benefits brochure · 2019-02-21 · everyone wants to lead their best life. we want tomorrow to be...
TRANSCRIPT
BENEFITS BROCHURE
Feel confident that someone is always on your side.
2014
Everyone wants to lead their best life. We want tomorrow to be better than yesterday and we want to know that when things get tough, we have all the support we need; whether it’s from family, friends or even a scheme like Bonitas. That’s why at Bonitas, we’re not just in the business of healthcare. Yes, we offer quality, affordable healthcare plans and benefits and yes, when you have a health issue, we’re there for you, but that’s just the beginning. Our business is about supporting your life. We start by making it simple to get the help you need, when you need it.
This means that we have a wide network of top doctors, hospitals and pharmacies, waiting to attend to you. We also have a range of products that are simple to understand so that you know exactly what you are insured for. They’re also simple to use, with up to 90% of your bills being paid directly by us so you don’t have to worry about paying out of your pocket. Most of all, our products are affordable and flexible, adapting to all needs and budgets.
At Bonitas, we believe everyone has the right to live their perfect life, and you can only do that when you know you have the support of people who care.
We want tomorrow to be better than yesterday and we want to know that when things get tough, we have all the support we need.
READY TO LIVE THE LIFE YOU DESERVE?
Benefits 2014 Page 03
INDEX
1.Why Bonitas? 01
2.Product Summary 03
3.BonComprehensive Option 06
4.BonClassic Option 10
5.Standard Option 14
6.
7.BonSave Option 18
Primary Option 22
8.BonEssential Option 26
13.Contact Details 55
9 .BonCap - Network Option 29
10.Chronic Benefits 30
11.Dental Benefits 33
12.At a Glance 45
295 211PRINCIPAL MEMBERS
651 518BENEFICIARIES
In the medical scheme industry, there is safety in numbers. The larger the scheme's membership base, the better its ability to spread the risk of high claims.
With over 295 211 principal members and651 518 beneficiaries covered, Bonitas iswell-equipped to ensure that size reallydoes count.
SIZE OF THE MEDICAL SCHEME
WHY BONITAS?At Bonitas we don’t promise, we do. From the moment we opened our doors over 31 years ago, we have worked hard at bringing affordable healthcare to everyone, and adding value to their lives. We know that part of getting better means you need to be able to focus on the things that matter and not worry about whether you’re covered or if your medical bills will be paid in full.
Bonitas Medical Fund is registered as a Medical Scheme in terms of the Medical Schemes Act. The Scheme complies with all aspects of the Medical Schemes Act. Trustees are elected by members. Trustees act in the best interest of the Scheme and its members. Benefits are approved by the Council for Medical Schemes.
Choosing a medical scheme with a relatively young beneficiary age and low pensioner ratio ensures you get value for money. This is because as people age, their medical costs rise and this tends to increase contributions.
DRASTICALLY LOWER THAN THE VAST MAJORITY OF OPEN SCHEMES IN THE INDUSTRY, BONITAS’ AVERAGE BENEFICIARY AGE IS 31.4 YEARS AND OUR PENSIONER RATIO IS 5.1%.
AVERAGE BENEFICIARY AGE
31.4yrsPENSIONER RATIO
5.1%
WE SUPPORT YOU BY OFFERING REAL BENEFITS THAT MATTER:
Prescribed Minimum Benefit (PMBs)covered at private hospitals
3.Healthy Solvency
8.
Pharmacy Direct provides courier delivery ofchronic medication nationally
5.Traditional options cover dentistry and optometry from risk
10.
Financially sound and reliable, Bonitas has an AA-Global Credit Rating reserve of over R2.7 billion, a solvency margin of 35.5% and administration costs of only 13.7% of gross contribution income. Making your life easier, our advanced support network translates our philosophy of “designed to support your life” into reality for you. Intelligently innovative, lucidly simple and easy to understand, our
13.7% ADMINISTRATION COST OF GROSS CONTRIBUTION INCOMEAA-
GLOBAL CREDIT RATING
35.5%SOLVENCY MARGIN
35.5%SOLVENCY RATIO
RESERVES OF OVER
R2.7 BILLION
FINANCIALLY SOUND AND RELIABLE
forward-thinking product options and exceptional service match what you look for in a scheme. Key indicators such as solvency ratio, average beneficiary age, pensioner ratio and claims ratio are known to provide a dependable indication of a medical scheme's long-term viability, financial stability and value for money.
BONITAS KEY INDICATORS
KEY INDICATORS
Solvency Ratio
Average Beneficiary Age
Pensioner Ratio
Non-Healthcare Expenses per Beneficiary Per Month
Non-Healthcare Expenses as a % of Risk Contribution Income
Non-Healthcare Expenses as a % of Gross Contribution Income
Principal Member
Beneficiaries
BONITAS
35.5%
31.4
5.1%
R144
14%
13.7%
295 211
651 518
OPEN SCHEME AVERAGE
29.1%
33.2
8.2%
R164
15.6%
13.6%
-
-
The table sets out the key indicators for Bonitas compared to the open scheme average based on the latest annual report (updated) from the Council for Medical Schemes
Bonitas’ solvency rate is one of the highest in the country overtaking the prescribed minimum solvency ratio of 25% which not only ensures the scheme has the ability to meetits financial commitments; it is also the most reliable indication of its financial dependability and ability to pay claims.
SOLVENCY RATIO
Expense ratios are an important indicator of whether a scheme offers value for money or not. Inevitably medical schemes have expenses (such as administration fees and broker commission)and the higher these “non-healthcare” costs, the less there is available to pay claims. Schemes with higher than average expense ratios generally don’t offer good value for money.
NON-HEALTHCARE EXPENSE RATIOS
HIV tests and flu vaccines on all options
4.Basket of supplementary benefits paid from risk
9.
An unlimited number of trips on international medical cover
2.Specialist Network
7.
On-site consultants
1.Largest GP Network
6.
This is the financial side of our business. Simply put, it gives you the information you need to reassure yourself that we’re in good shapetoday and into the future.
World Class Managed Care programmesand Clinically Approved (VCT) Programmes.
11.
GOVERNANCE
295 211PRINCIPAL MEMBERS
651 518BENEFICIARIES
In the medical scheme industry, there is safety in numbers. The larger the scheme's membership base, the better its ability to spread the risk of high claims.
With over 295 211 principal members and651 518 beneficiaries covered, Bonitas iswell-equipped to ensure that size reallydoes count.
SIZE OF THE MEDICAL SCHEME
WHY BONITAS?At Bonitas we don’t promise, we do. From the moment we opened our doors over 31 years ago, we have worked hard at bringing affordable healthcare to everyone, and adding value to their lives. We know that part of getting better means you need to be able to focus on the things that matter and not worry about whether you’re covered or if your medical bills will be paid in full.
Bonitas Medical Fund is registered as a Medical Scheme in terms of the Medical Schemes Act. The Scheme complies with all aspects of the Medical Schemes Act. Trustees are elected by members. Trustees act in the best interest of the Scheme and its members. Benefits are approved by the Council for Medical Schemes.
Choosing a medical scheme with a relatively young beneficiary age and low pensioner ratio ensures you get value for money. This is because as people age, their medical costs rise and this tends to increase contributions.
DRASTICALLY LOWER THAN THE VAST MAJORITY OF OPEN SCHEMES IN THE INDUSTRY, BONITAS’ AVERAGE BENEFICIARY AGE IS 31.4 YEARS AND OUR PENSIONER RATIO IS 5.1%.
AVERAGE BENEFICIARY AGE
31.4yrsPENSIONER RATIO
5.1%
WE SUPPORT YOU BY OFFERING REAL BENEFITS THAT MATTER:
Prescribed Minimum Benefit (PMBs)covered at private hospitals
3.Healthy Solvency
8.
Pharmacy Direct provides courier delivery ofchronic medication nationally
5.Traditional options cover dentistry and optometry from risk
10.
Financially sound and reliable, Bonitas has an AA-Global Credit Rating reserve of over R2.7 billion, a solvency margin of 35.5% and administration costs of only 13.7% of gross contribution income. Making your life easier, our advanced support network translates our philosophy of “designed to support your life” into reality for you. Intelligently innovative, lucidly simple and easy to understand, our
13.7% ADMINISTRATION COST OF GROSS CONTRIBUTION INCOMEAA-
GLOBAL CREDIT RATING
35.5%SOLVENCY MARGIN
35.5%SOLVENCY RATIO
RESERVES OF OVER
R2.7 BILLION
FINANCIALLY SOUND AND RELIABLE
forward-thinking product options and exceptional service match what you look for in a scheme. Key indicators such as solvency ratio, average beneficiary age, pensioner ratio and claims ratio are known to provide a dependable indication of a medical scheme's long-term viability, financial stability and value for money.
BONITAS KEY INDICATORS
KEY INDICATORS
Solvency Ratio
Average Beneficiary Age
Pensioner Ratio
Non-Healthcare Expenses per Beneficiary Per Month
Non-Healthcare Expenses as a % of Risk Contribution Income
Non-Healthcare Expenses as a % of Gross Contribution Income
Principal Member
Beneficiaries
BONITAS
35.5%
31.4
5.1%
R144
14%
13.7%
295 211
651 518
OPEN SCHEME AVERAGE
29.1%
33.2
8.2%
R164
15.6%
13.6%
-
-
The table sets out the key indicators for Bonitas compared to the open scheme average based on the latest annual report (updated) from the Council for Medical Schemes
Bonitas’ solvency rate is one of the highest in the country overtaking the prescribed minimum solvency ratio of 25% which not only ensures the scheme has the ability to meetits financial commitments; it is also the most reliable indication of its financial dependability and ability to pay claims.
SOLVENCY RATIO
Expense ratios are an important indicator of whether a scheme offers value for money or not. Inevitably medical schemes have expenses (such as administration fees and broker commission)and the higher these “non-healthcare” costs, the less there is available to pay claims. Schemes with higher than average expense ratios generally don’t offer good value for money.
NON-HEALTHCARE EXPENSE RATIOS
HIV tests and flu vaccines on all options
4.Basket of supplementary benefits paid from risk
9.
An unlimited number of trips on international medical cover
2.Specialist Network
7.
On-site consultants
1.Largest GP Network
6.
This is the financial side of our business. Simply put, it gives you the information you need to reassure yourself that we’re in good shapetoday and into the future.
World Class Managed Care programmesand Clinically Approved (VCT) Programmes.
11.
GOVERNANCE
Page 06 Benefits 2014
When it comes to health, you don’t want to compromise.
After all, your good health and that of your family is a vital part of your plan to live life on your terms. So why hold back when it comes to medical cover? Our BonComprehensive Option is designed for people like you. It’s the elite medical option and you can expect unlimited consultations above threshold as well as the flexibility of a savings option that gives you the freedom to choose where you spend your funds.
Major medical benefits:Unlimited surgical procedures and consultations at 300% Bonitas rate
BONCOMPREHENSIVE
WHAT WILL IT COST?
MAIN MEMBERRISK CONTRIBUTIONSAVINGS CONTRIBUTIONTOTAL CONTRIBUTION
R3 066R541R3 607
ADULT DEPENDANTRISK CONTRIBUTIONSAVINGS CONTRIBUTIONTOTAL CONTRIBUTION
R2 891R511R3 402
CHILD DEPENDANTRISK CONTRIBUTIONSAVINGS CONTRIBUTIONTOTAL CONTRIBUTION
R624R110R734
BONCOMPREHENSIVE
Elite medical option with surgical procedures and consultations at 300% of the Bonitas rate. Unlimited hospitalisation at any hospital. Cover for 53 Chronic conditions. Unlimited medication
and consultations in threshold. Infant paediatric, childhood illness, preventative care, Centre Diabetes Endocrinology (CDE) and supplementary benefits covered from risk.
