wooltru healthcare fund your …wooltruhealthcare.co.za/2015 campaign/wooltru healthcare 2015... ·...

YOUR CONTRIBUTIONS AND BENEFITS FOR 2015

WOOLWORTHS TCOE

PAGE 2 YOUR CONTRIBUTIONS FOR 2015

PAGE 3 SUMMARY OF 2015 BENEFIT LIMITS AND CO-PAYMENTS

PAGE 4 CHRONIC CARE, PMB CONDITIONS AND HIV/AIDS BENEFITS

PAGE 5 IMPORTANT INFORMATION TO MANAGE YOUR HEALTHCARE

PAGE 5 HOW TO MAKE A CLAIM

PAGE 6 YOUR HOSPITALISATION BENEFITS

PAGE 9 YOUR MATERNITY AND PREVENTATIVE TESTING BENEFITS

PAGE 10 YOUR DAY-TO-DAY (D2D) BENEFITS

PAGE 12 IMPORTANT CONTACT NUMBERS

WOOLTRU HEALTHCARE FUND

WOOLWORTHS TCOE

YOUR CONTRIBUTIONS FOR 2015 2

CORE OPTION CONTRIBUTIONS

INCOME CATEGORY MEMBER SPOUSE CHILD ADDITIONAL ADULT

R0 – R5 960 R814 R814 R326 R814

R5 961 – R7 030 R879 R879 R333 R879

R7 031 – R7 670 R1 306 R1 291 R428 R1 291

R7 671 – R8 630 R1 370 R1 348 R434 R1 348

R8 631 – plus R1 433 R1 407 R438 R1 407

PLUS OPTION CONTRIBUTIONS

MEMBER SPOUSE CHILD ADDITIONAL ADULT

R1 554 R1 523 R474 R1 523

EXTENDED OPTION CONTRIBUTIONS

MEMBER SPOUSE CHILD ADDITIONAL ADULT

R2 841 R2 756 R947 R2 756

ABBREVIATIONS

ADDITIONAL ADULTAdditional Adult is defined as a child over the age of 21, or the mother or father of the principal member who does not receive an income greater than the social pension and who is financially dependent on the member.

AGREED TARIFF The negotiated fee between the Fund and the relevant Service Provider.

AML Annual Medical Limit. This applies from 1 January 2015 to 31 December 2015 and is prorated for members who join during 2015.

CNP Core Option Network Provider – Core GPs and Specialists.

COST The full cost of the fees charged by the Service Provider.

DSP Designated Service Provider – Specialist Network for PMB conditions.

METREF Metropolitan Health Reference price for medicine.

PMB Prescribed Minimum Benefits (a specific minimum legislated package of benefits).

SERVICE PROVIDER Doctors, specialists, hospitals, pharmacists, etc.

WHFT Wooltru Healthcare Fund Tariff – the rate at which the Fund will pay a claim.

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YOUR DAY-TO-DAY (D2D) ANNUAL MEDICAL LIMITS (AML)

CORE PLUS EXTENDED

Benefits from Designated Service Provider (DSP) only.

Member: R4 140 Member: R8 660

Member + 1: R7 980 Member + 1: R17 100

Member + 2 or more: R10 500 Member + 2

or more: R25 600

SUMMARY OF 2015

BENEFIT LIMITS AND CO-PAYMENTS

Specialists out of hospitalMember: R1 290 annuallyFamily: R1 780 annually

Subject to Day-to-Day. Subject to Day-to-Day.

Internal prosthesis R48 400 annually. R48 400 annually. R48 400 annually.

External prosthesis R48 400 annually. R48 400 annually. R48 400 annually.

Private nursing R3 640 per month. R3 640 per month. R3 640 per month.

Chronic medicine non-PMBR9 500 per beneficiary per year for approved medication.

R10 800 per beneficiary per year for approved medication for depression.R11 800 per beneficiary per year for approved medication for osteoporosis.

Specialised dentistry in hospital

No benefit.Member: R11 200 annuallyFamily: R24 650 annually

Member: R11 850 annuallyFamily: R25 500 annually

Psychiatric treatment in hospital

Statutory PMB benefits only – 21 days annually. 21 days annually. 21 days annually.

