended length of stay or level of care is requested, the case manager will request supporting information to be able to make an informed clinical decision. If there is any doubt at all, a medical adviser will assist and motivation might be requested from your treating provider, if needed. All changes in initial approvals are communicated to the hospital and treating provider. With long-term cases, your family members may also be involved.



HOSPITAL NETWORKS


HOSPITAL

NAME SUBURB STANDARD SELECT BONFIT

EASTERN CAPE

Life Beacon Bay Hospital Beacon Bay ✓ ✓

Life Isivivana Private Hospital Humansdorp ✓ ✓

Life Mercantile Private Hospital Korsten ✓ ✓

Life Queenstown Private Hospital Queenstown ✓ ✓

Life St Dominic's Hospital Southernwood ✓ ✓

Life St George's Hospital Centrahil ✓ ✓

Life St James Hospital Southernwood ✓ ✓

Life St Mary's Private Hospital Mthatha ✓ ✓

FREE STATE

Life Rosepark Hospital Fichardt Park ✓ ✓

Netcare Vaalpark Hospital Vaalpark ✓ ✓

GAUTENG

Genesis Clinic Saxonwold ✓ ✓

Life Brenthurst Clinic Parktown ✓ ✓

Life Carstenhof Clinic Glen Austin ✓ ✓

Life Flora Clinic Floracliff e ✓ ✓

Life Fourways Hospital Fourways ✓ ✓

Life Robinson Private Hospital Randfontein ✓ ✓

Life Suikerbosrand Clinic Heidelberg ✓ ✓

Life Wilgeheuwel Hospital Radiokop Ext 13 ✓ ✓

Netcare Bougainville Private Hospital Daspoort ✓ ✓

Netcare Clinton Hospital New Redruth ✓ ✓

Netcare Femina Hospital Arcadia ✓ ✓

Netcare Jakaranda Hospital Muckleneuk ✓ ✓

Netcare Linmed Hospital Rynfi eld ✓ ✓

Netcare Montana Private Hospital Montanapark ✓ ✓

Netcare Moot General Hospital Rietfontein ✓ ✓

Netcare Sunward Park Hospital Sunward Park ✓ ✓

Netcare Union Hospital Alberton ✓ ✓

Netcare Unitas Hospital Lyttelton Manor ✓ ✓

KWAZULU-NATAL

Netcare Kingsway Hospital Amanzimtoti ✓ ✓

HOSPITAL NETWORKS



HOSPITAL


KWAZULU-NATAL

Netcare Kokstad Private Hospital Kokstad ✓ ✓

Netcare Parklands Hospital Overport ✓ ✓

Netcare St Anne's Hospital Pietermaritzburg ✓ ✓

Netcare St Augustine's Hospital Bulwer ✓ ✓

Netcare The Bay Hospital Richards Bay ✓ ✓

LIMPOPO

Netcare Pholoso Hospital Faunapark ✓ ✓

MPUMALANGA

Life Cosmos Hospital Witbank ✓ ✓

Life Midmed Hospital Middelburg ✓ ✓

Life Piet Retief Hospital Piet Retief ✓ ✓

NORTH WEST

Life Anncron Hospital Wilkoppies ✓ ✓

Life Peglerae Hospital Rustenburg ✓ ✓

Sunningdale Hospital Wilkoppies ✓ ✓

Wilmedpark Private Hospital Wilkoppies ✓ ✓

WESTERN CAPE

Life Bay View Private Hospital Mossel Bay ✓ ✓

Life Kingsbury Hospital Claremont ✓ ✓

Life Knysna Private Hospital Knysna ✓ ✓

Life West Coast Private Hospital Vredenburg ✓ ✓

Netcare Blaauwberg Hospital Sunningdale ✓ ✓

Netcare Ceres Private Hospital Ceres ✓ ✓

Netcare Christiaan Barnard Memorial Hospital Cape Town ✓ ✓

Netcare Kuils River Hospital Kuils River ✓ ✓

Netcare N1 City Hospital Goodwood ✓ ✓

HOSPITAL NETWORKS


HOSPITAL NETWORKS


DAY CLINICS


EASTERN CAPE

Medical Forum Theatre Mill Park ✓ ✓

FREE STATE

Bethlehem Medical Centre Bethlehem ✓ ✓

Bonnet Dr ML & Partners t/a Citymed Dagkliniek Dan Pienaar ✓ ✓

Cure Day Clinics - Bloemfontein Brandwag ✓ ✓

Welkom Medical Centre St Helena ✓ ✓

GAUTENG

Advanced Medgate Day Clinic Horizon View ✓ ✓

Birchmed Surgical Centre Birchleigh ✓ ✓

Boksburg Medical & Dental Centre (Theatre) Bardene ✓ ✓

Cure Day Clinics - Erasmuskloof Erasmuskloof Ext 3 ✓ ✓

Cure Day Clinics - Medkin Pretoria ✓ ✓

Cure Day Clinics - Midstream Midstream Estate ✓ ✓

Fauchard Clinic Florida Park ✓ ✓

Fordsburg Clinic Selby Ext 19 ✓ ✓

Germiston Medical & Dental Centre Lambton ✓ ✓

Intercare Day Hospital Hazeldean Hazelwood ✓ ✓

Intercare Day Hospital Irene Irene ✓ ✓

Intercare Sandton Day Clinic Morningside ✓ ✓

Karibu Day Clinic Benoni South ✓ ✓

Life Brooklyn Surgical Centre Brooklyn ✓ ✓

Life Pretoria North Surgical Centre Pretoria North ✓ ✓

Mayo Clinic of South Africa Constantia Kloof ✓ ✓

Medicross Constantia Park - Day Surgery Constantia Park ✓ ✓

Medicross Silverton Medical & Dental Centre (Theatre) Silverton ✓ ✓

Medicross The Berg - Day Theatre Bergbron ✓ ✓

Mercidoc Day Clinic Kempton Park ✓ ✓

Netcare Constantia Day Hospital Florida Park ✓ ✓

KWAZULU-NATAL

Bluff Medical & Dental Centre Bluff ✓ ✓

Care Clinic (Westville) Westville ✓ ✓

KZN Day Clinic Umhlanga Rocks ✓ ✓

Medicross Malvern - Day Surgery Malvern ✓ ✓


HOSPITAL NETWORKS


DAY CLINICS


KWAZULU-NATAL

Shelly Beach Day Clinic Shelly Beach ✓ ✓

Westridge Surgical West Ridge ✓ ✓

LIMPOPO

Mediclinic Limpopo Day Clinic Polokwane ✓ ✓

MPUMALANGA

Advanced Emalahleni Day Hospital Emalahleni ✓ ✓

Kriel Medical Centre Kriel ✓ ✓

NORTH WEST

Medicross Potchefstroom Baby Clinic Potchefstroom ✓ ✓

WESTERN CAPE

Advanced Durbanville Surgical Centre Newlands ✓ ✓

Aevitas Fertility Clinic Northern Paarl ✓ ✓

Cure Day Clinic - Stephen's Paarl George ✓ ✓

Cure Day Clinics - Somerset West Durbanville ✓ ✓

George Surgical Centre Monte Vista ✓ ✓

Life Sport Science Orthopaedic Surgical Day Centre Somerset West ✓ ✓

Mediclinic Durbanville - Day Clinic Durbanville ✓ ✓

Medicross Langeberg Medical & Dental Centre Durbanville ✓ ✓

Medicross Parow Medical & Dental Centre (Theatre) Pinelands ✓ ✓

Medicross Tokai Family Medical & Dental Centre Kraaifontein ✓ ✓

Monte Vista Kliniek Parow ✓ ✓

The Surgical Institute Tokai ✓ ✓

Wesfl eur Private Clinic Atlantis ✓ ✓



HOSPITAL

NAME SUBURB BONCAP

EASTERN CAPE

Life Beacon Bay Hospital Beacon Bay ✓

Life Isivivana Private Hospital Humansdorp ✓

Life Mercantile Private Hospital Korsten ✓

Life Queenstown Private Hospital Queenstown ✓

Life St Dominic's Hospital Southernwood ✓

Life St Mary's Private Hospital Mthatha ✓

Mthatha Private Hospital Mthatha ✓

Netcare Cuyler Hospital Uitenhage ✓

Netcare Settlers Private Hospital Grahamstown ✓

FREE STATE

Bethlehem Medical Centre Bethlehem ✓

Citymed Theatre Dan Pienaar ✓

Cure Day Clinics - Bloemfontein Brandwag ✓

Life Rosepark Hospital Fichardt Park ✓

Mediclinic Hoogland Bethlehem ✓

Netcare Kroon Hospital Kroonstad ✓

Netcare Pelonomi Private Hospital Heidedal ✓

Netcare Vaalpark Hospital Vaalpark ✓

St Helena Private Hospital St Helena ✓

Universitas Private Hospital Universitas ✓

Welkom Medical Centre St Helena ✓

GAUTENG

Advanced Groenkloof Day Hospital - Head Offi ce Muckleneuk ✓

Advanced Medgate Day Hospital Home Helderkruin ✓

Ahmed Kathrada Private Hospital Lenasia Ext 8 ✓

Arwyp Medical Centre Kempton Park ✓

Birchmed Surgical Centre Birchleigh ✓

Boksburg Medical & Dental Centre (Theatre) Bardene ✓

Botshilu Private Hospital Soshanguve ✓

Brooklyn Surgical Centre Brooklyn ✓

BONCAP HOSPITAL NETWORKSBONCAP HOSPITAL NETW

ORKS



HOSPITAL

NAME SUBURB BONCAP

GAUTENG

Centre of Advanced Medicine Waverley ✓

Centurion Day Hospital Centurion ✓

Clinix Botshelong-Empilweni Private Hospital Vosloorus Ext 9 ✓

Clinix Naledi-Nkanyezi Private Hospital Sebokeng ✓

Clinix Tshepo-Themba Private Hospital Dobsonville ✓

Cure Day Clinics - Erasmuskloof Erasmuskloof Ext 3 ✓

Cure Day Clinics - Fourways Fourways ✓

Cure Day Clinics - Medkin Pretoria ✓

Cure Day Clinics - Midstream Midstream Estate ✓

Dr S K Matseke Memorial Hospital Diepkloof Zone 6 ✓

Edenvale Day Clinic Edenvale ✓

Ekurhuleni Surgiklin Day Clinic Kempton Park ✓

Fauchard Clinic Florida Park ✓

Fordsburg Clinic Selby Ext 19 ✓

Germiston Medical & Dental Centre Lambton ✓

Intercare Hazeldean Day Hospital Hazelwood ✓

Intercare Irene Day Hospital Irene ✓

Intercare Sandton Day Hospital Morningside ✓

Kilnerpark Narko Clinic Kilner Park ✓

Lenmed Daxina Private Hospital Lenasia South ✓

Lenmed Randfontein Private Hospital Greenhills ✓

Life Brenthurst Clinic Parktown ✓

Life Carstenhof Clinic Glen Austin ✓

Life Eugene Marais Hospital Les Marais ✓

Life Glynnwood Hospital Benoni South ✓

Life Pretoria North Surgical Centre Pretoria North ✓

Life Robinson Private Hospital Randfontein ✓

Life Springs Parkland Clinic Pollak Park ✓

Life St Mary's Women's Clinic - Springsmed Maternity Home & Female Clinic Springs ✓