63 CHRONIC CONDITIONSCONDITIONS COVERED CENTRE FOR DIABETES AND ENDOCRINOLOGY (CDE) BIOLOGICAL DRUGS
UNLIMITEDMEDICATION, RADIOLOGY, PATHOLOGY AND SPECIALIST CONSULTATIONS IN THRESHOLD
SUPPLEMENTARY BENEFITSINFANT PAEDIATRIC BENEFIT CHILDHOOD ILLNESS BENEFIT COCHLEAR IMPLANTS AND INTERNAL NERVE STIMULATOR PREVENTATIVE CARE
100% BONITAS RATEUNLIMITED HOSPITALISATIONAT ANY HOSPITAL REFRACTIVE SURGERY BIOLOGICAL DRUGS
Benefits 2014 Page 07
OVERALL ANNUAL LIMIT (OAL) UNLIMITED
SURGICAL PROCEDURES AND CONSULTATIONS ARE PAID AT 300% OF THE BONITAS RATE
SUB-LIMITS APPLICABLE:
GP AND SPECIALIST CONSULTATIONS Unlimited
PATHOLOGY (100%) Unlimited
RADIOLOGY (SPECIALISED AND GENERAL) (100%) Unlimited
PARAMEDICAL SERVICES (ALLIED MEDICAL PROFESSIONS), E.G. SPEECH THERAPY, OCCUPATIONAL THERAPY, AUDIOLOGY, DIETETICS
Unlimited
ONCOLOGY1 R475 000 per family
BIOLOGICAL DRUGSR200 000 per family per annum (p.f.p.a.) included in the above limit. Pre-authorisation required, 10% co-payment applies, e.g, Herceptin
ORGAN TRANSPLANTS Unlimited
CHRONIC RENAL DIALYSIS (100%) Unlimited
MAXILLO-FACIAL SURGERY (100%) Unlimited, excluding orthognathic surgery
MEDICATION TO TAKE OUT (TTO) R420 per beneficiary, per admission
PHYSICAL REHABILITATION R38 000 per family
ALTERNATIVE TO HOSPITALISATION R12 700 per family
Major medical expenses are covered at 300% of Bonitas' rate. This benefit includes major medical events. All hospital admissions, oncology treatment and renal dialysis require pre-authorisation by Hospital Benefit Management, except in case of emergencies.
MAJOR MEDICAL BENEFITS
1 All members enrolled in clinical trials should inform the scheme.2 Comprehensive formulary up to benefit limit, restrictive formulary once benefit limit exceeded for PMBs. Refer to page 32 for a complete list of chronic conditions.
CHRONIC BENEFITS2
Covers medication for conditions that require medication on an ongoing basis. Subject to pre-authorisation.
53 conditions, R10 600 per beneficiary, R21 150 per family
CHRONIC CONDITIONS2 UP-TO-BENEFIT LIMIT OVER BENEFIT LIMIT
53 CONDITIONS R10 600 per beneficiary. R21 150 per family. Comprehensive formulary applies
PMBs only.Restrictive formulary
Centre for Diabetes and Endocrinology (CDE) Treatment of diabetes
Page 08 Benefits 2014
OUT OF HOSPITAL BENEFITS
Savings and ThresholdOUT OF HOSPITAL BENEFITS
Covers day-to-day medical expenses, e.g. GP and specialist consultations, acute medication, paramedical services, optometry, radiology, pathology, dentistry, etc.
SAVINGS PER MONTH R541 R511 R110
SAVINGS PER ANNUM R6 492 R6 132 R1 320
THRESHOLD BENEFIT
THRESHOLD R7 400 R6 700 R1 950
SELF-FUNDING GAP R908 R568 R630
Child DependantAdult DependantMain Member
ACUTE MEDICATION AND PHARMACY ADVISED THERAPYSubject to savings and/or threshold (100% of the Bonitas rate accrues to threshold) 25% co-payment in threshold
GP AND SPECIALIST CONSULTATIONS Subject to savings and/or threshold, 25% co-payment in threshold
GENERAL RADIOLOGY Subject to savings and/or threshold
PATHOLOGY Subject to savings and/or threshold
PARAMEDICAL SERVICES (ALLIED MEDICAL PROFESSIONS), E.G. SPEECH THERAPY, OCCUPATIONAL THERAPY, AUDIOLOGY, DIETETICS Subject to savings and/or threshold, 25% co-payment in threshold
OPTOMETRY Limited to R2 450 p.b. 25% co-payment in threshold
BASIC DENTISTRY1Subject to savings and/or threshold. 25% co-payment in threshold. Covered according to DENIS clinical protocols and Bonitas Dental Rate (BDT)1
SPECIALISED DENTISTRY1Subject to savings and/or threshold. 25% co-payment in threshold.Covered according to DENIS clinical protocols and Bonitas Dental Rate (BDT)1. Dental Hospital Admissions are paid from risk.
1 Subject to DENIS clinical protocols and Bonitas dental rate. Refer to page 37 to 44.
bonitas.co.za0860 002 108Bonitas-Medical-Fund @BonitasMedical
Benefits 2014 Page 09
MATERNITY CARE* PER EVENT (ANTE- AND POSTNATAL)
Unlimited hospitalisation, subject to pre-authorisation. Ante-natal classes to the value of R1 000 and private ward for post-delivery 12 ante-natal consultations, 2 X 2D scans and 4 post-natal consultations with a midwife
REFRACTIVE SURGERY* R15 900 per family at 100% Bonitas Rate, subject to pre-authorisation
IMMUNE DEFICIENCY RELATED TO HIV INFECTION*Unlimited, subject to Aid for AIDS (AfA) registrationClinical protocols apply
MENTAL HEALTH BENEFITS*R36 000 per family, R12 000 sub-limit for consultation in and out of hospital
SPECIALISED RADIOLOGY* (OUT OF HOSPITAL) R24 000 per family, subject to pre-authorisation
EMERGENCY MEDICAL TRANSPORTATION Subject to ER24 authorisation
ENDOSCOPIES* IN PRACTITIONERS’ ROOMS Unlimited, subject to pre-authorisation
PROSTHESES INTERNAL* R42 300 per family, subject to pre-authorisation
PROSTHESES EXTERNAL* R42 300 per family, subject to pre-authorisation
COCHLEAR IMPLANTS R158 000 per family
INTERNAL NERVE STIMULATORS R127 000 per family
HIV TEST AND FLU VACCINE 1 each per beneficiary, p.b.p.a.
Additional benefits, in or out of hospital:
SUPPLEMENTARY BENEFITS
* Subject to pre-authorisation.* All benefits are per annum, unless otherwise stated. * Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations.
INFANT PAEDIATRIC BENEFIT (OUT OF HOSPITAL PAID FROM RISK)3 consultations p.b.p.a. before the age of 1 year. 2 consultations p.b.p.a. between the ages of 1 and 2 years
CHILDHOOD ILLNESS BENEFIT (CONSULTATIONS PAID FROM RISK) 2 GP consultations p.b.p.a between the ages of 2 and 12 years
PREVENTATIVE CARE
WOMEN’S HEALTH1 mammogram every 3 years for females age 50 to 74 years. 1 pap smear every 3 years for females age 21 to 65 years
CARDIAC HEALTH 1 full lipogram per beneficiary
ELDERLY HEALTH1 Pneumoccocal vaccination above age 65. 1 Faecal Occult blood test p.b.p.a. between the ages of 50 and 75. 1 Bone Densitometry Screening test for females above the age of 65 years
CHILDREN’S HEALTH1 TSH test for infants below 1 month of age. Immunisation for children up to age 12 years, as specified in the Extended Programme on Immunisation (EPI)
APPLIANCES
GENERAL APPLIANCES R6 800 per family
WHEELCHAIRS AND LARGE ORTHOPAEDIC APPLIANCES Included in the General Appliances limit
STOMA PRODUCTS AND CPAP* MACHINES May exceed General Appliances limit by R4 750
HEARING AIDS R21 000 per family, biennial benefit (1 Jan 2014 - 31 Dec 2015)
OXYGEN: HOME VENTILATION* Unlimited, subject to pre-authorisation by Hospital Benefit Management
This summary is for information purposes only and does not supersede the rules of the fund. In the event of any discrepancy between the summary and the rules, the rules will prevail.
Page 10 Benefits 2014
Medical expenses tend to come when you can least afford them. Having to make co-payments to your doctor or pharmacist can put you under additional financial strain. Not with BonClassic Option, however. Our BonClassic Option is priced to give you quality cover but not to break the bank. Plus, if you use our network of suppliers, you won’t have to pay a single bill because we do it directly. On top of that, the savings facility gives you control over what medical expenses you spend your funds on.
Major medical benefits:Unlimited 100% Bonitas rate
BONCLASSIC
WHAT WILL IT COST?
MAIN MEMBERRISK CONTRIBUTIONSAVINGS CONTRIBUTIONTOTAL CONTRIBUTION
R2 261R252R2 513
ADULT DEPENDANTRISK CONTRIBUTIONSAVINGS CONTRIBUTIONTOTAL CONTRIBUTION
R1 942R216R2 158
CHILD DEPENDANTRISK CONTRIBUTIONSAVINGS CONTRIBUTIONTOTAL CONTRIBUTION
R558R 62R620
BONCLASSIC
Comes with a savings account facility which covers acute medication, Pharmacy Advice Therapy (PAT) and GP and specialist consultations plus radiology, pathology, paramedical services, dentistry and optometry.
Covers 63 chronic conditions, dentistry and cochlear implants. Unlimited hospitalisation at 100% of Bonitas’ rates; supplementary benefits paid from risk.
63 CHRONIC CONDITIONSCOVERED
OUT OF HOSPITALSAVINGS, OPTOMETRY, RADIOLOGY, PATHOLOGY, PARAMEDICAL SERVICES, BASIC AND SPECIALISED DENTISTRY
SUPPLEMENTARY BENEFITSPAID FROM RISKCOCHLEAR IMPLANTS
100% BONITAS RATEUNLIMITED HOSPITALISATION
Benefits 2014 Page 11
OVERALL ANNUAL LIMIT (OAL) UNLIMITED
BENEFITS PAYABLE AT 100% OF THE BONITAS RATE
SUB-LIMITS APPLICABLE:
GP AND SPECIALIST CONSULTATIONS (HOSPITAL) 100% of the Bonitas Rate. Subject to pre-authorisation
PATHOLOGY Payable from the OAL
RADIOLOGY (SPECIALISED) R22 200 per family
RADIOLOGY (GENERAL) Payable from the OAL
PARAMEDICAL SERVICES (ALLIED MEDICAL PROFESSIONS), E.G. SPEECH THERAPY, OCCUPATIONAL THERAPY, AUDIOLOGY, DIETETICS
Payable from the OAL
ONCOLOGY1 R315 000 per family
ORGAN TRANSPLANTS Subject to pre-authorisation
CHRONIC RENAL DIALYSIS Subject to pre-authorisation
MAXILLO-FACIAL SURGERY (100%) Payable from the OAL. Pre-authorisation required
MEDICATION TO TAKE OUT (TTO) R360 per beneficiary, per admission
PHYSICAL THERAPY (PHYSIOTHERAPY AND BIOKINETICS) Limited to R1 200 per beneficiary. Limited to R2 400 per family
Major medical expenses are covered at 100% of Bonitas' rate. This benefit includes major medical events. All hospital admissions, oncology treatment and renal dialysis require pre-authorisation by Hospital Benefit Management, except in case of emergencies.
MAJOR MEDICAL BENEFITS
1 All members enrolled in clinical trials should inform the scheme.2 Restrictive formulary. Refer to page 32 for a complete list of chronic conditions.
PHYSICAL REHABILITATION R38 000 per family
ALTERNATIVES TO HOSPITALISATION (STEP DOWN OR HOME NURSING)
R12 700 per family
CHRONIC BENEFITS2
Covers medication for conditions that require medication on an ongoing basis. Subject to pre-authorisation.
63 conditions, R8 700 per beneficiary, R18 000 per family
CHRONIC CONDITIONS2 UP-TO-BENEFIT LIMIT OVER BENEFIT LIMIT
63 CONDITIONS R8 700 per beneficiary per annum, R18 000 per family.
40% co-payment applies for the use of non-formulary drugs
If you exceed your benefit limits then only the 26 chronic disease list conditions are covered. The restrictive formulary will apply and medicine is to be obtained from the designated service provider, Pharmacy Direct. 40% co-payment will apply for the use of a non-designated service provider and the non-formulary drugs.
Page 12 Benefits 2014
OUT OF HOSPITAL BENEFITS
Includes savings plus pathology, radiology, physical therapy, dentistry and optical
OUT OF HOSPITAL BENEFITSCovers day-to-day medical expenses such as GP and specialist consultations, acute medication, pathology, radiology, paramedical services (Allied Medical Professions), optometry and dentistry.