Treatment in casualty/outpatients

3 visits per family per year to a limit of R1 500. Paid from Day-to-Day. Paid from Day-to-Day.

HIV/AIDS No limit. R210 annually for testing. R210 annually for testing.

SPECIFIC BENEFIT LIMITS

MEMBER CO-PAYMENTS

Non-PMB hospital admission

No co-payment. R590 for non-PMB and non-emergency admissions.

No co-payment.

Endoscopic co-payments:• Gastroscopy• Oesophagoscopy• Colonoscopy• Sigmoidoscopy

100% of Agreed Tariff if motivated by the Core Network Specialist.

100% of WHFT if performed in doctor’s rooms or ambulatory in an outpatient medical facility.

R1 700 co-payment if performed in a hospital and patient is booked into a ward.

300% of WHFT if performed in doctor’s rooms or ambulatory in an outpatient medical facility.

R1 700 co-payment if performed in a hospital and patient is booked into a ward.Examinations performed

by an ophthalmologistNo benefit.

MRI and CT scan co-payments


R1 700 for MRI and CT scans. Pre-authorisation is required.

No co-payment.

Caesarean co-payments100% of Agreed Tariff if motivated by the Core Network Specialist.

R2 290 for elective Caesareans. R2 290 for elective Caesareans.

Basic dentistry No benefit.R550 co-payment subject to pre-authorisation.

No co-payment.

Specialised dentistry No benefit.R590 co-payment subject to pre-authorisation.

No co-payment.

THE CHRONIC DISEASE LIST THE 26 PRESCRIBED MINIMUM BENEFIT (PMB) CONDITIONS

• Addison’s disease

• Asthma

• Bipolar mood disorder

• Bronchiectasis

• Cardiac failure

• Cardiomyopathy disease (disease of heart muscle)

• Chronic renal disease

• Coronary artery disease

• Chronic obstructive pulmonary disorder

• Crohn’s disease

• Diabetes insipidus

• Diabetes mellitus type 1 & 2

• Dysrhythmia (irregular heartbeats)

• Epilepsy

• Glaucoma

• Haemophilia

• HIV/AIDS

• Hyperlipidaemia (high cholesterol)

• Hypertension (high blood pressure)

• Hypothyroidism

• Multiple sclerosis

• Parkinson’s disease

• Rheumatoid arthritis

• Schizophrenia

• Systemic lupus erythematosus

• Ulcerative colitis

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FOR CHRONIC CARE APPLICATION FORMS AND QUERIES:

CORE MEMBERS must call 0800 765 432

PLUS AND EXTENDED MEMBERS must call 0802 228 922

NON-PMB CHRONIC MEDICINE R9 500 per beneficiary per year for approved medication.

R10 800 per beneficiary per year for approved medication for depression.R11 800 per beneficiary per year for approved medication for osteoporosis.

Subject to registration on our Chronic Care Programme – call 0800 765 432

CHRONIC CARE

HIV/AIDS BENEFITS

CORE PLUS EXTENDEDHIV counselling and testing (HCT) – testing fee for GPs

100% of cost at Core Network Provider.

100% of cost. R210 limit for testing.

100% of cost. R210 limit for testing.

Circumcision for uninfected adult and newborn males

100% of Agreed Tariff at chosen Core Network Provider.

100% of the WHFT rate paid from your D2D limit.

100% of cost, paid from your D2D limit.

IMPORTANT INFORMATION

TO MANAGE YOUR HEALTHCARE

5

HOW TO MAKE A CLAIM

CORE MEMBERS: Send all claims to CareCross, PO Box 44991, Claremont 7735.

PLUS AND EXTENDED MEMBERS: Send your claim via internal mail to the Wooltru Healthcare Fund, Cape Town.

OR mail your claim to us at PO Box 15403, Vlaeberg 8018.

Important notes:

• Check that your name, membership number and invoice (if you have paid) are correct.

• No faxes of invoices are accepted for payment. We only pay claims based on the original invoice.

• A claim is only valid for four months from the date of treatment. If you send it to us after four months, it will not be paid.

• You and your dependants’ identity numbers must be recorded with the Fund, otherwise claims may not be paid.

Membership of the Wooltru Healthcare Fund (‘the Fund’) is a compulsory condition of employment unless you are dependant on your spouse’s medical aid.