Life Suikerbosrand Clinic Heidelberg ✓

Mediclinic Legae Mabopane ✓

Medicross Silverton Medical & Dental Centre (Theatre) Silverton ✓

Medicross the Berg - Day Theatre Bergbron ✓

BONCAP HOSPITAL NETWORKS



HOSPITAL

NAME SUBURB BONCAP

GAUTENG

Midvaal Private Hospital Three Rivers ✓

Netcare Constantia Day Hospital Florida Park ✓

Netcare Garden City Hospital Mayfair West ✓

Netcare Jakaranda Hospital Muckleneuk ✓

Netcare Krugersdorp Hospital Krugersdorp ✓

Netcare Montana Private Hospital Montanapark ✓

Netcare Mulbarton Hospital Mulbarton ✓

Netcare Protea Day Clinic Krugersdorp ✓

Netcare Rand Hospital Berea ✓

Netcare Unitas Hospital Lyttelton Manor ✓

South Day Clinic Turff ontein ✓

Stix Morewa Memorial Hospital Selby ✓

The Fountain Private Hospital Carletonville ✓

Zamokuhle Private Hospital Hospital View ✓

Zuid-Afrikaans Hospitaal Muckleneuk ✓

KWAZULU-NATAL

Lorne Street Anaesthetic Clinic Durban ✓

Shelly Beach Day Clinic Shelly Beach ✓

Westridge Surgical West Ridge ✓

Howick Day Clinic Howick ✓

Life Empangeni Garden Clinic Empangeni ✓

Life Mount Edgecombe Hospital Phoenix ✓

Durdoc Medical Centre Durban ✓

Netcare St Augustine's Hospital Bulwer ✓

Netcare St Anne's Hospital Pietermaritzburg ✓

Life Chatsmed Garden Hospital Chatsworth ✓

Lenmed La Verna Hospital Ladysmith ✓

City Hospital Ltd Durban ✓

Lenmed Shifa Private Hospital Sydenham ✓

Netcare the Bay Hospital Richards Bay ✓

Mediclinic Newcastle Newcastle ✓

Hibiscus Hospital Port Shepstone ✓

Netcare Umhlanga Hospital Umhlanga Rocks ✓




HOSPITAL

NAME SUBURB BONCAP

KWAZULU-NATAL

Bluff Medical & Dental Centre Bluff ✓

Medicross Malvern - Day Surgery Malvern ✓

Medicross Pinetown Medical & Dental Centre (Theatre) Pinetown ✓

LIMPOPO

Clinix Phalaborwa Private Hospital Tzaneen ✓

Mediclinic Limpopo Phalaborwa ✓

Mediclinic Limpopo Day Clinic Chromite ✓

Mediclinic Thabazimbi Polokwane ✓

Mediclinic Tzaneen Thabazimbi ✓

Rustenburg Platinum Mine Private Hospital Polokwane ✓

MPUMALANGA

Advanced Emalahleni Day Hospital Emalahleni ✓

Kiaat Private Hospital Nelspruit ✓

Kriel Medical Centre Kriel ✓

Life Cosmos Hospital Witbank ✓

Life Midmed Hospital Middelburg ✓

Life Piet Retief Hospital Piet Retief ✓

Mediclinic Barberton Barberton ✓

Mediclinic Ermelo Ermelo ✓

Mediclinic Highveld Trichardt ✓

NORTH WEST

Andrew Saff y Memorial Hospital Marikana ✓

Clinix Itokolle-Victoria Private Hospital Mafi keng ✓

Life Anncron Hospital Wilkoppies ✓

Life Peglerae Hospital Rustenburg ✓

Medicare Centre - Rustenburg Rustenburg ✓

Mediclinic Brits Brits ✓

Medicross Potchefstroom Baby Clinic Potchefstroom ✓

Mooimed Private Hospital Potchefstroom ✓

Netcare Ferncrest Hospital Tlhabane ✓

Rustenburg Platinum Mines Hospital (Rustenburg Section) Bleskop ✓

Rustenburg Platinum Mines Hospital (Rustenburg Section) Bleskop ✓

Sunningdale Hospital Wilkoppies ✓




HOSPITAL

NAME SUBURB BONCAP

NORTH WEST

Vryburg Private Hospital Vryburg ✓

Wilmedpark Private Hospital Wilkoppies ✓

NORTHERN CAPE

Kimberley Narko Clinic (Pty) Ltd Kimberley ✓

Lenmed Health Kathu Private Hospital Kathu ✓

Lenmed Royal Hospital and Heart Centre Royldene ✓

Medi - Harts Day Clinic Hartswater ✓

Mediclinic Gariep Eltoro Park ✓

Mediclinic Upington Upington ✓

WESTERN CAPE

Advanced Durbanville Surgical Centre Durbanville ✓

Advanced Knysna Surgical Centre (Pty) Ltd Fisherhaven ✓

Advanced Panorama Surgical Centre (Pty) Ltd Panorama ✓

Advanced Vergelegen Surgical Centre Somerset West ✓

Advanced Worcester Surgical Centre Worcester ✓

Busamed Paardevlei Private Hospital Paardevlei ✓

Cango Medicentre Oudtshoorn ✓

Cape Dental Theatres Wynberg ✓

Cure Day Clinic - Stephen's Paarl Northern Paarl ✓

Cure Day Clinics - Bellville Bellville ✓

Cure Day Clinics - Somerset West (Pty) Ltd Somerset West ✓

Intercare Day Hospital Century City (Pty) Ltd Century City ✓

Life Bay View Private Hospital Mossel Bay ✓

Life West Coast Private Hospital Vredenburg ✓

Mediclinic Paarl Paarl ✓

Mediclinic Worcester Worcester ✓

Medicross Langeberg Medical & Dental Centre Kraaifontein ✓

Medicross Parow Medical & Dental Centre (Theatre) Parow ✓

Medicross Tokai Family Medical & Dental Centre Tokai ✓

Melomed Bellville Bellville ✓

Melomed Gatesville Gatesville ✓

Melomed Mitchells Plain Mitchells Plain ✓

Melomed Tokai Tokai ✓




HOSPITAL

NAME SUBURB BONCAP

WESTERN CAPE

Netcare Blaauwberg Hospital Sunningdale ✓

Netcare Kuils River Hospital Kuils River ✓

Netcare N1 City Hospital Goodwood ✓

Netcare UCT Private Academic Hospital Observatory ✓

Thembani Theatres Khayelitsha ✓

Vidamed Private Hospital Mossel Bay ✓

Wesfl eur Private Clinic Atlantis ✓


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 Schemes. PRE-CMS01-V6-07SEP2017.

LOCATE A PROVIDERLOCATE A PROVIDER


1. PRESCRIBED MINIMUM BENEFITSThe Fund will pay in full, without co-payment or use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefits as per Regulation 8 of the Act. The Fund will employ appropriate interventions aimed at improving the efficiency and effectiveness of healthcare provision, including such techniques as requirements for pre-authorisation the application of treatment protocols and the use of formularies (Regulation 8(3)).

Where a managed health care protocol or a formulary drug preferred by the Scheme, but excluding the Prescribed Minimum Benefits (PMB) algorithm as defined in the Regulation, has been ineffective or would cause harm to a beneficiary, the Scheme will fund the cost of the appropriate substitution treatment without a penalty to the beneficiary as required by Regulation 15H and 15I of the Act. DSP refers to Designated Service Providers.

2. LIMITATION AND RESTRICTION OF BENEFITS2.1 In cases of illness of a protracted nature, the Fund shall have the right to insist upon a member or dependant of a member consulting

any particular specialist the Fund may nominate in consultation with the attending practitioner.2.2 The Fund may require a second opinion in respect of proposed treatment or medicine which may result in a claim for benefits and

for that purpose the relevant beneficiary shall consult a dental or medical practitioner nominated by the Fund and at the cost of the Fund. In the event that the second opinion proposes different treatment or medicine to the first, the Fund may in its discretion require that the second opinion proposals be followed.

2.3 Unless otherwise decided by the Fund, benefits in respect of medicines obtained on a prescription are limited to one month’s supply (or to the nearest unbroken pack) for every such prescription or repeat thereof.

2.4 If the Fund or its managed healthcare organisation has funding guidelines or protocols in respect of covered services and supplies, beneficiaries will only qualify for benefits in respect of those services and supplies with reference to the available funding guidelines and protocols with due regard to the provision of Regulations 15(H) and 15(I).

2.5 If the Fund does not have funding guidelines or protocols in respect of benefits for services and supplies referred to in Annexure B, beneficiaries will only qualify for benefits in respect of those services and supplies if the Fund or its managed healthcare organisation acknowledges them as medically necessary, and then subject to such conditions as the Fund or its managed healthcare organisation may impose.

2.5.1 They are required to restore normal function of an affected limb, organ or system;2.5.2 No alternative exists that has a better outcome, is more cost-effective, or has a lower risk;2.5.3 They are accepted by the relevant service provider as optimal and necessary for the specific condition and at an appropriate level

to render safe and adequate care;2.5.4 They are not rendered or provided for the convenience of the relevant beneficiary or service provider;2.5.5 Outcome studies are available and acceptable to the Fund in respect of such services or supplies;2.5.6 They are not rendered or provided because of personal choice or preference of the relevant beneficiary or service provider, while

other medically appropriate, more cost-effective alternatives exist.2.6 The Fund reserves the right not to pay for any new medical technology or, investigational procedures, interventions, new drugs

or medicine as applied in clinical medicine, including new indications for existing medicines or technologies, unless the following clinical data relating to the above have been presented to and accepted by the Medical Advisory Committee and such data demonstrating their:

2.6.1 Therapeutic role in clinical medicine;2.6.2 Cost-efficiency and affordability;2.6.3 Value relative to existing services or supplies;2.6.4 Role in drug therapy as established by the Fund’s managed healthcare organisation.2.7 In the event that (non-PMB conditions):2.7.1 The treatment of an extended or chronic sickness condition becomes necessary; or2.7.2 A disease or a condition (including pregnancy) requires specialised or intensive treatment; or2.7.3 The treatment of any disease or condition becomes of a protracted nature or requires extended medicine and such treatment is

given in or by a non-DSP, the case may be evaluated in terms of the relevant managed healthcare programme and, having regard to the aforementioned diseases or conditions in question, the Fund may require and arrange:2.7.3.1 The transfer of that beneficiary to a public hospital or other DSP as arranged by the Fund where appropriate care is

available, with due regard to Regulation 8(3)(c); or2.7.3.2 The application of a limited drug formulary; or2.7.3.3 Both such transfer and restricted drug formulary in order to conserve or maximise efficient utilisation of available

benefits.2.8 In the event that a decision has been taken in terms of paragraph 2.7 above, the following conditions shall apply:2.8.1 In respect of PMBs, no benefit limit shall apply provided treatment is given in or by a public hospital or DSP referred to in paragraph

7.4 in Annexure D. If for any reason the beneficiary on BonCap voluntarily receives treatment in or by a non-DSP, the beneficiary shall be required to pay the difference between the DSP rate and the cost of such treatment.

2.8.2 In respect of non-PMB conditions, if the Fund or its managed healthcare organisation should determine that any annual benefit limits, as set out in Annexure B, and available to the beneficiary receiving such treatment, are likely to be exceeded in the course of the year, the beneficiary may be advised to move to a public hospital or DSP or to accept a limited drug formulary, or both, in order to conserve available benefits. In such DSP or public facility any costs incurred over and above the limit stipulated in Annexure B (excluding PMB conditions), shall be the member’s responsibility. The member may elect on behalf of himself or his beneficiary, to remain in the private hospital, or remain on the full drug formulary available, or both, in which event the Fund shall pay up to the benefit limit stipulated in Annexure B, where after the member shall be responsible for payment, direct to the private hospital, for any further treatment in such hospital or for payment direct to the supplier for further medicine.

2.9 The Scheme (or contracted managed care company on behalf of the Scheme) may from time to time contract with, or pilot with, or credential specific provider groups (networks) or centres of excellence, or supplier groups as determined by the Scheme in order to ensure cost effective and appropriate care. Beneficiaries are entitled to benefits from contracted networks appointed as the Scheme’s DSP for PMB benefits and other benefits (as set out in Annexure D).