GP CONSULTATIONS Subject to savings
SPECIALIST CONSULTATIONS Subject to savings
ACUTE MEDICATION AND PHARMACY ADVISED THERAPY Subject to savings
SAVINGS PER MONTH R252 R216 R62
SAVINGS PER ANNUM R3 024 R2 592 R744
Child DependantAdult DependantMain Member
GYNAECOLOGISTS Female beneficiaries, 1 visit per annum without referral
PAEDIATRICIANS No referral required for beneficiaries under age 2 years
ONCOLOGISTS AND OPHTHALMOLOGISTS No referral required
PATHOLOGY R2 400 per beneficiary, limited to R5 300 per family
PHYSICAL THERAPYIncluded in the hospital benefit. R1 200 per beneficiary limitedto R2 400 per family
GENERAL RADIOLOGY R2 400 per beneficiary limited to R3 700 per family
SPECIALISED RADIOLOGYIncluded in the hospital specialised radiology benefit. Subject to pre-authorisation
SPECIALIST CONSULTATIONSThe Bonitas General Practitioner Network is the designated service provider for the provision of all Prescribed Minimum Benefit Conditions (PMBs). A co-payment of 40% will apply for the use of a non-network general practitioner. The Bonitas Specialist Network is the scheme’s designated service provider for the provision of PMBs. No co-payment
will apply at a Specialist Network Provider. Specialist referral management will require all beneficiaries to obtain a referral from a GP to consult with a specialist. Specialist referral by a GP is also required for Prescribed Minimum Benefit conditions. The following exceptions apply:
PARAMEDICAL SERVICE (ALLIED MEDICAL PROFESSIONS), E.G. AUDIOLOGY, HEARING AID ACOUSTICIANS, OCCUPATIONAL THERAPY, ORTHOPTICS, PODIATRY, SPEECH THERAPY, DIETETICS AND SOCIAL WORKERS, NURSING SERVICES
R2 300 R3 500 R4 050 R4 300 R4 600
Main Member 1 Dependant 2 Dependants 3 Dependants 4+ Dependants
Benefits 2014 Page 13
OPTOMETRY R5 260 per family, per annum. 2 year cycle commenced 1 Jan 2013
OPTOMETRIC EXAMINATION 100% of cost in-network. R295 out-of-network
FRAMES AND PRESCRIPTION LENSES/ADD-ONS R700 per beneficiary
CLEAR SINGLE VISION R185 per lens or
CLEAR AQUITY FLAT-TOP BIFOCAL R430 per lens or
CLEAR AQUITY MULTIFOCAL R750 per lens or
CONTACT LENSES R1 635 per beneficiary
CONSERVATIVE DENTISTRY1Limited to R3 600 per family per annum. Subject to clinical protocols and Bonitas Dental Rate (BDT)
SPECIALISED DENTISTRY1Limited to R4 300 per family per annum.Subject to clinical protocols and Bonitas Dental Rate (BDT)
1 Subject to DENIS clinical protocols and Bonitas dental rate. Refer to pages 37 to 44. * Subject to pre-authorisation. * All benefits are per annum, unless otherwise stated. * Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations.
Additional benefits, in or out of hospital:
SUPPLEMENTARY BENEFITS
SUPPLEMENTARY BENEFITS
MATERNITY CARE PER EVENT (ANTE- AND POSTNATAL)Unlimited hospitalisation, subject to pre-authorisation by HBM. R980 for ante-natal classes. 12 ante-natal consultations, 2 X 2D scans and 4 post-natal consultations with a midwife
IMMUNE DEFICIENCY RELATED TO HIV INFECTION* Subject to Aid for AIDS (AfA) registration. Clinical protocols apply
MENTAL HEALTH BENEFITS*R31 700 per family. R12 400 sub-limit for consultations in and out of hospital. Subject to pre-authorisation
EMERGENCY MEDICAL TRANSPORTATION Subject to ER24 authorisation
ENDOSCOPIES* IN PRACTITIONERS’ ROOMS Unlimited, subject to pre-authorisation
PROSTHESES INTERNAL AND EXTERNAL R42 000 per family, subject to pre-authorisation
COCHLEAR IMPLANTS R158 000 per family
HIV TEST AND FLU VACCINE 1 each per beneficiary per annum
APPLIANCES
GENERAL APPLIANCES R6 300 per family
WHEELCHAIRS AND LARGE ORTHOPAEDIC APPLIANCES Included in the General Appliances limit
STOMA PRODUCTS AND CPAP* MACHINES Included in the General Appliances limit
HEARING AIDSR13 800 per family per annum over a 3 year cycle (cycle commenced 1 Jan 2013 - 31 Dec 2015)
OXYGEN: HOME VENTILATION* Unlimited, subject to pre-authorisation by Hospital Benefit Management
This summary is for information purposes only and does not supersede the rules of the fund. In the event of any discrepancy between the summary and the rules, the rules will prevail.
bonitas.co.za0860 002 108Bonitas-Medical-Fund @BonitasMedical
Page 14 Benefits 2014
Major medical expenses are covered at 100% of Bonitas rate. This benefit includes major medical events. All hospital admissions, oncology treatment and renal dialysis require pre-authorisation by Hospital Benefit Management, except in case of emergencies.
MAJOR MEDICAL BENEFITS
Major medical benefits: Unlimited 100% Bonitas rate
If you need a medical option that makes your money stretch further and covers all your needs, then this is the option for you.
At Bonitas we understand that getting sick is not exactly something you budget for, which is why we make sure you’ve got it covered. The Bonitas Standard Option is more than a hospital plan, it offers you and your family hospital cover, chronic cover plus generous day-to-day benefits. Best of all, it allows you to make full use of our GP and Specialist Networks, which means you should never have to make co-payments for treatment whether it’s in or out of hospital, subjectto benefit limits.
WHAT WILL IT COST?
MAIN MEMBERR2 186
ADULT DEPENDANTR1 891
CHILD DEPENDANT R639
STANDARD
STANDARD
Comprehensive hospital cover with generousday-to-day benefits.
Covers 42 chronic conditions. Unlimited annual benefits and hospitalisation at 100% Bonitas rate. Supplementary benefits paid from risk.
42 CHRONIC CONDITIONSCENTRE FOR DIABETES ANDENDOCRINOLOGY (CDE)
GENEROUS GP ANDDAY-TO-DAY BENEFITS BASIC AND SPECIALISED DENTISTRY AND OPTOMETRY
SUPPLEMENTARY BENEFITSPAID FROM RISKCOCHLEAR IMPLANTSINTERNAL NERVE STIMULATOR
100% BONITAS RATEUNLIMITED ANNUAL BENEFITS
Benefits 2014 Page 15
OVERALL ANNUAL LIMIT (OAL) UNLIMITED
BENEFITS PAYABLE AT 100% OF THE BONITAS RATE
SUB-LIMITS APPLICABLE:
GP AND SPECIALIST CONSULTATIONS Unlimited
PATHOLOGY Unlimited
RADIOLOGY (SPECIALISED AND GENERAL) Unlimited
PARAMEDICAL SERVICES (ALLIED MEDICAL PROFESSIONS), E.G. SPEECH THERAPY, OCCUPATIONAL THERAPY, AUDIOLOGY, DIETETICS
Unlimited
ONCOLOGY1 R264 500 per family
ORGAN TRANSPLANTS Unlimited
CHRONIC RENAL DIALYSIS Unlimited
MAXILLO-FACIAL SURGERY Unlimited, excluding orthognathic surgery
MEDICATION TO TAKE OUT (TTO) R360 per beneficiary, per admission
PHYSICAL REHABILITATION R38 000 per family
ALTERNATIVE TO HOSPITALISATION R12 700 per family
1 All members enrolled in clinical trials should inform the scheme.2 Comprehensive formulary up to benefit limit, restrictive formulary once benefit limit exceeded for PMBs. Refer to page 32 for a complete list of chronic conditions.
CHRONIC BENEFITS2
Covers medication for conditions that require medication on an ongoing basis, subject to pre-authorisation. 42 chronic conditions covered plus applicable chronic DTPs.
CHRONIC CONDITIONS2
UP TO BENEFIT LIMIT OVER BENEFIT LIMIT
42 CONDITIONS PROVIDER
R7 400 p.b. R14 800 p.f.
Comprehensive formulary at any pharmacyor dispensing GP
26 PMB conditions
Restrictive formulary at (DSP) Pharmacy Direct
Treatment of Diabetes Centre for Diabetes and Endocrinology
Chronic medical benefits:42 chronic conditions, R7 400 per beneficiary, R14 800 per family
OUT OF HOSPITAL BENEFITS
GP benefit plus day-to-day benefits, basic and specialised dentistry, optometry
OUT OF HOSPITAL BENEFITS
Covers day-to-day medical expenses e.g. GP and specialist consultations, acute medication, pathology, radiology, paramedical services (Allied Medical Professions), optometry, dentistry, etc.
GP BENEFITSA benefit has been created specifically for out of hospital general practitioner consultations empowering the GP to become your coordinator of care. By making use of a GP in the network, you are not only guaranteed that the doctor will charge the Bonitas rate, but that the benefit available is more generous.
A sub-limit applies to non-network visits; this limit is included in the GP benefit limit allowing you the flexibility to see any doctor when you are away from home. To find a network doctor near you, call 0860 00 2108 or visit our website: www.bonitas.co.za
Page 16 Benefits 2014
The Bonitas GP Network is the scheme’s designated service provider for the provision of Prescribed Minimum Benefits. PMBs are covered at 100% of scheme rate at DSP once benefits limits are exhausted. A 40% co-payment will apply for PMBs at a non-DSP once benefit limits are exhausted.
IN-NETWORK GP BENEFITS R3 200 R4 700 R5 200 R5 500 R5 900
NON-NETWORK GP BENEFITS**Benefit included in the network benefit
R1 050 R1 600 R1 750 R1 850 R2 000
Main Member 1 Dependant 2 Dependants 3 Dependants 4+ Dependants
GYNAECOLOGISTS Female beneficiaries, 1 visit per annum without referral
PAEDIATRICIANS No referral required for beneficiaries under age 2
ONCOLOGISTS AND OPHTHALMOLOGISTS No referral required
IN ADDITION TO THE DAY-TO -DAY BENEFIT THE FOLLOWING ARE ALSO PROVIDED:
CONSERVATIVE DENTISTRY1 Subject to clinical protocols and Bonitas Dental Rate (BDT)1
SPECIALISED DENTISTRY1Subject to clinical protocols and Bonitas Dental Rate (BDT)1 20% co-payment applies to orthodontic treatment
OPTOMETRY 2 year benefit, per beneficiary
OPTOMETRIC EXAMINATION 100% of cost in network, or R295 at a non-network provider
FRAMES AND PRESCRIPTION LENSES /ADD-ONS R800 per beneficiary
CLEAR SINGLE VISION R150 per lens or
CLEAR AQUITY FLAT-TOP BIFOCAL R325 per lens or
CLEAR AQUITY MULTIFOCAL R600 per lens or
CONTACT LENSES R1 550 per beneficiary
SPECIALIST CONSULTATIONSThe Bonitas Specialist Network is the scheme’s designated service provider for the provision of PMBs. No co-payment will apply at a Specialist Network Provider. Specialist referral management will require all beneficiaries to obtain a referral from a GP to consult with a specialist. Specialist referral by a GP is also required for Prescribed Minimum Benefit conditions.
The following exceptions apply:
DAY-TO-DAY BENEFITThe day-to-day benefit is the pool of benefits from which your GP can prescribe the appropriate care to improve your health. This benefit covers acute medication, out of hospital radiology, pathology, paramedical services (dietetics, occupational therapy,
speech therapy, social workers, audiology, physiotherapy and others) and includes specialist consultations which will only be payable on referral by your GP. Benefits are subject to your day-to-day benefit limit.
DAY-TO-DAY BENEFITS Sub-limit of R620 per beneficiary and R1 900 per family for Pharmacy Advised Therapy (PAT).
R3 600 R5 500 R5 900 R6 400 R6 950
Main Member 1 Dependant 2 Dependants 3 Dependants 4+ Dependants
1 Subject to DENIS clinical protocols and Bonitas dental rate. Refer to page 37 to 44.
Benefits 2014 Page 17
* Subject to pre-authorisation.* All benefits are per annum, unless otherwise stated. * Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations.
Additional Benefits, in or out of hospital:
SUPPLEMENTARY BENEFITS
MATERNITY CARE* PER EVENT (ANTE- AND POSTNATAL)Unlimited hospitalisation, subject to pre-authorisation. R950 for ante-natal classes, 12 ante-natal consultations, 2 X 2D scans and 4 post-natal consultations with a midwife
IMMUNE DEFICIENCY RELATED TO HIV INFECTION*R24 900 per beneficiary, subject to Aid for AIDS (AFA) registration. Clinical protocols apply
MENTAL HEALTH BENEFITS*R31 200 per family, subject to pre-authorisation. Includes a sub-limitof R12 200 for consultations in and out of hospital
SPECIALISED RADIOLOGY* (OUT OF HOSPITAL) R20 100 per family subject to pre-authorisation
EMERGENCY MEDICAL TRANSPORTATION Subject to ER24 authorisation
ENDOSCOPIES* IN PRACTITIONERS’ ROOMS Unlimited, subject to pre-authorisation
PROSTHESES INTERNAL AND EXTERNAL* R33 900 per family, subject to pre-authorisation
COCHLEAR IMPLANTS R158 000 per family
INTERNAL NERVE STIMULATORS R127 000 per family
HIV TEST AND FLU VACCINE 1 each per beneficiary, per annum
INFANT PAEDIATRIC BENEFIT (OUT OF HOSPITAL PAID FROM RISK)2 consultations before the age of 1 year. 1 consultation between the ages of 1 and 2 years per beneficiary
CHILDHOOD ILLNESS BENEFIT (CONSULTATIONS PAID FROM RISK) 2 GP consultation p.b.p.a between the ages of 2 and 12 years
APPLIANCES
GENERAL APPLIANCES R6 200 per family
WHEELCHAIRS AND LARGE ORTHOPAEDIC APPLIANCES Included in the General Appliances limit
STOMA PRODUCTS AND CPAP* MACHINES May exceed General Appliances limit by R5 000
HEARING AIDS R13 000 per family, biennial benefit (01 Jan 2014 - 31 Dec 2015)
OXYGEN: HOME VENTILATION* Unlimited, subject to pre-authorisation by Hospital Benefit Management
SUPPLEMENTARY BENEFITS
This summary is for information purposes only and does not supersede the rules of the fund. In the event of any discrepancy between the summary and the rules, the rules will prevail.
bonitas.co.za0860 002 108Bonitas-Medical-Fund @BonitasMedical
Page 18 Benefits 2014
Do you think that some medical allocations are too prescriptive? Do you prefer to decide where you’re going to spend your funds?