New employees have 30 days from their date of employment to apply for membership of the Healthcare Fund for themselves and their dependants. If they fail to do so, the prescribed waiting periods for certain benefits will apply. Supporting documents must accompany all applications.

CONTRIBUTIONSYour contribution is automatically deducted from your salary/pension and covers you for the full month, even if you resign part of the way through the month.

HEALTHCARE FUND STATEMENTSClaims are processed and paid every two weeks and a statement will be sent to you at your work address or e-mail address (if provided).

WHAT MUST I DO WHEN MY PERSONAL CIRCUMSTANCES CHANGE?You must notify the Fund within 30 days of any change in your membership status, for example if:• you get married• you get divorced• one of your dependants dies• your address or contact details change• your children no longer qualify for dependant membership in terms of the rules of the Fund• you retire.

Important: You need to notify the Fund within 30 days of the birth of your child or the adoption of a child.

WOOLTRU HEALTHCARE WEBSITE

To access your benefits or to update your personal details, or for more information please visit the Wooltru Healthcare Fund website: www.wooltruhealthcarefund.co.za

http://www.wooltruhealthcarefund.co.za

CORE PLUS EXTENDEDAmbulance services(Netcare – 082 911)

100% of Agreed Tariff. Unlimited if Designated Service Provider is used.

No benefits will be paid for unauthorised use of these services.

Hospitalisation

Private, provincial or state hospitals

100% of Agreed Tariff for authorised admissions if referred to hospital by a Core Network Provider.Emergency admissions will be paid in full.

Authorisation: 0800 765 432

100% of WHFT rate for authorised admissions.All non-PMB hospital admissions require a R590 co-payment paid on admission. No co-payment will be required for emergency admissions.


300% of WHFT rate for authorised admissions.100% of Agreed Tariff for general ward accommodation.


Ward accommodation Ward accommodation will be paid at general ward tariffs, subject to pre-authorisation.

Intensive care, high care, theatre and recovery room

Subject to case management confirmation every 72 hours (3 days).100% of Agreed Tariff.

Medication/materials in ward and theatre

100% of cost for all medication and materials dispensed in hospital if referred by a Core Network Provider.

100% of cost for all medication and materials dispensed in hospital.

100% of cost for all medication and materials dispensed in hospital.

Take-home medicine (discharge from hospital) Limited to 7 days.

GP and Specialists in-hospital, including surgery, procedures and consultations

100% of the Agreed Tariff rate for authorised admissions, if you are referred by a Core Network Provider.

100% of the WHFT rate.PMB admissions will be paid in full if you use a DSP – call 0800 765 432 for Specialist referral and authorisation.

300% of the WHFT rate.PMB admissions will be paid in full if you use a DSP – call 0800 765 432 for Specialist referral and authorisation.

Radiology (including MRIs, CT scans and radio-isotope studies)

100% of Agreed Tariff if requested by a Core Specialist on referral by a Core GP.Subject to authorisation.Authorisation: 0800 765 432

100% of the WHFT rate. R1 700 co-payment on all MRIs and CT scans. Pre-authorisation and motivation by a doctor is required.Authorisation: 0800 118 666

300% of the WHFT rate. Pre-authorisation and motivation by a doctor is required for MRIs and CT scans.Authorisation: 0800 118 666

Pathology 100% of Agreed Tariff if requested by a Core Specialist on referral by a Core GP.

100% of the WHFT rate. 300% of the WHFT rate.

Organ transplants, hospitalisation, organ and patient preparation

100% of Agreed Tariff if hospitalised by a Core Network Provider.


Blood transfusions 100% of the Agreed Tariff rate. 100% of the WHFT rate. 300% of the WHFT rate.

YOUR HOSPITALISATION BENEFITS6

IN HOSPITAL

NON-EMERGENCY:You must obtain authorisation at least two days before any non-emergency hospital admission or related treatment.

EMERGENCY:You must obtain authorisation within 24 hours of admission into hospital or by the next working day.

CORE AUTHORISATIONS:0800 765 432

PLUS AND EXTENDED AUTHORISATIONS: 0800 118 666

BENEFITS WILL BE ALLOCATED PRO RATA IF YOU JOIN DURING THE YEAR, EXCEPT FOR PMBs

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Transportation of blood and blood products 100% of the Agreed Tariff rate. 100% of the WHFT rate. 300% of the WHFT rate.