The Scheme reserves the right not to fund or partially fund services acquired outside of these networks provided reasonable

steps are taken by the Scheme to ensure access to the network, subject to PMBs. The Fund reserves the right not to pay for

EXCLUSIONSEXCLUSIONS


procedures performed by non-recognised providers (where applicable). Certain procedures may be associated with a significant learning curve and/or are not taught routinely at local universities and/or require special training and experience, including that aimed at maintenance of expertise, and/or need access to certain infrastructure for quality outcomes. Where such procedures have been identified by the Scheme’s managed care provider, recognised providers are those who have been acknowledged by same as meeting minimum training and practice criteria for the safe and effective performance of such procedures. Recognition occurs as a result of a formal application process by interested providers and adjudication of relevant information against competency guidelines by the managed care provider and/or appointed credentialing body. Criteria for formal recognition are informed by clinical evidence, clinical guidelines and/or expert opinion.

3. BENEFITS EXCLUDED INSOFAR AS THESE ARE NOT PRESCRIBED UNDER THE PMBs3.1 General exclusions The Fund will pay in full, without co-payment or use of deductibles, the diagnosis, treatment and care costs of the PMBs as per

Regulation 8 of the Act. The Fund will employ appropriate interventions aimed at improving the efficiency and effectiveness of healthcare provision, including such techniques as requirements for pre-authorisation, the application of treatment protocols, and the use of formularies (Regulation 8(3).

Where a managed health care protocol or a formulary drug preferred by the Scheme, but excluding the PMB algorithm as defined in the Regulation, has been ineffective or would cause harm to a beneficiary the Scheme will fund the cost of the appropriate substitution treatment without a penalty to the beneficiary as required by Regulation 15H and 15I of the Act.

Unless otherwise decided by the Fund (and with the express exception of medicines or treatment approved and authorised in terms of any relevant managed healthcare programme), expenses incurred in connection with any of the following will not be paid by the Fund:

3.1.1 All costs that exceed the annual or biennial maximum allowed for the particular category as set out in Annexure B, for the benefits to which the member is entitled in terms of the rules;

3.1.2 All costs for operations, medicines, treatments and procedures for cosmetic and aesthetic purposes or for personal reasons and not directly caused by or related to illness, accident or disease;

3.1.3 All costs for healthcare services if, in the opinion of the medical or dental adviser, such healthcare services are not appropriate and necessary based on current practice, evidence based medicine, cost effectiveness and affordability;

3.1.4 All costs for medicines for the treatment of chronic conditions not on the list of diseases covered, with the exception of medicines for the treatment of an excluded chronic condition which the Chronic Medicine Programme has specifically determined should be treated to achieve overall cost effective treatment of the beneficiary;

3.1.5 Futility of care: for members in a persistent vegetative state, where there has been no significant improvement and where the underlying cause is irreversible. Subject to an opinion from an independent panel of ethics experts.

3.2 Exclusions and indemnity in regard to third party claims3.2.1 It is recorded that the relationship between the Fund and its members shall at all times be deemed to be one of the utmost good

faith. The member therefore acknowledges and agrees that, notwithstanding anything to the contrary or not specifically set out in the rules or Annexures of the Fund, the member is under a duty of care to disclose all and any information or matters to the Fund.

3.2.2 The Fund shall be liable for the payment of any costs, subject to the Fund’s rules, incurred by a member, which arose or may have arisen, as a result of the actions or omissions of another party. In the event of claims reimbursed on behalf of the member which arose from the actions or omissions of any other party, the member shall:3.2.2.1 Be liable to repay to the Fund all amounts paid by the Fund and recovered by or on behalf of the member from the

party responsible to compensate such member, free of any legal costs or deductions that may have been incurred in the recovery of such amount;

3.2.2.2 Ensure that, prior to the settlement of any claim instituted against such other party, all the amounts set out above and paid by the Fund, are included in such claim and form part of any settlement amount, whether globular or separately;

3.2.2.3 Disclose to the Fund, alternatively, instruct his legal representative to disclose to the Fund, the full extent of any compensation awarded in respect of past and future medical expenses;

3.2.2.4 Sign all documentation as may be required by the Fund to obtain copies of all such information not in the Fund’s possession, relating to the member’s medical accounts and records from the relevant practitioners and/or medical institutions;

3.2.2.5 Sign all such documentation as may be required by the Fund, to proceed with a claim in the member’s name to recover any amounts expended by the Fund, subject to the Fund indemnifying the member against any costs which may arise as a result of the institution of such claim, if the Fund is satisfied that a valid claim exists and the member elects not to proceed with it;

3.2.2.6 Be deemed to be liable to repay all amounts expended by the Fund, as above, in the event of the member’s claim being finalized and paid in circumstances where no specific or separate award is made for the payment of medical or hospital expenses incurred;

3.2.2.7 Either personally or through his/her legal representative keep the Fund informed, whether called upon by the Fund to do so or not, as to the ongoing progress of his/her claim;

3.2.2.8 When requested by the Fund, whether prior to or subsequent to the Fund effecting any payments as referred to above, provide the Fund with a written undertaking signed by both the member and his/her legal representative so as to give full effect to what is contained in paragraphs 3.2.1 and 3.2.2.1 to 3.2.2.7 above;

3.3 Exclusions in regard to non-registered service providers The Fund shall not pay the costs for services rendered by:3.3.1 Persons not registered with a recognised professional body constituted in terms of an Act of Parliament; or3.3.2 Any institution, nursing home or similar institution, except a state or provincial hospital, not registered in terms of any law.3.4 Specific exclusions All costs for services rendered in respect of the following:3.4.1 Alternative Health Practitioners All services not listed in paragraph D1 of Annexure B:

3.4.1.1 Acupuncture on BonCap3.4.1.2 Aromatherapy3.4.1.3 Ayurvedics3.4.1.4 Herbalists3.4.1.5 Homoeopathy on BonCap3.4.1.6 Iridology3.4.1.7 Naturopathy on BonCap3.4.1.8 Osteopathy on BonCap

EXCLUSIONS


3.4.1.9 Phytotherapy on BonCap3.4.1.10 Reflexology3.4.1.11 Therapeutic Massage Therapy (Masseurs)

3.4.2 Ambulance services3.4.2.1 Services not authorised or included in the preferred provider contract (subject to Regulation 8(3).

3.4.3 Appliances, external accessories and orthotics3.4.3.1 Appliances, devices and procedures not scientifically proven or appropriate;3.4.3.2 Back rests and chair seats;3.4.3.3 Bandages and dressings (except medicated dressings);3.4.3.4 Beds and mattresses, pillows and overlays;3.4.3.5 Long term implantable ventricular assist devices and total artificial hearts” – e.g. Heart Ware and Berlin heart.3.4.3.6 Diagnostic kits, agents and appliances unless otherwise stated except for diabetic accessories;3.4.3.7 Electric tooth brushes;3.4.3.8 Humidifiers;3.4.3.9 Ionisers and air purifiers;3.4.3.10 Orthopaedic shoes and, inserts/levelers and boots unless specifically authorised and/or PMB;3.4.3.11 Pain relieving machines, e.g. TENS and APS;3.4.3.12 Stethoscopes and sphygmomanometers (blood pressure monitors);3.4.3.13 Portable cylinders are excluded on all options. Portable oxygen concentrators will be excluded on all options except for

BonComprehensive, and BonClassic, subject to preauthorisation and available appliance benefit;3.4.3.14 Electric wheelchairs and scooters.

3.4.4 Blood, blood equivalents and blood products3.4.4.1 Hemopure (bovine blood).

3.4.5 Dentistry3.4.5.1 Appointments not kept;3.4.5.2 Orthodontic treatment for individuals 18 years and older;3.4.5.3 Dental procedures or devices which are not regarded by the relevant managed healthcare programme as clinically

essential or clinically desirable;3.4.5.4 Orthognathic (jaw correction) surgery, other orthodontic related surgery and the associated laboratory cost;3.4.5.5 Instruction for oral hygiene;3.4.5.6 Nutrition and tobacco counseling;3.4.5.7 Caries susceptibility and microbiological tests;3.4.5.8 Oral hygiene evaluation;3.4.5.9 Crown and bridge procedures where there is no extensive tooth structure loss and associated laboratory costs;3.4.5.10 Electrognathographic recordings, pantographic recordings and other such electronic analyses;3.4.5.11 Fissure sealants on patients 16 years and older;3.4.5.12 Pulp tests and pulp capping (direct and indirect);3.4.5.13 Polishing of restorations;3.4.5.14 Ozone therapy;3.4.5.15 Metal base to full dentures, including the laboratory cost;3.4.5.16 The clinical fee of dental repairs, denture tooth replacements and the addition of a soft base to new dentures.(The

laboraroty fee will be covered at the scheme dental tariff where managed care protocols apply.);3.4.5.17 Diagnostic dentures and associated laboratory costs;3.4.5.18 Provisional crowns, including laboratory cost;3.4.5.19 Resin bonding for restorations charged as a separate procedure to the restoration;3.4.5.20 Dental bleaching;3.4.5.21 Porcelain veneers and inlays/onlays and associated laboratory costs;3.4.5.22 Pontics on second molars;3.4.5.23 Laboratory fabricated crowns on primary teeth;3.4.5.24 Fixed prosthodontics used to repair occlusal wear;3.4.5.25 Gold foil restorations;3.4.5.26 Surgical periodontics, which includes gingivectomies, periodontal flap surgery, tissue grafting and hemisection of a

tooth;3.4.5.27 Perio chip;3.4.5.28 Emergency crowns that are not placed for immediate protection in tooth injury and the associated laboratory costs;3.4.5.29 Orthodontic re-treatment and the associated laborartory costs;3.4.5.30 Lingual orthodontics;3.4.5.31 Implants on wisdom teeth (3rd molars);3.4.5.32 Orthodontic treatment for cosmetic reasons and associated laboratory costs;3.4.5.33 Sinus lifts;3.4.5.34 Bone augmentations;3.4.5.35 Bone and other tissue regeneration procedures;3.4.5.36 Dolder bars and associated abutments on implants including the laboratory cost;3.4.5.37 Laboratory cost where the associated dental treatment is not covered;3.4.5.38 Laboratory cost associated with mouth guards;3.4.5.39 Snoring appliances;3.4.5.40 High impact acrylic;3.4.5.41 Cost of mineral trioxide;3.4.5.42 Cost of gold, precious metal, semi-precious metal and platinum foil;3.4.5.43 Cost of invisible retainer material;3.4.5.44 Cost of bone regeneration material;3.4.5.45 Cost of prescribed toothpastes, mouth washes (e.g Corsodyl) and ointments;3.4.5.46 Topical application of fluoride in patients 16 years and older;3.4.5.47 Cost of dental materials in hospital;3.4.5.48 Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis;3.4.5.49 Crowns or crown retainers on wisdom teeth (3rd molars);3.4.5.50 Crown and bridge procedures of cosmetic reasons and associated laboratory costs;3.4.5.51 Occlussal rehabilitations and associated laboratory costs;

EXCLUSIONS


3.4.5.52 Provisional dentures and associated laboratory costs;3.4.5.53 Root canal therapy on wisdom teeth and primary (milk) teeth;3.4.5.54 Enamel microabrasion;3.4.5.55 Behaviour management;3.4.5.56 Intramuscular or subcutaneous injection;3.4.5.57 Special reports and dental testimony including dento-legal fees;3.4.5.58 The auto-transplantation of teeth;3.4.5.59 The closure of an oral-antral opening (item code 8909) when claimed during the same visit with impacted teeth (item

code 8941, 8943 and 8945);3.4.5.60 Hospitalisation (general anaesthetic): where the reason for admission to hospital is dental fear or anxiety; multiple

hospital admissions; where the only reason for admission to hospital is to acquire a sterile facility;3.4.5.61 Hospital and anaethetist claims will not be covered for the following procedures when performed under general

anaesthesia: apicectomies, dentectomies, frenectomies, conservative dental treatment (fillings, extractions and root canal therapy) in hospital for adults, professional oral hygiene procedures, implantology and associated surgical procedures and surgical tooth exposure for orthodontic reasons;

3.4.5.62 Treatment plan completed (currently code 8120);3.4.5.63 Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures;3.4.5.64 Laboratory delivery fees.