If so, you’re going to want the BonSave Option. This option lets you pay for certain medical needs from a savings account that accumulates every month. It is all about flexibility. Its savings portion lets you decide how you use your funds, giving you control and most importantly, the ability to use your money where you need it most.
Major medical benefits:Unlimited 150% Bonitas rate
BONSAVE
WHAT WILL IT COST?
MAIN MEMBERRISK CONTRIBUTIONSAVINGS CONTRIBUTIONTOTAL CONTRIBUTION
R1 293R265R1 558
ADULT DEPENDANTRISK CONTRIBUTIONSAVINGS CONTRIBUTIONTOTAL CONTRIBUTION
R1 002R205R1 207
CHILD DEPENDANTRISK CONTRIBUTIONSAVINGS CONTRIBUTIONTOTAL CONTRIBUTION
R388R80R468
BONSAVE
A host of day-to-day benefits, paid from savings account. Unlimited hospitalisation at 150% Bonitas rate. Chronic medicine for 26 Prescribed Minimum
Benefits obtained from Pharmacy Direct, basic dentistry, infant paediatric, childhood illness and supplementary benefits paid from risk.
CHRONIC MEDICINE FOR 26 PMBsDELIVERED BY PHARMACY DIRECT
OUT OF HOSPITAL BENEFITSCOVERED BY SAVINGS PLUS BASIC DENTISTRY
SUPPLEMENTARY BENEFITSPAID FROM RISK
100% BONITAS RATEUNLIMITED ANNUAL BENEFITS
Benefits 2014 Page 19
OVERALL ANNUAL LIMIT (OAL) UNLIMITED
BENEFITS PAYABLE AT 150% OF THE BONITAS RATE
SUB-LIMITS APPLICABLE:
GP AND SPECIALIST CONSULTATIONS Unlimited
PATHOLOGY Unlimited
RADIOLOGY (SPECIALISED AND GENERAL) Unlimited
PARAMEDICAL SERVICES (ALLIED MEDICAL PROFESSIONS), E.G. SPEECH THERAPY, OCCUPATIONAL THERAPY, AUDIOLOGY, DIETETICS
Unlimited
ONCOLOGY1 R264 500 per family
ORGAN TRANSPLANTS Unlimited
CHRONIC RENAL DIALYSIS PMBs, only covered as per state protocol
MAXILLO-FACIAL SURGERY Unlimited, excluding orthognathic surgery
MEDICATION TO TAKE OUT (TTO) R290 per beneficiary, per admission
PHYSICAL REHABILITATION R38 000 per family
ALTERNATIVE TO HOSPITALISATION R12 700 per family
Major medical expenses are covered at 150% of Bonitas’ rate. This benefit includes major medical events. All hospital admissions, oncology treatment and renal dialysis require pre-authorisation by Hospital Benefit Management, except in case of emergencies.
MAJOR MEDICAL BENEFITS
1 All members enrolled in clinical trials should inform the scheme.
CO-PAYMENT WILL APPLY TO THE BELOW PROCEDURES IN HOSPITAL
R1 000DEDUCTIBLE
R2 500DEDUCTIBLE
R5 000DEDUCTIBLE
1. Colonoscopy 2. Conservative Back Treatment3. Cystoscopy4. Facet Joint Injections5. Flexible sigmoidoscopy6. Functional Nasal Surgery7. Gastroscopy8. Umbilical Hernia Repair9. Hysteroscopy (but not endometrial
ablation)10. Myringotomy11. Tonsillectomy and Adenoidectomy
(except PMBs)12. Varicose Vein Surgery
1. Arthroscopy2. Diagnostic Laparoscopy3. Hysterectomy (except cancer and PMBs)4. Percutaneous Radiofrequency Ablations 5. Percutaneous rhizotomies6. Laparoscopic Appendectomy7. Laparoscopic Nephrectomy
1. Nissen Fundoplication (Reflux Surgery)2. Back Surgery including spinal fusion3. Joint replacements, e.g. Hip and Knee
replacements (except PMBs)4. Laparoscopic Pyeloplasty5. Laparoscopic Radical Prostatectomy
Page 20 Benefits 2014
CHRONIC BENEFITS1
Covers medication for conditions that require medication on an ongoing basis. Chronic Disease List (CDL) plus applicable chronic DTPs as per the Prescribed Minimum Benefits (PMB), at the Designated Service Provider (DSP), subject to pre-authorisation. 40 % co-payment will apply at a non-DSP.
PMBs only at DSP
CHRONIC CONDITIONS1 DESIGNATED SERVICE PROVIDER
26 PMBs RESTRICTIVEFORMULARY
Pharmacy Direct
OUT OF HOSPITAL BENEFITS
Savings plus basic dentistryOUT OF HOSPITAL BENEFITS
Covers day-to-day medical expenses, e.g. GP and specialist consultations, acute medication, paramedical (Allied Medical Professions), optometry, radiology, pathology, etc. The Bonitas Specialist Network is the scheme-designated service provider for the provision of PMBs. No co-payment will apply at a Specialist Network Provider, while in benefit.
1 Restrictive formulary. Refer to page 32 for a complete list of chronic conditions. 2 Subject to DENIS clinical protocols and Bonitas’ dental rate. Refer to pages 37 to 44. * Subject to pre-authorisation.* All benefits are per annum, unless otherwise stated. * Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations.
SAVINGS PER MONTH R265 R205 R80
SAVINGS PER ANNUM R3 180 R2 460 R960
Child DependantAdult DependantMain Member
GP CONSULTATIONS
Subject to savings. Once allocated savings for the year have been exhausted, 3 consultations per beneficiary, up to a maximum of 6 consultations per family will be paid from risk. Unused consultations will not be carried over to the following year
SPECIALIST CONSULTATIONS Subject to savings
ACUTE MEDICATION AND PHARMACY ADVISED THERAPY Subject to savings
GENERAL RADIOLOGY Subject to savings
PATHOLOGY Subject to savings
OPTOMETRY Subject to savings
PARAMEDICAL SERVICES (ALLIED MEDICAL PROFESSIONS), E.G. SPEECH THERAPY, OCCUPATIONAL THERAPY, AUDIOLOGY, DIETETICS
Subject to savings
BASIC DENTISTRY2Covered according to DENIS clinical protocols and Bonitas Dental Rate (BDT)
SPECIALISED DENTISTRY2 No benefit
Benefits 2014 Page 21
Additional benefits, in or out of hospital:
SUPPLEMENTARY BENEFITS
SUPPLEMENTARY BENEFITS
MATERNITY CARE* PER EVENT (ANTE- AND POSTNATAL)Unlimited hospitalisation, subject to pre-authorisation. R950 for ante-natal classes, 6 ante-natal consultations, 2 X 2D scans, 4 postnatal consultations with a midwife
IMMUNE DEFICIENCY RELATED TO HIV INFECTION*R24 800 per beneficiary, subject to Aid for AIDS (AfA) registration Clinical protocols apply
MENTAL HEALTH BENEFITS*R24 800 per family, subject to pre-authorisation and includes a sub-limit of R12 150 for consultations in and out of hospital
SPECIALISED RADIOLOGY* (OUT OF HOSPITAL) R17 000 per family, subject to pre-authorisation
EMERGENCY MEDICAL TRANSPORTATION Subject to ER24 authorisation
ENDOSCOPIES* IN PRACTITIONERS’ ROOMS Unlimited, subject to pre-authorisation
PROSTHESES INTERNAL AND EXTERNAL* PMBs only
HIV TEST AND FLU VACCINE 1 each per beneficiary, per annum
INFANT PAEDIATRIC BENEFIT (OUT OF HOSPITAL PAID FROM RISK)2 consultations before the age of 12 months1 consultation before the ages of 1 and 2 years
CHILDHOOD ILLNESS BENEFIT CONSULTATION PAID FROM RISK 1 GP consultation p.b.p.a. between the ages of 2 and 12 years
APPLIANCES
GENERAL APPLIANCES R5 600 per family
WHEELCHAIRS AND LARGE ORTHOPAEDIC APPLIANCES Included in the General Appliances limit
STOMA PRODUCTS AND CPAP* MACHINES May exceed General Appliances limit by R5 000
OXYGEN: HOME VENTILATION* Unlimited, subject to pre-authorisation by Hospital Benefit Management
This summary is for information purposes only and does not supersede the rules of the fund. In the event of any discrepancy between the summary and the rules, the rules will prevail.
* Subject to pre-authorisation.* All benefits are per annum, unless otherwise stated. * Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations.
bonitas.co.za0860 002 108Bonitas-Medical-Fund @BonitasMedical
Page 22 Benefits 2014
Major medical expenses are covered at 100% of Bonitas' rate. This benefit includes major medical events. All hospital admissions, oncology treatment and renal dialysis require pre-authorisation by Hospital Benefit Management, except in case of emergencies.
MAJOR MEDICAL BENEFITS
Not everyone needs the same level of day-to-day cover. For some, making sure that they and their family have the right quality cover when they need it most is the most important thing. If that’s you, and if affordability is important, then this is your option. The Primary Option combines affordability with great cover and benefits. It covers all your medical expenses at 100% of our rate and then offers a whole lot more on top of that.
Major medical benefits:Unlimited 100% Bonitas rate
WHAT WILL IT COST?
MAIN MEMBERR1 412
ADULT DEPENDANTR1 105
CHILD DEPENDANT R450
PRIMARY
CHRONIC MEDICINE FOR 26 PMBsDELIVERED BY PHARMACY DIRECT
PRIMARY
All major medical expenses at 100% of Bonitas rate. Unlimited hospitalisation. Substantial GP and day-to-day benefits, while supplementary benefits are
all paid from risk. Chronic medicine for 26 Prescribed Minimum Benefits are obtained from Pharmacy Direct.
GENEROUS GP CONSULTATIONS AND DAY-TO-DAY BENEFITSBASIC DENTISTRY, OPTOMETRY.
SUPPLEMENTARY BENEFITSPAID FROM RISK
100% BONITAS RATEUNLIMITED ANNUAL BENEFITS
Benefits 2014 Page 23
OVERALL ANNUAL LIMIT UNLIMITED
BENEFITS PAYABLE AT 100% OF THE BONITAS RATE
SUB-LIMITS APPLICABLE:
GP AND SPECIALIST CONSULTATIONS Unlimited
PATHOLOGY Unlimited
RADIOLOGY (SPECIALISED AND GENERAL) Unlimited
PARAMEDICAL SERVICES (ALLIED MEDICAL PROFESSIONS), E.G. SPEECH THERAPY, OCCUPATIONAL THERAPY, AUDIOLOGY, DIETETICS
Unlimited
ONCOLOGY1 R127 000 per family
ORGAN TRANSPLANTS PMBs, only covered as per state protocols
CHRONIC RENAL DIALYSIS PMBs, only covered as per state protocols
MAXILLO -FACIAL SURGERY Unlimited, excluding orthognathic surgery
MEDICATION TO TAKE OUT (TTO) R290 per beneficiary, per admission
PHYSICAL REHABILITATION R38 000 per family
ALTERNATIVE TO HOSPITALISATION R12 700 per family
1 All members enrolled in clinical trials should inform the scheme.2 Restrictive formulary. Refer to page 32 for a complete list of chronic conditions.