Donor costs Donor costs up to 100% of the Agreed Tariff rate if the procedure is performed by a Core Network Provider.


Immuno-suppressant drugs dispensed in hospital, including take-home medication

100% of the Agreed Tariff rate, but must be related to hospitalisation.

100% of the WHFT rate, but must be related to hospitalisation.

300% of the WHFT rate, but must be related to hospitalisation.

Auxiliary services in hospital:• Clinical psychology• Speech therapy• Occupational therapy• Physiotherapy

100% of the Agreed Tariff rate for authorised admissions by a Core Network Provider.

The service/procedure must be directly related to the authorised admission.

100% of the WHFT rate for authorised admissions.


300% of the WHFT rate for authorised admissions.


Psychiatric treatment in hospital or a registered facility

Statutory Prescribed Minimum Benefits only – 21 days.


Subject to pre-authorisation and limited to 21 days per beneficiary per year.Authorisation: 0800 118 666

Subject to pre-authorisation and limited to 21 days per beneficiary per year.Authorisation: 0800 118 666

Maxillo-facial and oral surgery

100% of Agreed Tariff, subject to pre-authorisation.Only covers facial trauma and removal of impacted wisdom teeth.

100% of the WHFT rate, subject to pre-authorisation. Only covers facial trauma.

300% of the WHFT rate, subject to pre-authorisation.Only covers facial trauma.

CORE PLUS EXTENDEDPeritoneal dialysis and haemodialysis

100% of Agreed Tariff via Core Network Provider.

100% of the WHFT rate and subject to pre-authorisation.


Oncology, radiotherapy and chemotherapy in and out of hospital (medication/chemicals, related radiology, including MRIs and CT scans, and pathology)

Limited to statutory Prescribed Minimum Benefits, subject to pre-authorisation and registration on the Oncology Programme.

Registration: 0800 765 432

100% of the WHFT rate, subject to pre-authorisation and registration on the Oncology Programme.


300% of the WHFT rate, subject to pre-authorisation and registration on the Oncology Programme.


Endoscopic examinations:• Gastroscopy• Oesophagoscopy• Sigmoidoscopy• ColonoscopyThese procedures can be performed in the doctor’s rooms or ambulatory in an outpatient/medical/surgical facility. If performed in hospital they will attract a member co-payment.

100% of Agreed Tariff, subject to clinical motivation by a Core Network Provider, and pre-authorisation.


100% of WHFT if these scopes are performed in the doctor’s rooms. 100% of WHFT if performed ambulatory in an outpatient/ medical/surgical facility. R1 700 co-payment if performed in hospital and patient is admitted. Anaesthetic costs related to these scopes will be limited to local or regional anaesthetic. NOTE: General anaesthetic costs are not covered.

300% of WHFT if these scopes are performed in the doctor’s rooms. 300% of WHFT if performed ambulatory in an outpatient/ medical/surgical facility.R1 700 co-payment if performed in hospital and patient is admitted. Anaesthetic costs related to these scopes will be limited to local or regional anaesthetic. NOTE: General anaesthetic costs are not covered.

Endoscopic examinations, other than those listed above

No benefit. 100% of WHFT.Anaesthetic costs related to these scopes will be limited to local or regional anaesthetic.NOTE: General anaesthetic costs are not covered.

300% of WHFT.Anaesthetic costs related to these scopes will be limited to local or regional anaesthetic.NOTE: General anaesthetic costs are not covered.

Examinations performed by an ophthalmologist: • Treatment of retina and choroids by cryotherapy • Pan retinal photocoagulation • Laser capsulotomy • Laser trabeculoplasty• Laser apparatus

No benefit. 100% of WHFT if these scopes are performed in the doctor’s rooms. 100% of WHFT if performed ambulatory in an outpatient/ medical/surgical facility. R1 700 co-payment if performed in hospital and patient is admitted. Anaesthetic costs related to these scopes will be limited to local or regional anaesthetic. NOTE: General anaesthetic costs are not covered.