3.4.6 Hospitalisation3.4.6.1 If application for a pre-authorisation reference number (PAR) for a clinical procedure, treatment or specialised radiology

is not made or is refused, no benefits are payable (refer to paragraphs 4.1, 4.5.6 and 4.5.7 of Annexure D);3.4.6.2 Accommodation and services provided in a geriatric hospital, old age home, frail care facility or similar institution (unless

specifically provided for in Annexure B).3.4.7 Infertility

3.4.7.1 Medical and surgical treatment , which is not included in the Prescribed Minimum Benefits in the Regulations to Act 131 of 1998, Annexure A, Paragraph 9, Code 902M, including:

• Assisted Reproductive Technology (ART),• In-vitro fertilisation (IVF);• Gamete Intrafallopian tube transfer (GIFT);• Zygote Intrafallopian tube transfer (ZIFT); and• Intracytoplasmic sperm injection (ICS).

3.4.7.2 Vasovasostomy (reversal of vasectomy).3.4.8 Maternity

3.4.8.1 3D and 4D scans;3.4.8.2 2D scans in excess of 2, unless motivated for an appropriate medical condition;3.4.8.3 Antenatal classes/exercises except on BonComprehensive, BonClassic, BonSave, Standard, Standard Select and

BonComplete.3.4.9 Medicine and injection material

3.4.9.1 Anabolic steroids and immunostimulants unless Prescribed Minimum Benefits;3.4.9.2 Contraceptives, oral, parenteral, foams, IUCDS and when used for skin conditions;3.4.9.3 Cosmetic preparations, emollients, moisturisers, medicated or otherwise, soaps, scrubs and other cleansers, sunscreen

and sun tanning preparations, medicated shampoos and conditioners, except for the treatment of lice, scabies and other microbial infections and coal tar products for the treatment of psoriasis;

3.4.9.4 Erectile dysfunction and loss of libido medical treatment;3.4.9.5 Patented and nutritional supplements including baby food and special milk preparations unless formalabsorptive

disorders and if registered by the relevant managed health care programme or MTCT prophylaxis and registered on the appropriate disease management programme or when used during and authorised hospital admission, subject to the relevant health care program;

3.4.9.6 Injection and infusion material, except for outpatient parenteral treatment (OPAT), diabetes and other prescribed minimum benefits;

3.4.9.7 The following medicines, unless they form part of the public sector protocols and specifically provided for in annexure B and are authorised by the relevant managed healthcare programme:3.4.9.7.1 Maintenance Rituximab (or other monoclonal antibodies) in the first line setting for haematological

malignancies;3.4.9.7.2 Liposomal amphotericin B for fungal infections;3.4.9.7.3 Any specialised drugs that have not convincingly demonstrated a median overall survival advantage of more

than 3 months in locally advanced or metastatic solid organ malignant tumours. (for example sorafenib for hepatocellular carcinoma, bevacizumab for colorectal and metastatic breast cancer). This does not include drugs that are deemed cost-effective for the specific setting, compared to standard therapy (excluding specialised drugs) as defined in established and generally accepted treatment protocols (for example, erlotinib in the second line treatment setting for non small cell lung cancer);

3.4.9.7.4 Trastuzumab for the treatment of HER2-positive early breast cancer and metastatic cancer on BonComplete, BonClassic, Standard, Standard Select, BonSave, BonFit, Primary, BonEssential, BonCap and Hospital Standard Options;

3.4.9.7.5 Carmustine wafers for the treatment of malignant gliomas;3.4.9.7.6 Any new chemotherapeutic drug that has not convincingly demonstrated a survival advantage of more than

3 months in advanced or metastatic malignancies, unless pre-authorised by the managed care organisation as a cost effective alternative to standard chemotherapy.

3.4.9.8 Medicines not included in a prescription from a medical practitioner or other healthcare professional who is legally entitled to prescribe such medicines (except for schedule 0, 1 and 2 medicines supplied by a registered pharmacist);

3.4.9.9 Medicines for intestinal flora;3.4.9.10 Medicines defined as exclusions by the relevant managed healthcare programme;3.4.9.11 Medicines not approved by the Medicine Control Council unless Section 21 approval is obtained and pre-authorised by

the relevant managed healthcare programme;3.4.9.12 Medicines not authorised by the relevant managed healthcare programme based on evidence based medicine, taking

into consideration cost-effectiveness and affordability;3.4.9.13 Patent medicines, household remedies and proprietary preparations and preparations not otherwise classified;3.4.9.14 Slimming preparations for obesity;

EXCLUSIONS


3.4.9.15 Smoking cessation and anti-smoking preparations, unless authorised as part of the wellness extender benefit. Excluded on BonCap;

3.4.9.16 Tonics, evening primrose oil, fish liver oils, multi-vitamin preparations and/or trace elements and/or mineral combinations (except for registered products that include haemotonics and those for use by infants and pregnant mothers);

3.4.9.17 Biological drugs except on BonComprehensive, BonClassic and Hospital Plus and Beta-Interferon for the treatment of Multiple Sclerosis as per the PMB algorithm unless specifically provided for in Annexure B;

3.4.9.18 All benefits for clinical trials and all treatment/admission costs relating to complications of trial drugs, unless pre-authorised by the relevant managed healthcare programme;

3.4.9.19 Diagnostic agents, unless authorised;3.4.9.20 Growth hormones, unless pre-authorised;3.4.9.21 Immunoglobulins and immune stimulants, oral and parenteral, unless pre-authorised;3.4.9.22 Medicines used specifically to treat alcohol and drug addiction, unless PMB.

3.4.10 Mental health3.4.10.1 Sleep therapy;3.4.10.2 Educational psychology visits for adult beneficiaries.

3.4.11 Non-surgical procedures and tests3.4.11.1 Epilation – treatment for hair removal;3.4.11.2 Hyperbaric oxygen therapy except for PMBs;3.4.11.3 Facet joint injections and percutaneous radiofrequency ablations (percutaneous rhizotomies) on BonCap only.

3.4.12 Optometry3.4.12.1 Coloured and other cosmetic effect contact lenses, and contact lens accessories and solutions;3.4.12.2 Optical devices which are not regarded by the relevant managed healthcare programme, as clinically essential or

clinically desirable except on BonSave, BonFit, BonClassic and BonComprehensive;3.4.12.3 Sunglasses and prescription sunglasses.

3.4.13 Organs and Haemopoietic Stem Cell (Bone Marrow) Transplantation and Immunosuppressive Medication3.4.13.1 Organs and haemopoietic stem cell (bone marrow) donations to any person other than to a member or dependant of a

member on this Fund.3.4.14 Paramedical Services

3.4.14.1 Pharmacy services3.4.15 Pathology and Medical Technology

3.4.15.1 Gene sequencing3.4.16 Physical therapy

3.4.16.1 X-rays performed by chiropractors;3.4.16.2 Chiropractor benefits in hospital;3.4.16.3 Physiotherapy for mental health admissions.

3.4.17 Prostheses internal and external3.4.17.1 Cochlear implants, unless specifically provided for in Annexure B;3.4.17.2 Osseo-integrated implants for dental purposes to replace missing teeth, unless specifically provided for in Annexure B;3.4.17.3 Total ankle replacement on BonEssential, BonSave, BonFit, Primary, BonCap and Hospital Standard;3.4.17.4 Implantable defibrillators on BonEssential, BonSave, BonFit, Primary, BonCap and Hospital Standard.

3.4.18 Radiology and radiography3.4.18.1 MRI scans ordered by a general practitioner, unless there is no reasonable access to a specialist;3.4.18.2 Positron Emission Tomography, except for appropriate diagnosis, staging, the monitoring of response to treatment and

investigation of residual tumour or suspected recurrence (restaging) e.g. Metatastic breast cancer on all options except on BonComprehensive and Hospital Plus, and PET plus PET-CT for screening;

3.4.18.3 Bone densitometry performed by a general practitioner or specialist not included in the Fund credentialed list;3.4.18.4 CT colonography (virtual colonoscopy) for screening;3.4.18.5 MDCT Coronary Angiography for screening;3.4.18.6 If application for a pre-authorisation reference number (PAR) for specialised radiology procedures is not made or is

refused, no benefits are payable (refer to paragraphs 4.1, 4.5.6 and 4.5.7 of Annexure D);3.4.18.7 All screening that has not been pre-authorised or is not in accordance with the Fund’s policies and protocols.

3.4.19 Surgical procedures3.4.19.1 Abdominoplasties and the repair of divarication of the abdominal muscles;3.4.19.2 Balloon sinuplasty on BonCap, BonEssential, BonFit, BonSave, Primary and Hospital Standard;3.4.19.3 Bilateral gynaecomastia;3.4.19.4 Blepharoplasties unless causing demonstrated functional visual impairment and pre-authorised;3.4.19.5 Breast augmentation;3.4.19.6 Breast reconstruction - unless mastectomy following cancer and pre-authorised;3.4.19.7 Breast reductions,3.4.19.8 All costs for cosmetic surgery performed over and above the codes authorised for admission;3.4.19.9 Deep brain stimulation for Parkinson’s and intractable epilepsy on BonCap, BonClassic, BonComplete, BonEssential,

BonFit, BonSave, Primary and Hospital Standard;3.4.19.10 Erectile dysfunction surgical procedures;3.4.19.11 Gender reassignment medical or surgical treatment;3.4.19.12 Genioplasties as an isolated procedure;3.4.19.13 Custom made hip arthroplasty for inflammatory and degenerative joint disease;3.4.19.14 Keloid surgery except for functional impairment;3.4.19.15 Laparoscopic unilateral primary inguinal hernia repair on BonCap, BonEssential, BonSave, BonFit, Primary and Hospital

Standard;3.4.19.16 Obesity- surgical treatment or bariatric surgery;3.4.19.17 Otoplasties;3.4.19.18 Pectus excavatum/carinatum;3.4.19.19 Percutaneous valve replacement, including transcatheter aortic valve implantation and repairs on BonCap, BonEssential,

BonSave, BonFit, Primary and Hospital Standard;3.4.19.20 Refractive surgery, unless specifically provided for in Annexure B;3.4.19.21 Revision of scars except for functional impairment;3.4.19.22 Rhinoplasties for cosmetic purposes;3.4.19.23 Robotic surgery, other than for radical prostatectomy where authorized by the managed care organisation; additional

EXCLUSIONS


costs relating to the use of the robot during such pre-authorised surgery, and including additional fees pertaining to theatre time, disposables and equipment fees remain excluded. Excluded on BonCap;

3.4.19.24 Uvulo palatal pharyngoplasty (UPPP and LAUP).3.5 Items not mentioned in Annexure B

3.5.1 Appointments which a beneficiary fails to keep;3.5.2 Autopsies;3.5.3 Cryo-storage of foetal stem cells and sperm;3.5.4 Holidays for recuperative purposes;3.5.5 Nuclear or radio-active material or waste;3.5.6 Travelling expenses;3.5.7 Veterinary products;3.5.8 Delivery charges or fees.

EXCLUSIONS

SECTION D:BENEFITS AND PROGRAMMES

BENEFITS AND PROGRAMMES



Chronic medicine is used on an ongoing basis to treat chronic health conditions such as diabetes, hypertension and hypothyroidism. You will need to apply for authorisation for your chronic medicine with us.

A 40% co-payment applies if you choose to use medicine which is not listed on the applicable formulary or if you do not use a Designated Service Provider where required.