CO-PAYMENT WILL APPLY TO THE BELOW PROCEDURES IN HOSPITAL
R1 000DEDUCTIBLE
R2 500DEDUCTIBLE
R5 000DEDUCTIBLE
1. Colonoscopy 2. Conservative Back Treatment3. Cystoscopy4. Facet Joint Injections5. Flexible sigmoidoscopy6. Functional Nasal Surgery7. Gastroscopy8. Umbilical Hernia Repair9. Hysteroscopy (but not endometrial
ablation)10. Myringotomy11. Tonsillectomy and Adenoidectomy
(except PMBs)12. Varicose Vein Surgery
1. Arthroscopy2. Diagnostic Laparoscopy3. Hysterectomy (except cancer and PMBs)4. Percutaneous Radiofrequency Ablations 5. Percutaneous rhizotomies6. Laparoscopic Appendectomy7. Laparoscopic Nephrectomy
1. Nissen Fundoplication (Reflux Surgery)2. Back Surgery including spinal fusion3. Joint replacements, e.g. Hip and Knee
replacements (except PMBs)4. Laparoscopic Pyeloplasty5. Laparoscopic Radical Prostatectomy
CHRONIC BENEFITS2
Covers medication for conditions that require medication on an ongoing basis.
Chronic Disease List (CDL) plus applicable chronic DTPs as per the Prescribed Minimum Benefits (PMB), at the Designated Service Provider (DSP), subject to pre-authorisation. 40% co-payment will apply at a non-DSP.
CHRONIC CONDITIONS2 DESIGNATED SERVICE PROVIDER
26 PMBsRESTRICTIVE FORMULARY
Pharmacy Direct
PMBs only at DSP
Page 24 Benefits 2014
OUT OF HOSPITAL BENEFITS
GP Network plus day-to-day benefits, basic dentistry and optometry
OUT OF HOSPITAL BENEFITSCovers day-to -day medical expenses, e.g. GP and specialist consultations, acute medication, pathology, radiology, paramedical services (Allied Medical Professions), optometry, dentistry etc.
GYNAECOLOGISTS Female beneficiaries, 1 visit per annum without referral
PAEDIATRICIANS No referral required for beneficiaries under age 2
ONCOLOGISTS AND OPHTHALMOLOGISTS No referral required
SPECIALIST CONSULTATIONSThe Bonitas Specialist Network is the scheme designated service provider for the provision of PMBs. No co-payment will apply at a Specialist Network Provider.
Specialist referral management will require all beneficiaries to obtaina referral from a GP to consult with a specialist. Specialist referral by a GP is also required for Prescribed Minimum Benefit Conditions.
The following exceptions apply:
The day-to-day benefit is the pool of benefits from which your GP can prescribe the appropriate care to improve your health. This benefit covers acute medication, out of hospital radiology, pathology,
paramedical services (dietetics, occupational therapy, speech therapy, social workers, audiology, physiotherapy and others) and includes specialist consultations which will only be payable on referral by your GP.
DAY-TO-DAY BENEFITS Sub-limit of R380 per beneficiary and R1 100 per family for Pharmacy Advised Therapy (PAT).
R1 600 R2 900 R3 400 R3 700 R4 000
Main Member 1 Dependant 2 Dependants 3 Dependants 4+ Dependants
GP BENEFITSA benefit has been created specifically for out of hospital general practitioner consultations empowering the GP to become your coordinator of care. By making use of a GP in the network, you are not only guaranteed that the doctor will charge the Bonitas rate, but the benefit available is more generous.
A sub-limit applies to non-network visits; this limit is included in the GP benefit limit allowing you the flexibility to see any doctor when you are away from home. To find a network doctor near you, call 0860 00 2108 or visit our website: www.bonitas.co.za
The Bonitas GP Network is the scheme’s designated service provider for the provision of Prescribed Minimum Benefits. A co-payment of 40% will thus apply for out-of-network visits once limits are exhausted.
IN-NETWORK GP BENEFITS R1 500 R2 850 R3 300 R3 600 R4 000
NON -NETWORK GP BENEFITS* *Benefit included in the network benefit
R 500 R 950 R1 100 R1 200 R1 350
Main Member 1 Dependant 2 Dependants 3 Dependants 4+ Dependants
DAY-TO -DAY BENEFIT
Benefits 2014 Page 25
IN ADDITION TO THE DAY TO DAY BENEFIT THE FOLLOWING IS ALSO PROVIDED:
CONSERVATIVE DENTISTRY1 Subject to clinical protocols and Bonitas Dental Rate (BDT)1
SPECIALISED DENTISTRY1 No benefit
OPTOMETRY 2 year benefit, per beneficiary
OPTOMETRIC EXAMINATION 100% of cost in network, or R295 at a non-network provider
FRAMES AND PRESCRIPTION LENSES /ADD-ONSR300 per beneficiary at a network provider. No benefit at a non-network provider
CLEAR SINGLE VISION R150 per lens or
CLEAR AQUITY FLAT-TOP BIFOCAL R325 per lens or
CLEAR AQUITY MULTIFOCAL (UP TO BIFOCAL LIMIT) R600 per lens or
CONTACT LENSES R750 per beneficiary
1 Subject to DENIS clinical protocols and Bonitas dental rate. Refer to page 37 to 44. * Subject to pre-authorisation.* All benefits are per annum, unless otherwise stated.
SUPPLEMENTARY BENEFITS
MATERNITY CARE* PER EVENT (ANTE- AND POSTNATAL)Unlimited hospitalisation, subject to pre-authorisation, 6 antenatal consultations, 2 X 2D scans and 4 post-natal consultations with a midwife
IMMUNE DEFICIENCY RELATED TO HIV INFECTION*R19 000 per beneficiary, subject to Aid for AIDS (AfA) registration. Clinical protocols apply
MENTAL HEALTH BENEFITS*R12 200 per family, subject to pre-authorisation, includes a sub-limit of R7 400 for consultations in and out of hospital
SPECIALISED RADIOLOGY* (JOINT LIMIT IN AND OUT OF HOSPITAL) R9 500 per family, subject to pre-authorisation
EMERGENCY MEDICAL TRANSPORTATION Subject to ER24 authorisation
ENDOSCOPIES* IN PRACTITIONERS’ ROOMS Unlimited subject to pre-authorisation
PROSTHESES INTERNAL AND EXTERNAL* PMBs only
HIV TEST AND FLU VACCINE 1 each per beneficiary, per annum
INFANT PAEDIATRIC BENEFIT (OUT OF HOSPITAL PAID FROM RISK)1 consultation before the age of 1 year.1 consultation between the ages of 1 and 2 years
CHILDHOOD ILLNESS BENEFIT CONSULTATION PAID FROM RISK 1 GP consultation p.b.p.a. between the ages of 2 and 12 years
APPLIANCES
GENERAL APPLIANCES R5 550 per family
WHEELCHAIRS AND LARGE ORTHOPAEDIC APPLIANCES Included in the General Appliances limit
STOMA PRODUCTS AND CPAP* MACHINES May exceed General Appliances limit by R5 000
HEARING AIDS R7 400 per family, biennial benefit (1 Jan 2014 - 31 Dec 2015)
OXYGEN: HOME VENTILATION* Unlimited subject to pre-authorisation by Hospital Benefit Management
Additional benefits, in or out of hospital:
SUPPLEMENTARY BENEFITS
This summary is for information purposes only and does not supersede the rules of the fund. In the event of any discrepancy between the summary and the rules, the rules will prevail.
bonitas.co.za0860 002 108Bonitas-Medical-Fund @BonitasMedical
Page 26 Benefits 2014
BONESSENTIAL
Solid, affordable and uncomplicated hospital plan. Unlimited hospitalisation at 100% of Bonita’s rate. Chronic medicine for 26 Prescribed
Minimum Benefits obtained from Pharmacy Direct. Infant paediatric, childhood illness and supplementary benefits covered from risk.
CHRONIC MEDICINE FOR 26 PMBsDELIVERED BY PHARMACY DIRECT
OUT-OF-HOSPITALBENEFITS FOR PMB CONDITIONS
SUPPLEMENTARY BENEFITSPAID FROM RISK
100% BONITAS RATEUNLIMITED HOSPITALISATION
Most people believe that quality healthcare cover has to be expensive and complicated. By now, you’ll know that’s not how we think at Bonitas. Take our BonEssential Option, for example.
This is the option you need if you want affordable hospital, incident and chronic cover. It is a solid, all-round and uncomplicated hospital plan. Like good health, the BonEssential Option is an essential part of your life that you cannot afford to be without.
Major medical benefits: Unlimited 100% Bonitas rate
WHAT WILL IT COST?
MAIN MEMBERR1 085
ADULT DEPENDANTR830
CHILD DEPENDANT R318
BONESSENTIAL
Benefits 2014 Page 27
OVERALL ANNUAL LIMIT UNLIMITED
BENEFITS PAYABLE AT 100% OF THE BONITAS RATE
SUB-LIMITS APPLICABLE:
GP AND SPECIALIST CONSULTATIONS Unlimited
PATHOLOGY Unlimited
RADIOLOGY (SPECIALISED AND GENERAL) Unlimited
PARAMEDICAL SERVICES (ALLIED MEDICAL PROFESSIONS), E.G. SPEECH THERAPY, OCCUPATIONAL THERAPY, AUDIOLOGY, DIETETICS
Unlimited
ONCOLOGY1 R264 500 per family
ORGAN TRANSPLANTS Unlimited
CHRONIC RENAL DIALYSIS PMBs, only covered as per state protocols
MAXILLO-FACIAL SURGERY Unlimited, excluding orthognathic surgery
MEDICATION TO TAKE OUT (TTO) R290 per beneficiary, per admission
PHYSICAL REHABILITATION R38 000 per family
ALTERNATIVE TO HOSPITALISATION R12 700 per family
Major medical expenses are covered at 100% of Bonitas’ rate. This benefit includes major medical events. All hospital admissions, oncology treatment and renal dialysis require pre-authorisation by Hospital Benefit Management, except in case of emergencies.
MAJOR MEDICAL BENEFITS
CO-PAYMENT WILL APPLY TO THE BELOW PROCEDURES IN HOSPITAL
R1 000DEDUCTIBLE
R2 500DEDUCTIBLE
R5 000DEDUCTIBLE
1. Colonoscopy 2. Conservative Back Treatment3. Cystoscopy4. Facet Joint Injections5. Flexible sigmoidoscopy6. Functional Nasal Surgery7. Gastroscopy8. Umbilical Hernia Repair9. Hysteroscopy (but not endometrial
ablation)10. Myringotomy11. Tonsillectomy and Adenoidectomy
(except PMBs)12. Varicose Vein Surgery
1. Arthroscopy2. Diagnostic Laparoscopy3. Hysterectomy (except cancer and PMBs)4. Percutaneous Radiofrequency Ablations 5. Percutaneous rhizotomies6. Laparoscopic Appendectomy7. Laparoscopic Nephrectomy
1. Nissen Fundoplication (Reflux Surgery)2. Back Surgery including spinal fusion3. Joint replacements, e.g. Hip and Knee
replacements (except PMBs)4. Laparoscopic Pyeloplasty5. Laparoscopic Radical Prostatectomy
1 All members enrolled in clinical trials should inform the scheme.
Page 28 Benefits 2014
CHRONIC BENEFITS1
Covers medication for conditions that require medication on an ongoing basis.
Chronic Disease List (CDL) plus applicable chronic DTPs as per the Prescribed Minimum Benefits (PMB), at the Designated Service Provider (DSP), subject to pre-authorisation. 40% co-payment will apply at a non-DSP.
PMBs only at DSP
CHRONIC CONDITIONS1 DESIGNATED SERVICE PROVIDER
26 PMBs RESTRICTIVE FORMULARY
Pharmacy Direct
OUT OF HOSPITAL BENEFITS
OUT OF HOSPITAL BENEFITSNo benefits for out of hospital expenses, except for the diagnosis, treatment and care of Prescribed Minimum Benefits where appropriate.
Additional benefits, in or out of hospital:
SUPPLEMENTARY BENEFITS
SUPPLEMENTARY BENEFITS
MATERNITY CARE* PER EVENTUnlimited hospitalisation. Subject to pre-authorisation. 6 ante-natal consultations, 2 x 2D scans and 4 post-natal consultations with a midwife
IMMUNE DEFICIENCY RELATED TO HIV INFECTION*R24 800 per beneficiary. Subject to Aid for AIDS (AfA) registration.Clinical protocols apply
MENTAL HEALTH BENEFITS* R24 800 per family in hospital only. Subject to pre-authorisation
EMERGENCY MEDICAL TRANSPORTATION Subject to ER24 authorisation
PROSTHESES INTERNAL AND EXTERNAL* PMBs only
HIV TEST AND FLU VACCINE 1 each per beneficiary, per annum
CHILDHOOD ILLNESS BENEFIT (CONSULTATION PAID FROM RISK) 1 GP consultation p.b.p.a between the ages of 2 and 12 years
This summary is for information purposes only and does not supersede the rules of the fund. in the event of any discrepancy between the summary and the rules, the rules will prevail.