300% of WHFT if these scopes are performed in the doctor’s rooms. 300% of WHFT if performed ambulatory in an outpatient/ medical/surgical facility. R1 700 co-payment if performed in hospital and patient is admitted. Anaesthetic costs related to these scopes will be limited to local or regional anaesthetic. NOTE: General anaesthetic costs are not covered.

IN DOCTOR’S ROOMS OR MEDICAL FACILITY IN HOSPITALBUT PAID FROM HOSPITAL BENEFITS

Basic dentistry procedures in hospital – removal of teeth and multiple fillings for children 7 years and younger

No benefit. 100% of the WHFT rate with a R590 co-payment subject to pre-authorisation.


Specialised dentistry procedures in and out of hospital – dental implants, removal of impacted wisdom teeth

No benefit. 100% of the WHFT rate, with a R590 co-payment, subject to pre-authorisation and limited to:R11 200 per member per yearR24 650 per family per year

300% of the WHFT rate, subject to pre-authorisation and limited to:R11 850 per member per yearR25 500 per family per year

Refractive surgery No benefit. 100% of the WHFT rate. Detailed motivation sent to Medical Advisor 5 working days before procedure.

300% of the WHFT rate. Detailed motivation sent to Medical Advisor 5 working days before procedure.

8

This brochure contains a brief summary of benefits and further conditions may apply as stated in the official rules of the Wooltru Healthcare Fund. Contact the call centre on 0800 118 666.

• Cone biopsy

• Cauterisation of warts

• Colposcopy

• Nasal polypectomy

• Nasal cautery

• Meibomian cyst excision

• Circumcision

• Drainage of superficial abscess

• Superficial foreign body removal

• Breast biopsy

The procedures listed below will not be authorised in hospital unless motivated for and approved.You must obtain authorisation by calling: CORE: 0800 765 432 PLUS AND EXTENDED: 0800 118 666

CORE PLUS EXTENDED

Private nursing in lieu of hospitalisation OR frail care

100% of Agreed Tariff and limited to R3 640 per beneficiary per month.Subject to clinical motivation by a Core Network Provider.

100% of WHFT and limited to R3 640 per beneficiary per month.Subject to clinical motivation by GP or Specialist.

300% of WHFT and limited to R3 640 per beneficiary per month.Subject to clinical motivation by GP or Specialist.

Internal prosthesis(including external fixators, colostomy kits, and appliances placed in the body as an internal adjuvant during an operation)

100% of Agreed Tariff, if inserted by a Core Network Specialist.Subject to pre-authorisation and limited to R48 400 per beneficiary per year.


Subject to pre-authorisation and limited to R48 400 per beneficiary per year.Where pre-authorisation is not obtained, no benefit will be available.Authorisation: 0800 118 666

Subject to pre-authorisation and limited to R48 400 per beneficiary per year.Where pre-authorisation is not obtained, no benefit will be available.Authorisation: 0800 118 666

External prosthesis(including hearing aids, hearing aid repairs, wheelchairs and C-pap machines)

Subject to written motivation which must be received 72 hours before the request for pre-authorisation. Benefits are subject to the terms, conditions and protocols of the Designated Service Provider (DSP). Limited to R48 400 per beneficiary per year.Authorisation: 0800 765 432



Medical and surgical appliances

100% of Agreed Tariff, subject to clinical motivation.

100% of the WHFT rate, subject to clinical motivation.Subject to available Day-to-Day benefits where pre-authorisation is not obtained.

300% of the WHFT rate, subject to clinical motivation.Subject to available Day-to-Day benefits where pre-authorisation is not obtained.

Healthcare provided outside of Southern AfricaMembers must pay the provider, and then claim from the Fund.Southern Africa means South Africa, Namibia, Lesotho and Swaziland.

No benefit. 100% of the WHFT rate paid from applicable benefit categories as indicated above (including hospitalisation).Refunds to members in equivalent SA rand currency only.You are advised to buy travel insurance when travelling outside of Southern Africa.

100% of the WHFT rate paid from applicable benefit categories as indicated above (including hospitalisation).Refunds to members in equivalent SA rand currency only.You are advised to buy travel insurance when travelling outside of Southern Africa.