BENEFITS FOR CHRONIC MEDICINE

Plan Formulary Where to get your medicine Conditions covered Benefi t limits

BonComprehensive Comprehensive Any pharmacy 60 R1 3 1 7 0 per benefi ciary R26 240 per family

BonClassic RestrictiveAny network pharmacy if you have benefi ts available; thereafter, Pharmacy Direct

47 R1 0 790 per benefi ciary R22 320 per family

BonComplete Restrictive Pharmacy Direct 31 PMB cover + 4 additional conditions for children

BonSave Restrictive Pharmacy Direct 27 PMBs only PMB cover

BonFit Restrictive Pharmacy Direct 27 PMBs only PMB cover

Standard ComprehensiveAny network pharmacy if you have benefi ts available; thereafter, Pharmacy Direct

45 R 9 150 per benefi ciary R18 360 per family

Standard Select Comprehensive Pharmacy Direct 45 R 9 150 per benefi ciary R18 360 per family

Primary Restrictive Pharmacy Direct 27 PMBs only PMB cover

Hospital Plus Restrictive Pharmacy Direct 27 PMBs only PMB cover

Hospital Standard Restrictive Pharmacy Direct 27 PMBs only PMB cover

BonEssential Restrictive Pharmacy Direct 27 PMBs only PMB cover

BonCap BonCap Pharmacy Direct 27 PMBs only PMB cover

HOW TO APPLY FOR CHRONIC MEDICINEFollow these three easy steps:

Step 1:Get a prescription from your doctor

Step 2:Log in to www.bonitas.co.za and apply online orCall us on 0860 002 108 or email [email protected] orAsk your doctor or pharmacist to call us on 0861 100 220 and apply on your behalf

Step 3:Once your application has been assessed, you will receive a medicine access card listing the medicines to be paid from your chronic medicine benefi t.

WHAT HAPPENS IF MY APPLICATION IS DECLINED?If your application is declined, you may need to: • Send us a motivation from your GP• Send us additional test results• Consider using diff erent medicine

CHRONIC MEDICINE

HAVE THE FOLLOWING INFORMATION WHEN YOU APPLY: • Your membership number• The benefi ciary’s date of birth• The ICD-10 code for the condition• The doctor’s practice number• The name and dosage details of the medicine you

require

CHRONIC MEDICINE



HOW DO I UPDATE MY MEDICINE?When you apply for chronic medicine, you are approved for treatment of your chronic condition and not a specifi c medicine only. This means that when you need to change or add a new medicine for your condition, you can do this quickly and easily at your pharmacy or Pharmacy Direct with your new prescription without having to contact us.

All prescriptions are only valid for 6 months. Please make sure you send an updated prescription every 6 months to your pharmacy or Pharmacy Direct to ensure you continue to receive your medicine.

CONSIDER GENERICS TO MAKE YOUR BENEFITS STRETCH FURTHERA generic drug is a pharmaceutical equivalent to a brand-name product in dosage, strength, use, quality and performance. Generics are usually cheaper than originals but work just as well, helping you get more value for money as they attract no or minimal co-payments.

DETAILS FOR CHRONIC MEDICINECall: 0860 002 108Email: [email protected]: 0800 223 670

CHRONIC MEDICINE



Please note: You fi rst need to register for the chronic medicine benefi t before you can register with Pharmacy Direct.

Pharmacy Direct is the Designated Service Provider for chronic medicine. They will deliver your medicine to your home, work or to the nearest Post Offi ce, depending on your needs, at no extra cost. If your medicine is declined or if further information is required to assess your request, this will be communicated to you and your treating doctor.

HOW DO I REGISTER WITH PHARMACY DIRECT?Follow these three easy steps:

Step 1:Make sure you’ve applied for the chronic medicine benefi t and have your prescription available. Please make sure your prescription is valid.

Step 2:Visit www.pharmacydirect.co.za and download the application form or apply online. You can also call them on 0860 027 800 or email [email protected] to request the form.

Step 3:Complete the form and email it to [email protected] or fax it to 0866 114 000 or 0866 114 001. Please ensure you include your prescription with your application form. Your prescription must contain the following information:• Medical aid number• Dependant code• Number of repeats

Please note: An original prescription is required for schedule 5 and 6 medicine.

HOW SOON CAN I EXPECT DELIVERY OF MY MEDICINE?Medicine is automatically dispensed on a 28-day cycle. Pharmacy Direct uses an advanced scheduling and planning system to deliver medicine to patients on a monthly basis. If your medicine has been authorised, you should receive it based on the timelines below.

Case Dispatch time Note Delivery time

First time delivery of urgent/life-threatening medicine Within 24-48 hours* 24-72 hours after leaving Pharmacy

Direct, depending on your location24-72 hours, depending on location

First time delivery of other chronic medicine Within 3-5 working days 24-72 hours after leaving Pharmacy

Direct, depending on your location24-72 hours, depending on location

Delivery of medicine where a new, valid prescription has been received

Within 3-5 working days 24-72 hours after leaving Pharmacy Direct, depending on your location

24-72 hours, depending on location

*Please note: This is dependent on your medicine being approved and Pharmacy Direct being alerted.

MAKE SURE YOUR PRESCRIPTION IS UPDATEDBy law prescriptions are only valid for 6 months. It is essential that you update your prescription at least 30 days before it expires to continue to recieve your medicine. You can use the contact details below to update your prescription.

ENSURE YOU DON’T HAVE ANY OUTSTANDING MEDICINE CO-PAYMENTSIf you have any outstanding co-payments, your medicine will not be dispatched. Please contact Pharmacy Direct on the contact details below to resolve any such issues and ensure to continue to receive your medicine. Please use your membership number as the reference number when making any payments to Pharmacy Direct.

REGISTER WITH PHARMACY DIRECT

DETAILS FOR PHARMACY DIRECTWeb: www.pharmacydirect.co.zaCall: 0860 027 800 Email: [email protected]: 0866 1140 00/1/2

REGISTER WITH PHARMACY DIRECT



Your pharmacist can dispense over-the-counter medicine to you without a prescription from a doctor. Also known as Pharmacy Advised Therapy, this type of medicine is used to treat mild sore throats, colds, coughs and other minor ailments.

Claims for over-the-counter medicine are paid from your savings or day-to-day benefi ts. Please make sure that you have benefi ts available or your claim will be rejected.

Plan Benefi t limit

BonComprehensive Paid from available savings and/or above threshold benefi t

BonClassic Paid from available savings

BonComplete Paid from available savings and/or above threshold benefi t

BonSave Paid from available savings

BonFit Paid from available savings

StandardR 740 per benefi ciaryR2 240 per family Paid from available day-to-day benefi ts

Standard SelectR 740 per benefi ciaryR2 240 per family Paid from available day-to-day benefi ts

PrimaryR 465 per benefi ciary R1 360 per familyPaid from available day-to-day benefi ts

Hospital Plus No benefi t

Hospital Standard No benefi t

BonEssential No benefi t

BonCap Limited to R 90 per eventMaximum of R 250 per benefi ciary

ACUTE MEDICINEAcute medicine is medicine prescribed by a doctor that you require to treat a condition for a short period of time. For example, antibiotics to treat a stomach bug. This is covered as follows:

Plan Benefi t limit

BonComprehensive Paid from available savings and/or above threshold benefi t

BonClassic Paid from available savings

BonComplete Paid from available savings and/or above threshold benefi t

BonSave Paid from available savings

BonFit Paid from available savings

Standard Paid from available day-to-day benefi ts

Standard Select Paid from available day-to-day benefi ts

Primary Paid from available day-to-day benefi ts

Hospital Plus No benefi t

Hospital Standard No benefi t

BonEssential No benefi t

BonCap Joint limit with MRIs and CT scans and blood tests

OVER-THE-COUNTER AND ACUTE MEDICINE

OVER-THE-COUNTER AND ACUTE MEDICINE


MATERNITY BENEFITS


Our maternity benefi ts are designed to give your little one the best possible start. These benefi ts are paid from risk, so they will not aff ect your savings or day-to-day benefi ts. To get even more value, make sure you use a provider on our network.

THE FOLLOWING IS COVERED, PER PREGNANCY:

Benefi t BonComprehensiveBonClassic,Standard,

Standard Select

BonComplete,BonSave

Primary,BonFit

Hospital Plus,Hospital

Standard,BonEssential

BonCap

Private room ✓ No benefi t No benefi t No benefi t No benefi t No benefi t

Antenatal consultations 12 12 6 6 6 No benefi t

2D ultrasound scans 2 2 2 2 2 No benefi t

Postnatal consultations 4 4 4 4 4 No benefi t

Antenatal classes with a midwife R 1 160 R 1 160 R 1 160 No benefi t No benefi t No benefi t

Amniocentesis 1 1 1 1 1 No benefi t

Newborn hearing screening (In or out of hospital)

✓ ✓ ✓ ✓ ✓ ✓

Congenital hypothyroidism screening for children under 1 month old

✓ ✓ ✓ ✓ ✓ ✓

Baby bag ✓ ✓ ✓ ✓ ✓ ✓

YOU MUST PRE-AUTHORISE YOUR HOSPITAL STAYWe require a pre-authorisation number for your pregnancy. This can be done from 20 weeks onwards. Please call us on 0860 002 108 or email [email protected] to pre-authorise your hospital stay. You will need to provide us with the following information:• Membership number• Name and surname• Date of expected delivery• Type of delivery• Procedure and ICD-10 codes• Name and practice numbers of the hospital and your treating doctor/s

GET THE BONITAS BABY BAGWe give all pregnant members a beautiful mother and baby bag to congratulate you on the arrival of your bundle of joy. You will need to register to receive the baby bag after you have obtained a hospital admission authorisation number for your delivery. You can register between your 24th week of pregnancy and 6 weeks after the birth of your baby.

Ensure you have the following information on hand:• Membership number• Name and surname• Contact details• Delivery address• Alternative delivery address• Date of expected delivery

Then call us on 0860 002 108 or email [email protected]

Please note: In order to ensure that you receive the Bonitas baby bag, the courier company will be in contact with you to arrange a suitable date and time for delivery.

MATERNITY BENEFITS



We off er a range of benefi ts to help keep your children healthy. These include cover for visiting the paediatrician, taking your child to the doctor and telephonic advice.

SCREENING AND WELLNESSThese benefi ts are paid from risk so they will not impact your savings or day-to-day benefi ts.

Benefi t BonComprehensiveBonClassic,Standard,

Standard Select

BonComplete,BonSave

Primary,BonFit, BonCap

Hospital Plus,Hospital

Standard,BonEssential

Childhood immunisations ✓ No benefi t

Newborn hearing screening (In or out of hospital)

✓ ✓ ✓ ✓ ✓

Congenital hypothyroidism screening for children under 1 month old

✓ ✓ ✓ ✓ ✓

1 fl u vaccine per child ✓ ✓ ✓ ✓ ✓

BABYLINEParents are often confronted with a variety of children’s health issues - particularly in the fi rst 3 years. To educate and support Bonitas moms and dads and to ensure their benefi ts last longer, we’ve partnered with Paed-IQ’s Babyline service - the fi rst dedicated children’s health advice line in South Africa.

The benefi t is available on all Bonitas plans, for children under 3 years. Babyline is a 24-hour children’s health advice line. This means that parents can contact Babyline 24 hours a day, 7 days a week, 365 days a year. Any parental concerns or any health enquiry will be answered by paediatric trained nurses under specialist supervision. Developed in conjunction with the Department of Paediatrics at the University of Pretoria, and used by the top providers of child health advice in the USA, this system of telephone advice guarantees members access to the best in professional advice and standardised paediatric protocols. Babyline strives to give parents access to the best possible resources to improve the health of every child. This is a service that strives to give parents peace of mind and potentially save unnecessary trips to the ER as well as provide anxious parents with urgent healthcare advice to keep their children safe and happy.