1 Restrictive formulary. Refer to page 32 for a complete list of chronic conditions.* Subject to pre-authorisation.* All benefits are per annum, unless otherwise stated.
bonitas.co.za0860 002 108Bonitas-Medical-Fund @BonitasMedical
Benefits 2014 Page 29
Major medical expenses are covered at 100% of the Bonitas rate. This benefit includes major medical events. All hospital admissions, oncology treatment and renal dialysis require pre-authorisation, except in the case of emergencies.
Pre-authorisation is required for all non-emergency admissions. Emergencies require authorisation within 48 hours of being admitted to hospital or the first working day if over a weekend.
MAJOR MEDICAL BENEFITS
Too often, people avoid going to the doctor because they’re a little cash-strapped or it’s a week away from pay day and every cent is spent. Well, at Bonitas, your health is the most important thing to us.
That’s why our Bonitas BonCap Option gives you access to a professional network of medical experts when you need them, not just when you can afford them. You see, we pay them directly at predetermined rates, which means you’ll never see a bill. What’s more, we help you take control of your health by easily letting you know what you’re covered for and getting the treatment you deserve at no extra cost.
Major medical benefits: Unlimited 100% of the Bonitas rate
BONCAP – NETWORK
*BONCAP CONTRIBUTIONS (CALCULATED ON PENSIONABLE INCOME)
INCOME BAND
MAIN MEMBER
ADULT DEPENDANT
CHILD DEPENDANT
0 to R5 700 R615.00 R583.00 R290.00
R5 701 to R9 300 R748.00 R707.00 R342.00
R9 301 to R12 700 R1 219.00 R1 086.00 R462.00
R12 701+ R1 496.00 R1 332.00 R567.00
Contributions are calculated according to the pensionable income and number of principal members and number of child dependants.
BONCAP-NETWORK
All major medical expenses at 100% of Bonitas rate, with no overall annual limit. Substantial GP and day-to-day benefits with additional supplementary benefits.
Chronic Medicine for 26 Prescribed Minimum Benefits are obtained from Pharmacy Direct.
CHRONIC MEDICINE FOR 26 PMBsDELIVERED BY PHARMACY DIRECT
OUT-OF-HOSPITAL BENEFITSAT NETWORK PROVIDERS
SUPPLEMENTARYADDITIONAL BENEFITS, IN OR OUT OF HOSPITAL.
100% BONITAS RATEUNLIMITED ANNUAL BENEFITS
Page 30 Benefits 2014
OVERALL ANNUAL LIMIT UNLIMITED
BENEFITS PAYABLE AT 100% OF THE BONITAS RATE
SUB-LIMITS APPLICABLE:
GP AND SPECIALIST CONSULTATIONS Unlimited
PATHOLOGY Limited to R19 500, except for PMBs
GENERAL RADIOLOGY Unlimited
SURGICAL PROCEDURES Limited to R13 500 per family per annum
BLOOD TRANSFUSION Limited to R14 200 per family per annum
PHYSIOTHERAPY AND OCCUPATIONAL THERAPY R3 300 per family per annum
ONCOLOGY 1, CHEMO AND RADIOLOGY PMBs only
ORGAN TRANSPLANTS PMBs only
CHRONIC RENAL DIALYSIS PMBs only
MAXILLO-FACIAL SURGERY R13 500 per family, included in surgical procedures
MEDICATION TO TAKE OUT (TTO) R290 per beneficiary, per admission
ALTERNATIVES TO HOSPITALISATION (STEP DOWN OR HOME NURSING) Limited to R11 000 per family per annum, pre-authorisation required
PHYSICAL REHABILITATION PMBs only
1 All members enrolled in clinical trials should inform the scheme2 Subject to BonCap medicine formulary. For a complete list of chronic conditions refer to page 32
CHRONIC MEDICINE BENEFITS2
Prescribed Minimum Benefits only, subject to the designated service provider, Pharmacy Direct and the Network option chronic medicine programme and formulary.
Chronic Disease List (CDL) plus applicable chronic DTPs as per the Prescribed Minimum Benefits (PMB), at the Designated Service Provider (DSP).
CHRONIC CONDITIONS2 DESIGNATED SERVICE PROVIDER
26 PMBsRESTRICTIVEFORMULARY
Pharmacy Direct
Covers day-to-day medical expenses incurred out of hospital, for example: GP consultations, acute medication, pathology, radiology, optometry and dentistry.
OUT OF HOSPITAL BENEFITS
DAY-TO-DAY BENEFITS
GP CONSULTATIONS12 consultations per beneficiary per annum subject to the BonCap GP network. Authorisation is required after the 12th visit. PMBs only after the 12th visit, subject to managed care protocols
OUT-OF-NETWORK CONSULTATIONS1 visit per beneficiary or 2 visits per family to a maximum of R800 and 20% co-payment (except emergencies). No benefit for facility fees
ACUTE MEDICATION Subject to the BonCap Acute Medicine Formulary
Benefits 2014 Page 31
OVER-THE-COUNTER MEDICATION Limited to R205 per beneficiary, maximum of R70 per script
SPECIALIST CONSULTATIONS3 visits per beneficiary limited to R2 400 or 5 visits per family limited to R3 550. Subject to referral from a network GP and pre-authorisation
OCCUPATIONAL THERAPY AND PHYSIOTHERAPY PMBs only, on referral from a network GP
GENERAL RADIOLOGY List of approved investigations. On referral from a network GP
PATHOLOGY List of approved investigations. On referral from a network GP
BASIC DENTISTRY1 Subject to DENIS managed care protocols and approved codes.
Covered at Bonitas Dental Rate:
• 1 consultation p.b.p.a.
• 1 emergency consultation p.b.p.a for pain and sepsis
• 1 preventative treatment p.b.p.a.
• Extractions (removal of teeth) in dental rooms
• 4 fillings and 4 X rays p.b.p.a.
• Plastic dentures: 1 set per family in a 2 year period for beneficiaries 21 years and older. 20% co-payment applies
SPECIALISED DENTISTRY No benefit
OPTOMETRY 2 year benefit, per beneficiary. Benefit commenced 1 Jan 2013. Subject to DSP at PPN network:
• 1 pair of spectacles every 24 months at a PPN provider
• 1 optometric examination per beneficiary
• PPN frame, No benefit at a non-network provider
• 1 pair of clear Aquity single vision lenses or 1 pair of clear Aquity
bifocal lenses
• Clear Aquity multifocal lenses covered up to the cost of the
bifocal lenses
SUPPLEMENTARY BENEFITS
MATERNITY CARE* PER EVENT (ANTE- AND POST NATAL)Subject to BonCap GP network.Neonatal care limited to R35 000 per family
IMMUNE DEFICIENCY RELATED TO HIV INFECTION*Subject to managed care protocols and registration on the BonCap HIV/AIDS programme
MENTAL HEALTH BENEFITS* PMBs only. Subject to the BonCap GP network
SPECIALISED RADIOLOGY* (JOINT LIMIT IN AND OUT OF HOSPITAL) R8 900 per family, included in the OAL and subject to pre-authorisation
EMERGENCY MEDICAL TRANSPORTATION Subject to ER24 authorisation
PROSTHESES INTERNAL* (IN HOSPITAL) PMBs only
PROSTHESES EXTERNAL No benefit
APPLIANCES (INCLUDES GENERAL APPLIANCES, WHEELCHAIRS, STOMA PRODUCTS, CPAP*, HEARING AIDS)
R4 200 per family, in and out of hospital, included in theOAL and subject to pre-authorisation
OXYGEN THERAPY AND HOME VENTILATION Subject to pre-authorisation
HIV TEST AND FLU VACCINE 1 each per beneficiary, per annum
Additional benefits, medical expenses incurred in or out of hospital. All of the following benefits are paid from the Overall Annual Limit and are subject to benefit limits:
SUPPLEMENTARY BENEFITS
This summary is for information purposes only and does not supersede the rules of the fund. in the event of any discrepancy between the summary and the rules, the rules will prevail.
1 Dental benefits. Refer to page 35 to 36.* Subject to pre-authorisation.* All benefits are per annum, unless otherwise stated. * Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations.
bonitas.co.za0860 002 108Bonitas-Medical-Fund @BonitasMedical
Page 32 Benefits 2014
26 PMBsBONSAVE, PRIMARY, BONESSENTIAL, BONCAP
BONCOMPREHENSIVE STANDARD BONCLASSIC
PMBs as per Chronic Disease Listincluding 270 Diagnosis and treatment Pairs (DTP) as indicated in regulation 29.(1) (0) of the Medical Schemes Act.
In addition to the 26 PMB conditions the following 27 diseases are covered, including applicable chronic Diagnosis and treatment Pairs (DTP) as indicated in regulation 29(1)(0) of the Medical Schemes Act.
In addition to the 26 PMB conditions the following 16 diseases are covered including applicable chronic Diagnosis and treatment Pairs (DTP) as indicated in regulation 29(1)(0) of the Medical Schemes Act.
In addition to the 26 PMB conditions the following 37 diseases are covered including applicable chronic Diagnosis and treatment Pairs (DTP) as indicated in regulation 29(1)(0) of the Medical Schemes Act.
26 PMBs1. Addison’s Disease2. Asthma3. Bipolar Mood Disorder4. Bronchiectasis5. Cardiac Failure6. Cardiomyopathy7. Chronic Renal Disease8. Chronic Obstructive
Pulmonary Disease9. Coronary Artery Disease10. Crohn’s Disease11. Diabetes Insipidus12. Diabetes Mellitus Type 113. Diabetes Mellitus Type 214. Dysrhythmias15. Epilepsy16. Glaucoma17. Haemophilia18. Hyperlipidaemia19. Hypertension20. Hypothyroidism21. Multiple Sclerosis22. Parkinson’s Disease23. Rheumatoid Arthritis24. Schizophrenia25. Systemic Lupus
Erythematosus26. Ulcerative Colitis
1. Acne2. Allergic Rhinitis3. Ankylosing Spondylitis4. Attention Deficit Disorder5. Behcet’s Disease6. Barrett’s Oesophagus7. Dermatitis8. Eczema9. Generalised Anxiety Disorder10. Gastro-Oesophageal Reflux
(GORD)11. Gout12. Huntington’s Disease13. Hypoparathyroidism14. Myaesthenia Gravis15. Narcolepsy16. Neuropathies17. Obsessive Compulsive
Disorder18. Osteoporosis19. Paget’s Disease20. Panic Disorder21. Pemphigus22. Polyarteritis Nordosa23. Post-Traumatic Stress
Syndrome24. Pulmonary Interstitial Fibrosis25. Systemic Sclerosis26. Tourette’s Syndrome27. Zollinger-Ellison Syndrome
+ 26 PMBs
1. Acne2. Allergic Rhinitis3. Ankylosing Spondylitis4. Attention Deficit Disorder5. Barrett’s Oesophagus6. Behcet’s Disease7. Dermatitis8. Eczema9. Gastro-Oesaphageal Reflux
(GORD)10. Gout11. Narcolepsy12. Obsessive Compulsive
Disorder13. Panic Disorder14. Post-Traumatic Stress
Syndrome15. Tourette’s Syndrome
16. Zollinger-Ellison Syndrome
+ 26 PMBs
1. Alzheimer disease (early onset)
2. Angina3. Ankylosing Spondylitis4. Attention Deficit Disorder –
in children 5 to 18 years old5. Benigen Prostatic
Hypertrophy6. Barrett’s Oesophagus7. Bulimia Nervosa8. Cancer9. Cardiac Arrhythmias10. Chronic Bronchitis11. Cushing Syndrome12. Cystic Fibrosis13. Deep Vein Thrombosis14. Depression15. Dermatomyositis16. Eczema17. Emphysema18. Gastro-Oesaphageal Reflux
(GORD)19. Generalised Anxiety
Disorder20. Gout21. Hormone Replacement
Therapy22. Hypoparathyroidism23. Infective Endocarditis24. Ischeamic heart disease25. Motor Neuron Disease26. Obsessive Compulsive
Disorder27. Osteoporosis28. Paget’s Disease29. Panic Disorder30. Paraplegia/Quadriplegia31. Polyarteritis Nordosa32. Post-Traumatic Stress
Syndrome33. Pulmonary Interstitial
Fibrosis34. Scleroderma35. Thromboangitis Obliterans36. Tourette’s Syndrome37. Zollinger-Ellison Syndrome
+ 26 PMBs
CHRONIC DISEASE LIST
CHRONIC MEDICINE MANAGEMENTTo apply for chronic medicine authorisation the member, doctor or pharmacist can call chronic medicine management on 0860 100 608. Alternatively, members, doctors or pharmacists may apply for chronic medication online by logging onto the Medscheme website www.medscheme.co.za
Designated service provider for chronic medication - Pharmacy DirectTo apply for the delivery of chronic medication, phone Pharmacy Direct (0860 027 800) or visit the website (www.pharmacydirect.co.za) and request an application form.
bonitas.co.za0860 002 108Bonitas-Medical-Fund @BonitasMedical
Benefits 2014 Page 33
General informationDENIS, a fully accredited managed care organisation, manages your dental benefits on behalf of your medical scheme. There is a pre-defined benefit per procedure which is paid at the published Bonitas Dental Rate (see www.denis.co.za for the list of dental rates).Your dentist will also be able to provide information regarding your benefits, as DENIS supplies all dentists with a Chairside Guide, which illustrates the dental benefits. Benefits for dentistry are paid on a fee for service basis. This means that for every procedure done by a dentist, there is a fee that is charged. These fees may differ from dentist to dentist. Your fund pays a benefit for each procedure which may differ from the fee charged by your dentist. It is your right to negotiate this difference with your dentist. Please refer to the dental benefit table on pages 37 to 44 for the benefits per option and per treatment category. Familiarise yourself with the defined benefits as well as listed exclusions in the dental benefit table before visiting your dentist. By doing so, you will be fully aware of what your fund will pay towards your treatment.