OTHER BENEFITSPAID FROM HOSPITAL BENEFITS

9

Cholesterol screening (Tariff code 4027) Limited to one per adult every two years

Glucose strip test (Tariff code 4050) Limited to one per adult every two years

Mammogram (Tariff code 34100 + 3605) Limited to one per female (over 40 years) every two years or clinically indicated (family history)

Pap smear (Tariff code 4566) Limited to one per adult female every year

HIV test (Tariff code 3932) Limited to one per beneficiary every year

Glaucoma screening (Tariff code 3014) Limited to one screening per adult (over 40 years) every two years

Prostate screening (Tariff code 4519) Limited to one screening per male (over 50 years) every year

HPV vaccine (Nappi code 710020 – Cervarix) (Nappi code 710429 – Gardasil) All female beneficiaries (non-HIV) between the ages of 9 and 16

CORE PLUS EXTENDEDSubject to pre-authorisation and registration on the Maternity Programme within the first 12 weeks of pregnancy

Registration: 0800 765 432 Registration: 0800 118 666 Registration: 0800 118 666

Vaginal delivery 100% of Agreed Tariff. 100% of WHFT rate. 300% of WHFT rate.

Caesarean section


100% of WHFT rate.Member co-payment of R2 290 where no clinical motivation for the Caesarean has been received from the gynaecologist.

300% of WHFT rate.Member co-payment of R2 290 where no clinical motivation for the Caesarean has been received from the gynaecologist.

Two ultrasound scans, at 12 and 24 weeks 100% of Agreed Tariff. 100% of Agreed Tariff 100% of Agreed Tariff

Ward rate

General ward rates, subject to the following: Normal delivery (3 days)Caesarean section (4 days)



Pathology 100% of Agreed Tariff. 100% of Agreed Tariff. 300% of WHFT rate.

YOUR MATERNITY BENEFITS

PREVENTATIVE TESTING

TEST PER YEAR TARIFF CODE

Full Blood Count 1 3755

Blood Test: Blood Group 1 3764

Blood Test: Rhesus Antigen 1 3765

Urine Culture 1 3893

HIV Elisa or Other Screening Test 1 3932

Rubella Antibody 1 3948

VDRL (Venereal Disease Research Laboratory) 1 3949

Glucose Strip Test 1 4050

Urine Analysis Dipstick 13 4188

HIV Antibody Rapid Test 1 4614

THE COST OF THE TEST – PAID BY THE FUND | THE CONSULTATION – PAID FROM YOUR AML

ADDITIONAL MATERNITY PATHOLOGY PAID BY THE FUND

10

CORE PLUS EXTENDEDYou may ONLY use a Core Network Provider.

You may use any provider and claims will be met at the maximum rates reflected below. PMB conditions will be paid at the Designated Service Provider Agreed Tariff if a DSP is used.

General Practitioner (GP) 100% Agreed Tariff at chosen Core Network Provider.

100% of the WHFT rate paid from your D2D limit.


Specialists Only authorised Specialists are paid, limited to:

R1 290 per year for a single member.R1 780 per year for a family.The above includes the cost of consultation, medication, procedures, radiology and pathology.

100% of the WHFT rate paid from your D2D limit.PMBs will be paid at the Agreed Tariff if you use a DSP Specialist – call 0800 765 432 for Specialist referral and authorisation.

100% of cost, paid from your D2D limit.PMBs will be paid at the Agreed Tariff if you use a DSP Specialist – call 0800 765 432 for Specialist referral and authorisation.

26 Prescribed Minimum Benefits (PMB) chronic medication

100% of approved medication.Subject to registration on our Chronic Care programme.

Call 0800 765 432


Call 0802 228 922


Call 0802 228 922

Chronic medicine non-PMB R9 500 per beneficiary per year for approved medication.R10 800 per beneficiary per year for approved medication for depression.R11 800 per beneficiary per year for approved medication for osteoporosis.

Subject to registration on our Chronic Care Programme.Call 0800 765 432

Biological chronic medicine benefits

No benefit. Limited to R125 000 per beneficiary per year. Subject to registration on our Chronic Care programme.Call 0802 228 922

Limited to R125 000 per beneficiary per year. Subject to registration on our Chronic Care programme.Call 0802 228 922

Pathology and radiology 100% of Agreed Tariff upon referral by the Core Network Provider.