Parents or caregivers can simply call 0860 999 121 and they will be put through to a paediatric trained registered nurse. The nurse will ask a series of questions depending on the concern raised by the parent/caregiver. Please have your Bonitas membership number on hand. Thereafter, the parent/caregiver will be given professional advice on what to do next and whether the symptoms are urgent enough to visit the ER or maybe their doctor or specialist. If necessary, the nurse will advise who is the most appropriate healthcare provider to see the child.

The following services are available:• Home care advice • Clinic/Primary Care/GP referral for the same day • Clinic/Primary Care/GP referral for the next day • After-hours care within the next 6 hours • Immediate referral to ER

Please note: Babyline is a general paediatric health advice service and does not provide a diagnosis or prescription. If you feel your child requires urgent medical attention, please take your child to the nearest healthcare facility. Make sure you have your Bonitas membership number available when you call.

CHILDCARE BENEFITSCHILDCARE BENEFITS



INFANT PAEDIATRIC BENEFITAvailable for children under the age of 2, the infant paediatric benefi t covers consultations with a paediatrician. The benefi t is paid from risk so it will not aff ect your savings or day-to-day benefi ts.

Benefi t BonComprehensiveStandard,Standard

Select

BonComplete,BonSave, BonFit,

Hospital Plus,Hospital Standard

Primary BonClassic, BonEssential, BonCap

Consultations for children under 1 year

3 2 2 1 No benefi t

Consultations for children between 1 and 2 years

2 2 1 1 No benefi t

CHILDHOOD ILLNESS BENEFITThe childhood illness benefi t is available for benefi ciaries aged between 2 and 12. It covers consultations with a GP and is paid from risk so it will not impact your savings or day-to-day benefi ts.

Benefi t BonComprehensive, Standard,Standard Select

BonComplete, BonSave, BonFit,Primary, Hospital Plus,

Hospital Standard, BonEssentialBonClassic, BonCap

GP consultations per child between ages 2 and 12

2 1 No benefi t

CHILDCARE BENEFITS



Our optical benefi ts are designed to off er our members cost-eff ective, quality eye care. Our contracted service provider for optical benefi ts is Iso Leso. However, optical benefi ts for BonComplete are managed by PPN.

YOUR OPTICAL BENEFITS DEPEND ON THE PLAN YOU HAVE CHOSENThe table below shows a breakdown of optical benefi ts per plan. Optical benefi ts work on a two-year cycle, which means you can only access your benefi t once every two years. There must be at least 24 months between each optical claim per benefi ciary. Remember, each benefi ciary can either have glasses or contact lenses, not both. Services not covered by the matrix should be paid directly to the practice, or can be refunded from available savings. All tariff s below are inclusive of VAT.

Benefi t BonComprehensive BonClassicStandard, Standard

SelectBonComplete Primary BonSave,

BonFit BonCap

Provider Iso Leso PPN Iso Leso

Limit

Paid from available savings and/or above threshold benefi t R2 880 per benefi ciary

R5 300 per family

R5 550 per family

Paid from available savings

R4 270 per family

Paid from available savings

Subject to managed care protocolsand preferred provider

Cycle (based on the date of your previous claim)

Paid from available savings and/or above threshold benefi t

Once every 24 months




*Eye test(sublimit)

One per benefi ciary at a network provider

or

R 350 per benefi ciary at a non-network provider


or



or



or


*Single vision lenses(glass/plastic) or

R 150 per benefi ciary


R 2 1 5 per benefi ciary


*Bifocal lenses (glass/plastic) or





*Multifocal lenses(glass/plastic)





*Frames R 740 per benefi ciary



R 350 perbenefi ciary

*Contact lenses

R1 790 per benefi ciary




Please note: There are no optical benefi ts for Hospital Plus, Hospital Standard and BonEssential.* Sublimits applied - included in overall limit.

DO I HAVE TO USE THE CONTRACTED SERVICE PROVIDER?Iso Leso is our Contracted Service Provider for optometry for BonClassic, Standard, Standard Select and Primary.PPN is the Contracted Service Provider for optometry for BonComplete.

They will charge you a negotiated rate on prescription lenses and consultation to ensure your benefi ts stretch as far as possible while ensuring you receive high quality, professional service.

OPTICAL BENEFITSOPTICAL BENEFITS



WHAT HAPPENS IF I USE ANOTHER OPTOMETRIST?You can visit a non-contracted provider if you choose, but you will have to pay cash and submit your claim to [email protected]. Members on the BonComplete option will have to submit their claims to [email protected].

Remember, we have not negotiated rates with these practitioners, so they may be more expensive and include co-payments. Your available savings can be used to cover the shortfall for optical benefi ts, if applicable.

Please note: Claims older than 4 months from the date of service will not be accepted for payment.

HOW DO I FIND AN OPTOMETRIST ON THE NETWORK? To fi nd an Iso Leso provider call 011 340 9200 or email [email protected]. If you are on BonComplete, call 086 1103 529 or visit www.ppn.co.za to fi nd an optometrist on the network.

WHY WOULD MY CLAIM BE DENIED?Payment will be declined under the following circumstances: • Where no script is indicated• Where no ICD-10 codes are indicated• Where the script is less than 0.50 D sphere or 0.50 D cylinder (with no sphere) in both eyes in the case of spectacles• Invoices that do not comply with VAT legislation requirements• Where the claim is older than 4 months from the date of service

IMPORTANT INFORMATION TO NOTEIso Leso practices are not entitled to collect the unpaid portion for the above products from the patient unless they are: • Lens enhancements and add-ons (such as tints or ARC)• The diff erence on the frame value over the specifi c plan maximum benefi t• The diff erence on the contact lens value over the specifi c plan maximum

benefi t

Spectacle lens prescriptions must be included in both paper and electronic claims. Please contact your service provider for assistance in this regard.

PPN providers are not entitled to charge BonComplete members more than the negotiated rate and can only collect patient portions where you elected a frame or any lens enhancements higher than the optical limit specifi ed.

DETAILS FOR ISO LESOCall: 011 340 9200Fax: 011 782 5601Email: [email protected]: www.isoleso.co.za

DETAILS FOR PPNCall: 0861 103 529Email: [email protected]: www.ppn.co.za

DIABETICS TAKE NOTEThe status of your blood glucose can aff ect the outcome of your consultation. Please ensure that your blood glucose level is stable as per your doctor’s guidelines before booking an eye examination.

OPTICAL BENEFITS



Our dental benefi ts are managed by DENIS, the largest network of dental professionals in South Africa. All dental procedures have pre-defi ned benefi ts, which are paid at the Bonitas Dental Tariff . All dental benefi ts are subject to managed care protocols and interventions, which may include the requirement of treatment plans and/or x-rays prior to benefi t application.

HOW DO I FIND A DENTIST ON THE NETWORK?The DENIS network has several dentists located nationwide. To fi nd a dentist on the network near you, go to www.denis.co.za and use the Find a Dentist tool.

HOW DO I SUBMIT CLAIMS TO DENIS?Follow these three easy steps:

Step 1:Ensure the following details are clearly visible on your claim:• Your membership number• The dentist’s details and practice registration number• The correct dependant name and code (see your membership card)• The treatment date• The relevant procedure codes• The tooth numbers (if applicable)• The relevant ICD-10 codes

Step 2:Email your claim to [email protected] orPost the original copies of your dental claims to Private Bag X 1, Century City, 7446, Cape Town

WHICH DENTAL BENEFITS DO I NEED PRE-AUTHORISATION FOR?• Crown and bridge procedures• Orthodontics• Implants• Hospitalisation • Intravenous / Conscious sedation• Periodontics• Plastic denture and partial metal frame dentures

Please note: If you do not get pre-authorisation for these procedures and treatments, we will not pay for it.

HOW DO I GET PRE-AUTHORISATION FOR THESE DENTAL PROCEDURES?We require the following information for pre-authorisation:• Hospital practice number• Anaesthetist practice number• Treating clinician• Hospital admission date• Procedure code(s) with ICD-10 code(s) and where relevant the applicable tooth numbers• Main reason as to why the procedure is needed• Medical report of special medical conditions (if applicable)

To get pre-authorisation for dental procedures in hospital or under intravenous (IV) / conscious sedation, please call 0860 336 346 or fax the required information to 0866 770 336.

To get pre-authorisation for crowns and bridges, orthodontics or implants, you will need to email the required information to the relevant email address:• Crown and bridge procedures [email protected]• Orthodontics [email protected]• Implants [email protected]• Plastic dentures / Partial metal frame dentures [email protected] or 0860 336 346

Please note: X-rays may be needed for the removal of impacted teeth.

DENTAL BENEFITS

REMEMBER:Please remember to obtain pre-authorisation for plastic dentures and partial metal frame dentures by calling the DENIS call centre on 0860 336 346 or email [email protected]

DENTAL BENEFITS



WHERE CAN I GET MORE INFORMATION ON MY BENEFITS FOR SPECIALISED DENTAL PROCEDURES?DENIS supplies all dentists with a guide that illustrates the dental benefi t management methodology and the amount charged for that procedure. Where the amount your dentist charges and the amount we will pay for a specifi c procedure diff er, you have the right to negotiate this diff erence with your dentist. You can also visit www.denis.co.za to learn more.

WILL I HAVE ANY CO-PAYMENTS?A co-payment of R3 000 is applicable on all hospital admissions for dentistry on BonClassic, BonComplete, Standard, Standard Select, BonSave, BonFit, Primary, Hospital Plus and Hospital Standard. This does not apply to emergency hospital admissions. There are also co-payments for orthodontics on Standard, Standard Select and BonComplete.

If you apply for authorisation for crown and bridge procedures after the treatment has been done, you will have to pay a 20% co-payment.

Please note: Failure to pre-authorise orthodontic treatment will result in payment only from the date of authorisation for the remaining months of treatment, provided that the treatment is clinically indicated.

WHAT OTHER DENTAL BENEFITS DO I HAVE ACCESS TO?As a Bonitas member, you are automatically a member of the Dental Wellness Programme. You will receive various treatment-related information leafl ets and oral screenings, advice and dental products will be provided at your company’s wellness days.

Visit www.denis.co.za for more information.

DETAILS FOR DENIS Call: 0860 336 346Fax: 0866 770 336Email: [email protected] claims: [email protected] hospital authorisations: [email protected] orthodontic and implant authorisations: [email protected] crown and bridge authorisations: [email protected] periodontal authorisations: [email protected]

DENTAL BENEFITS


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RADIOLOGY BENEFITSX-rays and ultrasounds MRI and CT scans

(Pre-authorisation required)

In-hospital Out-of-hospital In-hospital Out-of-hospital

BonComprehensive Unlimited Savings and/or above threshold Unlimited R29 840

BonClassic UnlimitedR2 960 per beneficiaryR4 590 per family

R27 610

BonComplete Unlimited Savings and/or above threshold R22 220

BonSave Unlimited Savings R22 220

BonFit Unlimited Savings R15 000

Standard Unlimited Day-to-day benefits R24 860

Standard Select Unlimited Day-to-day benefits R24 860

Primary Unlimited Day-to-day benefits R12 380

Hospital Plus Unlimited No benefit R27 610

Hospital Standard Unlimited No benefit R24 860

BonEssential Unlimited No benefit R15 000 No benefit

BonCap Unlimited Joint limit with acute medicine and blood tests R11 060 No benefit

RADIOLOGY BENEFITS

Please note: Benefits for MRI and CT scans are per family.



This programme gives you access to a team of professionals that off ers the medical, emotional and fi nancial support you need.

WHAT DOES THE PROGRAMME OFFER?One of your fi rst concerns after a cancer diagnosis will be the fi nancial implications of treating your illness. The programme off ers members diagnosed with cancer emotional support and manages your oncology benefi ts on your behalf by liaising with your doctor on your treatment plan and, where possible, matching it to your available benefi ts.