Conservative dentistryAll conservative dental benefits, as set out in the dental benefit table, are covered at the Bonitas Dental Rate (BDT).
Specialised dentistryAll specialised dental benefits, as set out in the dental benefit table, are covered at the Bonitas Dental Rate (BDT). The following specialised dental benefits must be pre-authorised:• Crown and Bridge procedures;• Orthodontics;• Implants;• Intravenous Conscious Sedation; and• Periodontics.
What is pre-authorisation?Benefit pre-authorisation is the prior approval of any of the above-listed specialised dental treatments.
How do I get pre-authorisation?• Call: 0860 336 346• Have the following information ready when you phone DENIS: - Your Bonitas membership number - Name of the practitioner and his/her telephone number and practice registration number - A treatment plan including all relevant procedure codes and applicable tooth numbers, including diagnostic codesOnce authorisation has been obtained, cover for the treatment is subject to fund rules, exclusions and benefit protocols.
What happens if I fail to apply for pre-authorisation?Procedures and treatment not pre-authorised will not attract a benefit with the exception of crown and bridge procedures where a 20% penalty will apply if authorisation is applied after the treatment has been done. Penalties do not apply to emergency hospital admission. Failure to pre-authorise orthodontic treatment will result in a payment ONLY from date of authorisation for the remaining months of treatment, provided that the treatment is clinically indicated. Co-payments for specialised dentistry are levied for orthodontics on the Standard option.
How do I get pre-authorisation for crown and bridge procedures?• Call: 0860 336 346 • Send your treatment plan and clear clinical records together with the laboratory invoice to [email protected] or alternatively post to: Denis, Private Bag X 1, Century City, 7446, Cape Town
BONITAS DENTAL BENEFIT INFORMATION
DENTAL BENEFITS (DENIS)
Page 34 Benefits 2014
• Further information may be requested in order to process your application.• Assessment of a treatment plan and radiographic documentation is required for consideration of crown and bridge benefits. Should the benefit be approved, an authorisation letter will be sent to your treating dental practitioner.
How do I get pre-authorisation for implant procedures?• Call: 0860 336 346 • Send your treatment plan (including all three phases) to [email protected] or alternatively fax it to 0866 770 336 or post to: Denis, Private Bag X 1, Century City, 7446, Cape Town • Further information may be requested in order to process your application. • Assessment of a treatment plan is required for consideration of implant benefits. Should the benefit be approved, an authorisation letter will be sent to your treating dental practitioner.
How do I get pre-authorisation for orthodontic procedures?• Call: 0860 336 346 • Send your treatment plan and clear clinical records to [email protected] or alternatively post to: Denis, Private Bag X 1, Century City, 7446, Cape Town • Further information may be requested in order to process your application. • Assessment of a treatment plan and radiographic documentation is required for consideration of orthodontic benefits. Should the benefit be approved, an authorisation letter will be sent to your treating dental practitioner. • Pre-authorisation is required for removable appliance therapy, functional appliance therapy, partial fixed appliance therapy (preliminary treatment) and comprehensive fixed appliance therapy.
How do I apply for registration on the Periodontal Programme? • This benefit is only available to those members on the Standard, BonClassic and BonComp options who are registered on the periodontal programme. • To apply for the Periodontal Programme, submit your CPITN score (supplied to you by your dental practitioner), together with your periodontal treatment plan to [email protected], or alternatively fax to 0866 770 336. • Further clinical records may be requested to process your application. • Benefit is limited to conservative, non-surgical therapy only and will only be applied to members who are registered on the Periodontal Programme.
General anaesthetic and hospitalisationHospitalisation benefit for dentistry is not automatically covered and is subject to pre-authorisation, where admission protocols apply.
How to get authorisation before going to hospital and for intra-venous conscious sedationContact us on 0860 336 346, at least 48 hours prior to the planned procedure. Have the following information ready when you phone us: • your Bonitas membership number• the date of admission• name of the practitioner and his/her telephone number and practice registration number• the anaesthetist’s practice number and contact details• the name and telephone number of the hospital • all relevant procedure codes and applicable tooth numbers, including diagnostic codes
• in certain instances an X-ray, clinical report or additional information will be requested in order to process your pre-authorisation• if the hospital admission is authorised, you will be supplied with an authorisation number, via your preferred method (fax or email)• the hospital account will be paid according to the time allocated on the authorisation letter. Hospital accounts exceeding this time will be the member’s liability• in the event of an emergency after hours, let DENIS know about your hospitalisation as soon as possible.
Note: If you do not obtain authorisation before your hospital admission, the associated costs (hospital and anaesthetic accounts) will not be paid.
Dental Wellness ProgrammeAs a Bonitas member, you are automatically a member of the Dental Wellness Programme. You will receive various treatment-related information leaflets and at your company’s Wellness Days oral screenings, advice and dental products are provided.
Get your dental claims to Denis!Post the original copies of your dental claims to: Denis, Private Bag X 1, Century City, 7446, Cape TownAlternatively, you can email your dental claims to [email protected]
When submitting a claim, please ensure the following details are clearly visible:• 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 applicable tooth numbers. • The relevant ICD-10 codes. • If you have already paid for the treatment, ensure that the appropriate receipt is attached.
DENIS contact detailsCall centre: 0860 336 346 Call centre fax: 0866 770 336Email (enquiries): [email protected] (claims): [email protected] (hospital authorisations): [email protected] (orthodontic and implant authorisations): [email protected] Email (crown and bridge authorisations): [email protected] Email (periodontal authorisations): [email protected]
Stale claimsIn terms of the Medical Schemes Act, claims that are not received within four months from the end of the month in which the service was provided, are regarded as stale and will not be eligible for benefit. In the event of a dispute regarding the benefit information illustrated in the benefit table, following, the rules of the fund will prevail.
Benefits 2014 Page 35
Dental benefits are managed by DENIS at the Bonitas Dental rate (BDT) and are subject to a DENIS Designated Service Provider Network for conservative out of hospital services. If there is no Designated Service Provider in the member’s area, the member needs to contact DENIS prior to treatment. This option does not provide benefits for any specialised dentistry, with the exception of limited maxillo-facial dentistry. Dental benefits are subject to managed care protocols and managed care interventions which may include the requirement of treatment plans and/or radiographs prior to benefit application. Only the dental codes listed in the table below will be covered under this option except in the case of authorised hospitalisation and authorised PMB events. In the event of a dispute, the registered rules of the scheme prevail.
There is no overall annual limit on BonCap for 2014. The Maxillo-Facial benefit resides under the benefit for Surgical Procedures. The Surgical
Procedure benefit has a limit of R13 500 per family per year. Access to a Maxillo-facial specialist is ONLY on referral from a dentist on the DENIS Designated Service Provider Network and authorised by DENIS. All dental-related hospitalisation, including PMBs, must be pre-authorised* by DENIS and is subject to the BonCap Hospital Network. Hospital procedures not pre-authorised will be subject to a co-payment of R5 000 on the hospital account for both private and public hospitals if authorisation is applied for after the treatment has been done. If authorisation is obtained for an elective procedure in a non-network hospital, a co-payment of R5 000 is applicable on the hospital account. Emergencies require authorisation within 48 hours of the first working day.
Please note that ALL dental claims (out of hospital dentistry, in hospital dentistry and related anaesthetics) will be processed by Medscheme.
BONCAP DENTAL BENEFIT TABLE 2014
CODE BENEFIT DENIS BENEFIT INFORMATION
8101 Consultation 1 check-up per beneficiary per year
8104 Specific Consultation (emergency) 1 specific (emergency) consultation for pain and sepsis per beneficiary per year
8107 and/or 8112 Intra-Oral X-rays 4 X-rays in total per beneficiary per year
8115 Extra-Oral X-rays 1 per beneficiary in a 3 year period for Maxillo-facial related treatment ONLY. Extra-oral X-ray to be submitted to DENIS for review
81558159
8161 or 8162
8163
Polishing of TeethScaling and Polishing
Fluoride Treatment
Fissure Sealant
1 polish OR 1 scaling and polishing per beneficiary per year. 1 treatment per year for beneficiaries from 5 years of age and under 16 years of age.(8161: 5 - 12 years of age; 8162: 13 - 15 years of age)
1 per tooth in a 3 year period for beneficiaries younger than 16 years of age
810981108145
Infection ControlInstrument SterilisationLocal Anaesthetic
1 set per beneficiary per visit. (A Set: 8109 x 2, 8110 x 1 and 8145 x 1)
81418143
Inhalation Sedation(Laughing gas in dental rooms)
Inhalation sedation limited to extensive dental treatment only:• 8141 First 15 minutes• 8143 Each additional 15 minutes
8131 81328133
Emergency Root Canal Therapy Benefit for emergency treatment only. Recement inlay, onlay, crown or veneer.NOTE: Root canal treatment on 3rd molar is not covered.
8307 Pulp Treatments Benefit for amputation of pulp of primary teeth
8201
8202
8935
Extractions(Removal of teeth)
Code 8201 is charged for the first extraction in a quadrant.Code 8202 is charged for each additional extraction in a quadrant.Treatment of septic sockets
Page 36 Benefits 2014
CODE BENEFIT DENIS BENEFIT INFORMATION
834183428343834483518352835383548367836883698370
Dental Fillings Benefit for 4 fillings per beneficiary per year.Benefit for fillings are granted once per tooth in 365 days. Benefit for re-treatment of a tooth is subject to managed care protocols.
82318232823382348235823682378238823982408241
Plastic Dentures One set of plastic dentures (an upper and a lower) per family in a 2 year period for beneficiaries 21 years and older. 20% co-payment applies. The appropriate laboratory codes will be covered. 20% co-payment applies.
8259 Denture Rebase Rebase of dentures once per family per year for beneficiaries 21 years and older. 20% co-payment applies. The appropriate laboratory codes will be covered. 20% co-payment applies.
8263826982718273
Denture Repairs Repairs to existing dentures twice per family per year for beneficiaries 21 years and older. 20% co-payment applies. The appropriate laboratory codes will be covered. 20% co-payment applies..
8937821382148953894189438945
Maxillo-facial Surgery in dental chair* Surgery in the dental chair – DENIS Designated Service Provider; access to a maxillo-facial specialist by DENIS pre-authorisation ONLY. A limit of R13 500 per family per year.Surgical removal of tooth.Surgical removal of residual roots.Surgical removal of impacted teeth.Cover for PMB treatment.
NOTE: No benefit for Osseo-integrated implants and Orthognathic surgery.
8144 IV Conscious Sedation in the rooms* Pre-authorisation from DENIS is required.Benefit is limited to extensive dental treatment.
Hospitalisation*(General anaesthetic)
Pre-authorisation from DENIS is required, subject to a preferred provider network.General anaesthetic benefits are only available for the following: • Extensive dental treatment for children younger than 5 years of age• For the removal of impacted teeth • PMB admissions
Benefits 2014 Page 37
BON
ITAS
DEN
TAL
BEN
EFIT
TAB
LE 2
014
DEN
TAL
BEN
EFIT
TA
BLE
BON
CLAS
SIC*
**ST
AND
ARD
BO
NSA
VE A
ND
PRI
MAR
Y
CONSERVATIVE
DENTISTRY
CON
SULT
A-TI
ON
S2
annu
al c
heck
-ups
per
be
nefic
iary
(onc
e in
6 m
onth
s).
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BD
T
2 an
nual
che
ck-u
ps p
er
bene
ficia
ry (o
nce
in 6
mon
ths)
.Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.Co
vere
d at
the
BD
T
2 an
nual
che
ck-u
ps p
er
bene
ficia
ry (o
nce
in 6
mon
ths)
Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s Co
vere
d at
the
BD
T
X-RA
YS: I
N-
TRA-
ORA
L
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BD
T
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Cove
red
at t
he B
DT
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Cove
red
at t
he B
DT
X-RA
YS: E
X-TR
A-O
RAL
1 pe
r ben
efici
ary
in a
3 y
ear p
erio
d Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.