100% of the WHFT rate, paid from your D2D limit.

R1 700 co-payment on all MRIs and CT scans. Authorisation and motivation obtained at least 72 hours before scan.

100% of cost, paid from your D2D limit.Authorisation and motivation obtained at least 72 hours before scan.

Certain procedures performed in doctor’s rooms.

Except procedures listed at the bottom of page 8

100% if performed by the Core Network Provider.

100% of the WHFT rate, paid from your D2D limit. Excluding general anaesthetic.

100% of cost, paid from your D2D limit.Excluding general anaesthetic.

Basic dentistry – consultations, fillings, extractions, scaling and polishing

100% at Core Network Provider. 100% of the WHFT rate, paid from your D2D limit.


WHEN YOUR AML IS EXHAUSTED, YOU WILL BE REQUIRED TO PAY THE PROVIDERS/SERVICES IN FULL.

SEE THE SUMMARY OF YOUR D2D BENEFIT LIMITS ON PAGE 3.

YOUR DAY-TO-DAY BENEFITS PAID FROM YOUR AML

BENEFITS WILL BE ALLOCATED PRO RATA IF YOU JOIN DURING THE YEAR, EXCEPT FOR PMBs

11

CORE PLUS EXTENDEDSpecialised dentistry – dentures, crowns and bridges

No benefit. 100% of the WHFT rate, paid from your D2D limit.


Optical benefits – eye test, frames, lenses, contact lenses

One pair of clear mono or bifocal lenses and one standard frame OR one pair of contact lenses per beneficiary every 24 months at a Core Network Optometrist.



Prescribed acute medicine 100% of formulary medication. 100% of MetRef, subject to your D2D. 100% of MetRef, subject to your D2D.

Over-the-counter medicine No benefit. 100% of MetRef rate, paid from your D2D limit.

100% of MetRef, paid from your D2D limit.

Associated health services (chiropractor, homoeopath, naturopath, dietician)



Auxiliary services out of hospital:• Clinical psychology• Speech therapy• Audiology• Occupational therapy• Podiatry• Orthoptics• Dietetics• Biokinetics• Physiotherapy



ECG tests(heart monitor)

Benefits for clinically appropriate indications by Core Network Provider.

100% of WHFT, paid from your D2D limit.


Out-of-area benefit and emergency visits/outpatients

Limited to 3 visits per family per year up to a limit of R1 500.



Healthcare provided outside of Southern Africa.Members must pay the provider, and then claim from the Fund.Southern Africa means South Africa, Namibia, Lesotho and Swaziland.

No benefit. 100% of the WHFT rate paid from applicable benefit categories as indicated above (including hospitalisation).Refunds to members in equivalent SA rand currency only.

100% of the WHFT rate paid from applicable benefit categories as indicated above (including hospitalisation).Refunds to members in equivalent SA rand currency only.

DISCLAIMER

This brochure outlines the benefits available to employees through the Company’s participation in the Wooltru Healthcare Fund. It is intended as a general outline of benefits and, in the event of a dispute,

the rules of the Wooltru Healthcare Fund will apply.

Although every precaution was taken to ensure the accuracy of information contained in this schedule, the official rules of the Wooltru Healthcare Fund will prevail, should a dispute arise.

Contact the call centre on 0800 118 666

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CORE PLUS EXTENDED

Hospital Authorisation0800 765 432Fax: 021 413 0512

0800 118 666Fax: 021 480 2755

0800 118 666Fax: 021 480 2755

Specialist Authorisation 0800 765 4320800 765 432

For PMB diagnosis only.0800 765 432

For PMB diagnosis only.

Chronic Care 0800 765 432 0802 228 922 0802 228 922

Maternity Programme0800 765 432Fax: 021 413 0512

0800 118 666 0800 118 666

Oncology Programme0800 765 432Fax: 021 413 0512

0800 118 666 0800 118 666

HIV Programme0860 101 110

Fax: 021 413 10640861 888 300

Fax: 0861 888 3010861 888 300

Fax: 0861 888 301

IMPORTANT CONTACT NUMBERS

Wooltru Healthcare Fund

PO Box 15403, Vlaeberg 8018

Telephone: 021 480 4849 E-mail: [email protected]

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