THE PROGRAMME COVERS:• Unlimited terminal care benefi t (subject to pre-authorisation)• Pathology• MRI, radioisotope, CAT and PET scans (the latter to be motivated and

approved) and pre-authorised separately to allow payment from the cancer benefi t

• Radiotherapy• Chemotherapy and drugs associated with chemotherapy

(e.g. antinausea medication)• Approved related medicine• General radiology and pathology• Oncologist post-active consultations only• Consultations with a social worker• Mammograms• Medicine for terminal illness• Approved nutritional supplements• Pain management• Home oxygen (subject to pre-authorisation)

HOW DO I REGISTER ON THE PROGRAMME?Step 1To register on the programme, simply call on 0860 100 572 or email us at [email protected] Please ensure you have the following information available:• Your membership number• The benefi ciary’s details• Your doctor’s details, including practice number

Step 2Once you and your team of doctors agree on a treatment plan, ask your doctor to forward your treatment plan to us, as oncology treatment is subject to pre-authorisation and case management.

Step 3Once we receive your treatment plan, an oncology case manager will be assigned to you to handle your case.

WHAT HAPPENS NEXT?The Oncology Disease Management team will review and capture your details, disease information and proposed treatment plan. If necessary, a member of the clinical team will contact your doctor to discuss more appropriate or cost-eff ective treatment alternatives.

After the treatment plan has been assessed and approved, authorisation will be sent to your treating doctor. You will also be sent an authorisation letter. The letters will indicate the treatment authorised, the approved quantities and the validity period of your authorisation.

HOW DO I GET AUTHORISATION FOR RELATED TREATMENT, SUCH AS SURGERY?Surgery or related procedures are covered from hospital benefi ts and not the oncology benefi t, so you will need to get pre-authorisation.

To get pre-authorisation, call us on 0860 002 108 or email us at [email protected].

CANCER PROGRAMME

GET ACCESS TO THE BEST CAREWe’ve partnered with The Independent Clinical Oncology Network (ICON) to give you access to quality care. ICON represents 80% of the private practising oncologists in South Africa. The partnership with Bonitas focuses on the enhancement of every aspect of quality of care including patient centredness, clinical outcomes and aff ordability of care for all plans, excluding BonComprehensive.

REMEMBERPlease make sure that your doctor advises the Oncology Disease Management team of any change in your treatment, as your authorisation will need to be reassessed and updated.

CANCER PROGRAMME



PLEASE INCLUDE THE FOLLOWING INFORMATION IN YOUR EMAIL, OR HAVE IT ON HAND WHEN YOU CALL US:• Membership number• Benefi ciary name and date of birth • Date of admission and proposed date of the operation• Name of the doctor, his/her telephone number and practice number• Name of the hospital, their telephone number and practice number• All the relevant procedure and associated medical diagnosis codes (your doctor can assist you with this)

HOW DO I GET SERVICES SUCH AS HOSPICE OR HOME NURSING?If you need services such as hospice or home nursing, you need to contact the hospital pre-authorisation team (call 0860 002 108 or email [email protected]). You can also contact the above number if you have complications like dehydration, excessive vomiting, or need to be hospitalised for pain control. Failure to do so may result in your claims being rejected or paid from the incorrect benefi t (e.g. savings or other day-to-day benefi ts) as there will not be a matching oncology authorisation.

CANCER BENEFITSOption Benefi t per

familyTerminal care benefi t

Alternatives to hospital per family (sub-acute facilities, hospice, private nursing)

Social worker benefi t per family

*BonComprehensive R589 000

Unlimited subject to pre-authorisation

R15 760 N/A

BonClassic R390 900 R15 760 R2 700

BonComplete R328 100 R15 760 R2 700

BonSave R328 100 R15 760 R2 700

BonFit R328 100 R15 760 R2 700

Standard R328 100 R15 760 R2 700

Standard Select R328 100 R15 760 R2 700

Primary R157 600 R15 760 R2 700

*Hospital Plus R589 000 R15 760 R2 700

Hospital Standard R328 100 R15 760 R2 700

BonEssential R328 100 R15 760 R2 700

BonCap PMB cover only

*BonComprehensive and Hospital Plus off er additional benefi ts for biological drugs.

DETAILS FOR CANCER MANAGEMENTCall: 0860 100 572Email: [email protected]

CANCER PROGRAMME



Our HIV/AIDS programme helps individuals with HIV/AIDS live longer, more productive lives. Run by Aid for AIDS, South Africa’s leader in HIV/AIDS management and care, the programme takes a revolutionary, integrated approach to HIV/AIDS management.

WHAT DOES THE HIV/AIDS PROGRAMME OFFER?Our programme is designed to meet the needs of patients and equip them with the treatment and tools to lead normal, fulfi lled lives. It acts as a care-coordinator between Bonitas, doctors, pathology labs, pharmacies and patients. Supported by a team of respected clinicians in their fi eld and backed by a custom IT system that has become the gold standard in HIV/AIDS disease management, the programme enables the optimal care of patients with an end-to-end solution. Shaped over years of clinical research and expertise, our methods are considered as the industry standard by healthcare professionals globally.

WHAT DOES THE PROGRAMME COVER?The programme off ers the following services to members:• Medicine to treat HIV (including drugs to prevent mother-to-child transmission and infection after sexual assault or needlestick injury) • Treatment to prevent opportunistic infections such as pneumonia, TB and fl u• Regular pathology tests to monitor disease progression and response to therapy• Regular pathology tests to detect possible side-eff ects of treatment• HIV-related consultations to visit your doctor to monitor your clinical status• Ongoing patient support via a team of trained and experienced counsellors• Clinical guidelines and telephonic support for doctors• Help in fi nding a registered counsellor for face-to-face emotional support

Over and above the payment of the necessary medicine and pathology claims, the programme provides benefi ciaries with much needed support and advice on how to manage the condition. This entails both clinical and emotional support. They are routinely called by counsellors to check how they are doing, receive reminders when they are due for bloods tests and so on.

Remember, cover for HIV/AIDS is unlimited if you register on the programme and follow the managed care guidelines and protocols.

HOW DO I REGISTER WITH AID FOR AIDS?If you are HIV-positive, you must register with Aid for AIDS as soon as possible in order to make use of this benefi t.

Step 1:Know your status. If you are worried that you might be infected with HIV, ask your doctor or clinic to test you. Remember, all members are entitled to one free HIV test a year at a participating clinic or Bonitas wellness day.

Step 2:If the results show that you are HIV-positive, call 0860 100 646 and request an application form to join the HIV/AIDS programme.

Step 3:Complete the form with your doctor and fax it to 0800 600 773 or email it to [email protected].

WHAT HAPPENS AFTER I HAVE REGISTERED?Our highly qualifi ed medical team will check the details on your form. If necessary, we will review medical details and discuss the most medically appropriate and cost-eff ective treatment with your doctor. Once treatment has been agreed upon, you and your doctor will be sent a detailed treatment plan, which explains the approved medicine, as well as the regular tests that need to be done to ensure that the medicine is working correctly and safely.

You will need to visit your doctor for regular examinations and tests. Your doctor will contact Aid for AIDS to keep us informed about your condition. This will be outlined in your treatment plan. You will also receive reminders from us, advising you of when to visit the doctor for a check-up and when to have blood tests done.

WHAT IF MY TREATMENT PLAN CHANGES?We work closely with your doctor to review your medicine and test results regularly. If we notice that your condition is not improving, your treatment plan may be amended. We will automatically update this to ensure you always have access to your benefi ts and the best possible treatment.

HIV/AIDS PROGRAMME

REMEMBERPharmacy Direct is the designated service provider for medicine on the HIV/AIDS programme. You must register with Pharmacy Direct to obtain your medicine to avoid co-payments.

HIV/AIDS PROGRAMME



WILL I RECEIVE COUNSELLING AND SUPPORT SERVICES?Our treatment support staff give patients one-on-one attention to make sure you understand how to take your medicine and the importance of sticking to your treatment plan. We also off er a dedicated telephone line, to off er support and advice to help you live a long, healthy life. Counselling is also off ered to provide emotional and psychological support. You will be routinely called by counsellors to check how you are doing and will receive reminders when you are due for bloods tests and so on.

WILL MY STATUS BE KEPT CONFIDENTIAL?Absolutely! Every eff ort is made to keep members’ HIV status confi dential. The staff members at our Aid for AIDS unit have all signed confi dentiality agreements and work in a dedicated unit. They use separate telephone, fax, email and private mailbag facilities to ensure patients’ details are kept confi dential.

DETAILS FOR AID FOR AIDSCall: 0860 100 646Fax: 0800 600 773Email: [email protected]: www.aidforaids.co.zaMobi-site: www.aidforaids.mobiPlease call me: 083 410 9078

HIV/AIDS PROGRAMME



This programme is based on the principles of patient-centred care and embraces a personalised approach. It takes all your other medical needs into account, including any other chronic conditions you may have. In addition, we will continue to work with your doctor who looks after your chronic conditions in order to provide co-ordinated quality care.

WHAT DOES THE PROGRAMME OFFER?• Continued access to your treating doctor, your authorised chronic medicine and all required blood and laboratory tests• Access to a Health Coach who will provide you with guidance and support on managing all your chronic diseases as well as diabetes• Online tools to help you make informed choices such as the Bonitas Health Portal and Personal Health Record• Material to educate you on diabetes and empower you to manage it• Access to our extensive family practitioner, specialist and nursing network

We will share information with your doctor so that he/she is equipped to manage your condition more eff ectively. We can also arrange for a nurse to visit you and provide one-on-one support to ensure you manage your diabetes eff ectively.

WHO CAN JOIN THE PROGRAMME?All Bonitas members with diabetes will have automatic access to the programme and its benefi ts once they have registered their chronic benefi ts (except for BonCap members).

WILL THIS AFFECT THE BENEFITS I HAVE CURRENTLY AVAILABLE FOR MY DIABETES MANAGEMENT?You can continue to see your treating doctor and will have access to cover for GP consultations, blood and other laboratory tests, dietician and podiatrist services, an ophthalmologist consultation and a visit with a nurse educator. You will receive more detailed communication based on your specifi c Care Plan.

WILL MY CHRONIC MEDICATION BE COVERED?Your chronic medicine authorisations will remain unchanged. No new quantity limits, medicine formularies or medicine exclusions will be applied from 1 May 2017.

This includes no changes to the consumables you use (such as strips and needles). Queries and updates relating to these authorisations can be sent to [email protected]. You can also call us on 0860 002 108.

WILL MY DIABETES DOCTOR BE ON THE NETWORK?We encourage you to remain with your current doctor if you are happy with the care you receive. If your doctor is already part of the Bonitas network, this will ensure you do not have to pay any co-payments.

The majority of diabetes doctors are already contracted to the Bonitas network, which means that you should not have any co-payments. The Bonitas networks are open to any Family Practitioner or specialist who wishes to participate. You can fi nd out if your doctor is already on the Bonitas network by contacting the call centre on 0860 002 108, logging in on the Bonitas website and using the “Find a Doctor” tool or by SMSing “Find” to 43899. Alternatively you can ask your doctor directly.

DO I STILL GET MY CHRONIC MEDICINES FROM MY NORMAL SUPPLIER?Pharmacy Direct is a courier pharmacy and is the preferred provider for chronic medication. Pharmacy Direct will also provide a free glucometer to qualifying patients that have registered with them.

DIABETES MANAGEMENT PROGRAMME

REMEMBER:We request that all members nominate the doctor that they want to continue looking after their chronic conditions and grant us informed consent so that wecan monitor the treatment and management of your diabetes (and other chronic conditions) and share information with your doctor.





IS THERE ANY ADDITIONAL SUPPORT OR INFORMATION AVAILABLE THAT I CAN ACCESS?You can access YourHealth Portal on the Bonitas Member Zone to look up medical information on your condition. It is an interactive and informative tool where you can complete questionnaires, read articles and enrol on helpful tutorials about your chronic condition.

HOW CAN I SUBMIT MY CLAIMS?If your doctor is not on the network and asks you to pay cash up front, you can submit your claims directly to us (email to [email protected], post to Bonitas Claims Department, PO Box 74, Vereeniging, 1930 or submit your claim at one of our walk-in centres). We will refund you directly, up to the Scheme Rate.

DETAILS FOR DIABETES PROGRAMMECall: 0860 002 108Email: [email protected]



The back and neck programme helps members living with chronic back and neck pain treat the cause of their pain and improve their quality of life. Run by Documentation Based Care (DBC) and Workability (in Port Elizabeth and Bloemfontein only), the programme incorporates the best protocols to improve functional ability and work capability - successfully and eff ectively - with minimum pain.

WHAT DOES THE BACK AND NECK PROGRAMME COVER?The programme takes a comprehensive and holistic approach to chronic pain and off ers individualised treatment to patients. After an initial assessment, benefi ciaries receive treatment twice a week for up to 6 weeks. We cover the full cost of the programme.

This multidisciplinary programme includes treatment from doctors, physiotherapists and biokineticists to treat severe neck and back pain. The treatment consists of active exercise with appropriate weights and motion. After the initial treatment, you receive a home-based programme to maintain results long-term.

Please note: The programme does not cover the costs of x-rays, scans and prescribed medicines

HOW DOES THE PROGRAMME WORK?Step 1:You will be assessed by a biokineticist and a doctor. This includes a physical examination and tests to check range of movement, nerve health and more.

Step 2:The doctor will take your medical history and explain the possible cause of the chronic pain and the DBC protocol to you.

Step 3:A treatment plan will be put together for you. A patient contract is then signed committing you to 6 weeks of treatment, twice a week.Sessions are an hour long (30 minutes with a biokineticist and 30 minutes with a physiotherapist).

Step 4:After the initial 6 sessions, the doctor will re-examine you to determine progress and to discuss your improvement. The protocol is repeated 6 sessions over 3 weeks – each an hour – 30 minutes with the physiotherapist and 30 minutes with the biokineticist. If all is well, you are discharged with a home exercise programme. You will also be able to attend maintenance sessions with the biokineticist on a regular basis to support you after your recovery.

WHO CAN ACCESS THIS BENEFIT?This benefi t is available to members identifi ed by the Active Disease Risk Management Team and providers may contact us to register eligible benefi ciaries. Identifi ed or eligible members are then referred to the programme. Members may also contact DBC directly. This benefi t is not available to members on BonCap.

WHAT HAPPENS IF I DO NOT USE DBC BEFORE SPINAL SURGERY?If you are on BonClassic, Standard, Standard Select or BonComplete and you choose to go for spinal surgery without fi rst visting DBC, you will have to pay a R5 650 co-payment.

If you are on the Hospital Plus option and you choose to go for spinal surgery without fi rst visiting the DBC or Workability (in Port Elizabeth and Bloemfontein only), you will have to pay a R6 900 co-payment.

BACK AND NECK PROGRAMME

DETAILS FOR BACK AND NECKCall: 0860 105 104

BACK AND NECK PROGRAMME



The hip and knee programme manages hip and knee replacements. Our partners for the programme are Improved Clinical Pathway Services (ICPS) and JointCare. ICPS and JointCare are groups of orthopaedic surgeons that specialise in performing hip and knee replacements according to standardised clinical care pathways. These care pathways have been developed in accordance with evidence-based outcomes to ensure that the quality of the hip and/or knee replacement is of highest standard and to ensure the best health outcomes.

WHAT DOES THE PROGRAMME OFFER?The programme helps you to take an active part in planning for your recovery for hip or knee surgery as well as ensuring peace of mind by off ering a cost-eff ective and high-quality replacement. It uses a multidisciplinary team dedicated to assist with rapid and successful recovery, keeping patients as comfortable as possible during the healing period.

WHAT DOES THE PROGRAMME COVER?The programme has been established to assist you in taking an active part in planning your care and recovery for hip or knee surgery as well as ensuring fi nancial peace of mind. It is available to members on BonClassic, Standard, Standard Select, BonComplete and Hospital Plus.

The fi rst step of the programme is a consultation with an orthopaedic surgeon on the network. If the decision for surgery is made after the consultation, then ICPS or JointCare will apply for pre-authorisation on your behalf. This will allow you access to the hip and knee programme and ensure payment in full (subject to your prosthesis benefi t) with no co-payment for the procedure. The ICPS or JointCare surgeon will give you a booklet providing you with information on the programme.

ICPS and JointCare will manage your procedure and all the related claims submission on your behalf including:• All hospital costs • Surgeons and anaesthetist fees • Prosthesis (subject to the prosthesis benefi t) • Physiotherapist costs (pre, intra and post-operative)

HOW DO I FIND AN ORTHOPAEDIC SURGEON ON THE ICPS NETWORK?Call 0861 112 666 and you will be given the details of an ICPS or JointCare orthopaedic surgeon closest to you.

WHAT HAPPENS IF I DO NOT USE A SURGEON ON THE ICPS NETWORK?If you choose not to use an ICPS or JointCare orthopaedic surgeon and you are admitted for hip or knee surgery you will have to pay a R5 650 co-payment on admission to hospital. This applies to BonClassic, Standard and BonComplete. If you are on the Standard Select option you are only allowed to use the ICPS and JointCare network.

On Hospital Plus, the R6 900 co-payment will not apply when a hip or knee replacement is performed by a provider contracted to ICPS or JointCare.

DO ICPS AND JOINTCARE PROVIDE THE BEST SERVICE?ICPS and JointCare work according to standardised clinical care pathways. These care pathways have been developed in accordance with evidence-based outcomes to make sure that the quality of the replacement is of the highest standard and to make sure that you have the best health outcomes.

HIP AND KNEE PROGRAMME

DETAILS FOR ICPS AND JOINTCARECall: 0861 112 666Website: www.icpservices.co.za

PLEASE NOTE:Your doctor must request authorisation for your hip or knee replacement.

HIP AND KNEE PROGRAMME


WELLNESS SCREENINGWe offer a free wellness screening for each member, once a year, on all our plans. The wellness screening is made up of carefully selected tests to help you get a clear picture of your health. These tests are the first step in detecting serious chronic conditions such as hypertension, heart disease and diabetes.

The wellness screening includes:• A blood pressure test• A blood glucose test• A cholesterol test• A BMI test and• A waist-to-hip ratio measurement

Where can I do a wellness screening?You can complete your wellness screening at a Bonitas wellness day or a Dis-Chem, Clicks or Pick ’n Pay pharmacy. All tests must be done at the same time.

WELLNESS EXTENDERThe Wellness Extender can be used to pay for extra consultations with a GP, biokineticist, dietician or physiotherapist or a programme to stop smoking.

Plan Wellness Extender benefit per family, per year

BonComprehensive R2 420BonClassic R1 670BonComplete R1 670BonSave R1 2 10BonFit R1 2 10Standard R1 670Standard Select R1 670Primary R1 2 10Hospital Plus R1 670Hospital Standard R1 2 10BonEssential R 860BonCap No benefit

How do I activate the Wellness Extender?Once a main member or adult dependant has completed the wellness screening, that member and any child dependants can then access the Wellness Extender. The Wellness Extender will be automatically activated once the wellness screening has been completed.

Please note: All claims for the Wellness Extender are paid at the Bonitas Rate. Adult dependants must complete the wellness screening to access the Wellness Extender.

WELLNESS BENEFITSW

ELLNESS BENEFITS


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The International Travel Benefi t off ers Bonitas members cover for medical emergencies when they travel outside the borders of South Africa. Cover is provided for up to 90 days per trip and is limited to R5 million per person. The benefi t is managed by ER24 and is underwritten by Bryte Insurance Company Limited, an authorised fi nancial services provider. Limits, terms and conditions apply. These are outlined in the policy wording and documents that can be found on www.brytesa.com.

WHOM DOES THIS BENEFIT COVER?We pay claims for emergency medical and related expenses, to the medical services provider, while the dependant(s) are on an insured journey. This applies to all options except BonCap.

Please note: Benefi ciaries must be over 3 months of age.

WHAT DOES THIS BENEFIT COVER?We pay claims for emergency medical and related expenses while on an insured journey to the provider of the medical expenses.

Cover is:

• Provided for up to 90 days per trip, irrespective of the number of trips made during the year• Limited to R5 million per person up to a maximum of R10 million per family• Subject to certain exclusions (such as pre-existing conditions which is limited to R100 000 and certain sports activities)

This benefit includes cover for the following:

• Emergency medical expenses• Medical evacuation and transport• Hospitalisation• Out-patient and in-patient treatment• Optical and dental expenses• Mandatory vaccine expenses• Travel assist services

Limits, terms and conditions apply. These are outlined in the policy wording and documents.

HOW DO I GET ACCESS TO THIS BENEFIT?Call 0860 329 329 or 010 205 3100 or email [email protected] to activate your international travel cover when you are planning to travel out of the country. Please note that the turnaround time for receipt of policy documents is 24 business hours. Read the policy documents carefully to ensure that you understand all the terms and conditions.

HOW DO I GET EMERGENCY ASSISTANCE WHILE I’M TRAVELLING?Bryte Travel Assist has been appointed to provide emergency assistance. Emergency medical services are available 24 hours a day, 7 days a week. Call +1 416 642 2910 as soon as possible if you need assistance. Reverse call charges are also accepted.

INTERNATIONAL TRAVEL BENEFIT

DETAILS FOR INTERNATIONAL TRAVELCall: 0860 329 329Email: [email protected]: www.brytesa.com

INTERNATIONAL TRAVEL BENEFIT



ER24 is the designated service provider for all emergency medical services for Bonitas members and their registered dependants.

WHAT DOES THIS BENEFIT COVER?This benefit includes:

• Emergency medical response by road or air to the scene of the medical emergency• Transfer to the closest appropriate medical facility by road or air• Instructions on how to manage the emergency while waiting for the ambulance (e.g. start CPR)• Inter-hospital transfers (subject to authorisation) in accordance with Scheme Rules• Medical information and assistance hotline• Trauma counselling and referral to appropriate healthcare professionals as required• Member/dependant validation• Medical information and assistance hotline where trained personnel provide trauma counselling, medical emergency advice and HIV

counselling

WHAT DO I NEED TO DO IN THE CASE OF A MEDICAL EMERGENCY?Step 1Call 084 124. Provide your name, telephone number and medical aid number.

Step 2Give a brief description of the incident and the severity thereof. Provide the address/location (road name, number and nearest crossroad) of the scene of the incident. Stay on the phone and ensure that ER24 has all the details of the incident.

WHAT HAPPENS IF I DO NOT USE ER24 IN AN EMERGENCY?If you use another service provider, a 40% co-payment will apply. Ensure that ER24 is informed that you have used another service provider as well as the reason for this. The account must be submitted to [email protected] no later than 30 days after the date of service.

EMERGENCY MEDICALSERVICES

DETAILS FOR ER24Call: 084 124Email: [email protected]: www.er24.co.za

DISPLAY YOUR ER24 STICKERS PROUDLYWhen you join Bonitas, you will receive specially designed ER24 car stickers.

Please ensure that these are attached to your vehicle as described in the letter sent with the stickers.

EMERGENCY MEDICAL SERVICES

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 Schemes.

Please note: Product rules, limits, terms and conditions apply. Where there is a discrepancy between the content provided in this brochure, the website and the Scheme Rules, the Scheme Rules will prevail. The Scheme Rules are available on request. Benefits are subject to approval from the Council for Medical Schemes PRE-CMS01-V6-06SEP2017.

Bonitas Medical Fund

@BonitasMedical

0860 002 108

www.bonitas.co.za

Report fraud on the Whistleblower Hotline0800 112 811

2018 bonitas broker_cover.indd - your health and actuarial ... one pagers/2018 bonitas broker...

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