Addi
tion
al b
enefi
t m
ay b
e co
nsid
ered
w
here
spe
cial
ised
den
tal t
reat
men
t is
re
quire
d.Co
vere
d at
the
BD
T
1 pe
r ben
efici
ary
in a
3 y
ear p
erio
dBe
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.
Addi
tion
al b
enefi
t m
ay b
e co
nsid
ered
w
here
spe
cial
ised
den
tal t
reat
men
t is
re
quire
d.Co
vere
d at
the
BD
T
1 pe
r ben
efici
ary
in a
3 y
ear p
erio
d.Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.
Cove
red
at t
he B
DT
ORA
L H
YGIE
NE
2 an
nual
sca
le a
nd p
olis
h tr
eatm
ents
pe
r ben
efici
ary
(onc
e in
6 m
onth
s).
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Be
nefit
for fi
ssur
e se
alan
ts is
lim
ited
to
ben
efici
arie
s yo
unge
r tha
n 16
yea
rs
of a
ge.
Bene
fit fo
r flu
orid
e is
lim
ited
to
bene
ficia
ries
you
nger
tha
n 16
yea
rs
of a
ge.
Cove
red
at t
he B
DT
2 an
nual
sca
le a
nd p
olis
h tr
eatm
ents
pe
r ben
efici
ary
(onc
e in
6 m
onth
s).
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Be
nefit
for fi
ssur
e se
alan
ts is
lim
ited
to
ben
efici
arie
s yo
unge
r tha
n 16
yea
rs
of a
ge.
Bene
fit fo
r flu
orid
e is
lim
ited
to
bene
ficia
ries
you
nger
tha
n 16
yea
rs
of a
ge.
Cove
red
in B
DT
2 an
nual
sca
le a
nd p
olis
h tr
eatm
ents
pe
r ben
efici
ary
(onc
e in
6 m
onth
s).
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Be
nefit
for fi
ssur
e se
alan
ts is
lim
ited
to
ben
efici
arie
s yo
unge
r tha
n 16
yea
rs
of a
ge.
Bene
fit fo
r flu
orid
e is
lim
ited
to
bene
ficia
ries
you
nger
tha
n 16
yea
rs
of a
ge.
Cove
red
in B
DT
Den
tal b
enefi
ts a
re p
aid
at t
he B
onit
as D
enta
l rat
e (B
DT)
. Hos
pita
lisat
ion
and
cert
ain
spec
ialis
ed
dent
istr
y pr
oced
ures
and
tre
atm
ent
mus
t be
pre
-aut
hori
sed*
. Pro
cedu
res
and
trea
tmen
t no
t
pre-
auth
oris
ed w
ill n
ot a
ttra
ct a
ben
efit,
wit
h th
e ex
cept
ion
of c
row
n an
d br
idge
pro
cedu
res
whe
re
a 20
% p
enal
ty w
ill a
pply
if a
utho
risa
tion
is a
pplie
d fo
r aft
er t
he t
reat
men
t ha
s be
en d
one.
Fai
lure
to
pre-
auth
oris
e or
thod
onti
c tr
eatm
ent
will
resu
lt in
a p
aym
ent
ON
LY fr
om d
ate
of a
utho
risa
tion
for t
he
rem
aini
ng m
onth
s of
tre
atm
ent,
pro
vide
d th
at t
he t
reat
men
t is
clin
ical
ly in
dica
ted.
Pen
alti
es d
o no
t ap
ply
to e
mer
genc
y ho
spit
al a
dmis
sion
. Co-
paym
ents
are
levi
ed fo
r Ort
hodo
ntic
s on
the
St
anda
rd o
ptio
n.
Den
tal b
enefi
ts a
re s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s an
d m
anag
ed c
are
inte
rven
tion
s w
hich
may
in
clud
e th
e re
quire
men
t of
tre
atm
ent
plan
s an
d/or
radi
ogra
phs
prio
r to
bene
fit a
pplic
atio
n.
Sche
me
excl
usio
ns a
pply
to
dent
al b
enefi
ts. I
n th
e ev
ent
of a
dis
pute
, the
regi
ster
ed ru
les
of t
he
sche
me
prev
ail.
BonC
ompr
ehen
sive
opt
ion*
*Th
e de
ntal
ben
efits
of t
he B
onCo
m o
ptio
n w
ill b
e pa
id fr
om t
he m
embe
r’s
avai
labl
e sa
ving
s an
d/or
thr
esho
ld li
mit
. The
den
tal b
enefi
ts a
s pu
blis
hed
belo
w w
ill a
pply
, sub
ject
to
DEN
IS m
anag
ed
care
pro
toco
ls a
nd m
anag
ed c
are
inte
rven
tion
s w
hich
incl
ude
pre-
auth
oris
atio
n w
here
nec
essa
ry.
Pre-
auth
oris
atio
n is
requ
ired
for c
row
ns, o
rtho
dont
ics,
impl
ants
, per
iodo
ntic
s, h
ospi
tal a
nd IV
co
nsci
ous
seda
tion
. A 2
5% c
o-pa
ymen
t in
thr
esho
ld a
pplie
s to
all
cons
erva
tive
and
spe
cial
ised
de
ntal
pro
cedu
res
and
trea
tmen
t. C
o-pa
ymen
ts a
re n
ot a
pplic
able
to
max
illo-
faci
al s
urge
ry a
nd
hosp
ital
isat
ion.
Ple
ase
note
tha
t M
edsc
hem
e w
ill b
e re
spon
sibl
e fo
r the
pay
men
t of
all
dent
al c
laim
s on
the
Bon
Com
opt
ion.
BonC
lass
ic**
* Co
nser
vati
ve d
enti
stry
lim
ited
to
R3 6
00 p
er fa
mily
per
ann
um.
Spec
ialis
ed d
enti
stry
lim
ited
to
R4 3
00 p
er fa
mily
per
ann
um.
Page 38 Benefits 2014
DEN
TAL
BEN
EFIT
TA
BLE
BON
COM
PREH
ENSI
VEBO
NCL
ASSI
CST
AND
ARD
BO
NSA
VE A
ND
PRI
MAR
Y
ORA
L H
YGIE
NE
Sche
me
excl
usio
ns:
• O
ral h
ygie
ne in
stru
ctio
ns•
Ora
l hyg
iene
eva
luat
ion
• Pr
ofes
siona
lly a
pplie
d flu
orid
e fo
r
bene
ficia
ries 1
6 ye
ars a
nd o
lder
• D
enta
l ble
achi
ng
Sche
me
excl
usio
ns:
• O
ral h
ygie
ne in
stru
ctio
ns•
Ora
l hyg
iene
eva
luat
ion
• Pr
ofes
siona
lly a
pplie
d flu
orid
e
for b
enefi
ciar
ies 1
6 ye
ars a
nd o
lder
• D
enta
l ble
achi
ng
Sche
me
excl
usio
ns:
• Ora
l hyg
iene
inst
ruct
ions
• Ora
l hyg
iene
eva
luat
ion
• Pro
fess
iona
lly a
pplie
d fl
uori
de fo
r be
nefic
iari
es 1
6 ye
ars
and
olde
r• D
enta
l ble
achi
ng
Sche
me
excl
usio
ns:
• Ora
l hyg
iene
inst
ruct
ions
• Ora
l hyg
iene
eva
luat
ion
• Pro
fess
iona
lly a
pplie
d fl
uori
de fo
r b
enefi
ciar
ies
16 y
ears
and
old
er• D
enta
l ble
achi
ng
FILL
INGS
Bene
fit fo
r filli
ngs a
re g
rant
ed o
nce
per
toot
h in
365
day
s.Be
nefit
for r
e-tr
eatm
ent o
f a to
oth
is su
bjec
t to
man
aged
care
pro
toco
ls.
Cove
red
at th
e BD
T.A
trea
tmen
t pla
n an
d X-
rays
may
be
requ
ired
for m
ultip
le fi
lling
s.Sc
hem
e ex
clus
ions
:•
Filli
ngs t
o re
stor
e te
eth
dam
aged
due
to
toot
hbru
sh a
bras
ion,
att
ritio
n, e
rosio
n an
d
flu
oros
is
• Re
sin b
ondi
ng fo
r res
tora
tions
that
are
ch
arge
d as
a se
para
te p
roce
dure
to th
e
rest
orat
ion
• Th
e po
lishi
ng o
f res
tora
tions
•
Gold
foil r
esto
ratio
ns
• O
zone
ther
apy
Bene
fit fo
r filli
ngs i
s gra
nted
onc
e pe
r too
th
in 3
65 d
ays.
Bene
fit fo
r re-
trea
tmen
t of a
toot
h is
subj
ect
to m
anag
ed ca
re p
roto
cols.
Co
vere
d at
the
BDT.
A tr
eatm
ent p
lan
and
X-ra
ys m
ay b
e re
quire
d fo
r mul
tiple
filli
ngs.
Sche
me
excl
usio
ns:
• Fi
lling
s to
rest
ore
teet
h da
mag
ed d
ue to
to
othb
rush
abr
asio
n, a
ttrit
ion,
ero
sion
and
flu
oros
is
• Re
sin b
ondi
ng fo
r res
tora
tions
that
are
ch
arge
d as
a se
para
te p
roce
dure
to th
e
rest
orat
ion
• Th
e po
lishi
ng o
f res
tora
tions
•
Gold
foil r
esto
ratio
ns
• O
zone
ther
apy
Bene
fit fo
r filli
ngs i
s gra
nted
onc
e pe
r too
th
in 3
65 d
ays.
Bene
fit fo
r re-
trea
tmen
t of a
toot
h is
subj
ect
to m
anag
ed ca
re p
roto
cols.
Co
vere
d at
the
BDT.
A tr
eatm
ent p
lan
and
X-ra
ys m
ay b
e re
quire
d fo
r mul
tiple
filli
ngs.
Sche
me
excl
usio
ns:
• Fi
lling
s to
rest
ore
teet
h da
mag
ed d
ue to
to
othb
rush
abr
asio
n, a
ttrit
ion,
ero
sion
and
flu
oros
is
• Re
sin b
ondi
ng fo
r res
tora
tions
that
are
ch
arge
d as
a se
para
te p
roce
dure
to th
e
rest
orat
ion
• Th
e po
lishi
ng o
f res
tora
tions
•
Gold
foil r
esto
ratio
ns
• O
zone
ther
apy
Bene
fit fo
r filli
ngs i
s gra
nted
onc
e pe
r too
th
in 3
65 d
ays.
Bene
fit fo
r re-
trea
tmen
t of a
toot
h is
subj
ect
to m
anag
ed ca
re p
roto
cols.
Co
vere
d at
the
BDT.
A tr
eatm
ent p
lan
and
X-ra
ys m
ay b
e re
quire
d fo
r mul
tiple
filli
ngs.
Sche
me
excl
usio
ns:
• Fi
lling
s to
rest
ore
teet
h da
mag
ed d
ue to
to
othb
rush
abr
asio
n, a
ttrit
ion,
ero
sion
and
flu
oros
is
• Re
sin b
ondi
ng fo
r res
tora
tions
that
are
ch
arge
d as
a se
para
te p
roce
dure
to th
e
rest
orat
ion
• Th
e po
lishi
ng o
f res
tora
tions
•
Gold
foil r
esto
ratio
ns
• O
zone
ther
apy
ROO
T CA
NAL
TH
ERAP
Y AN
DEX
TRAC
TIO
NS
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BDT.
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BDT.
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BDT.
Bene
fit is
subj
ect t
o m
anag
ed ca
re p
roto
cols.
Bene
fit fo
r roo
t can
al in
clud
es a
ll tee
th
exce
pt p
rimar
y te
eth
and
perm
anen
t mol
ars.
Cove
red
at th
e BD
T.
Sche
me
excl
usio
ns:
• Ro
ot ca
nal t
hera
py o
n pr
imar
y (m
ilk) t
eeth
• Ro
ot ca
nal t
hera
py o
n w
isdom
teet
h
(3rd
mol
ars)
• D
irect
and
indi
rect
pul
p ca
ppin
g
pr
oced
ures
Sche
me
excl
usio
ns:
• Ro
ot ca
nal t
hera
py o
n pr
imar
y (m
ilk) t
eeth
• Ro
ot ca
nal t
hera
py o
n w
isdom
teet
h
(3rd
mol
ars)
• D
irect
and
indi
rect
pul
p ca
ppin
g
pr
oced
ures
Sche
me
excl
usio
ns:
• Ro
ot ca
nal t
hera
py o
n pr
imar
y (m
ilk) t
eeth
• Ro
ot ca
nal t
hera
py o
n w
isdom
teet
h
(3rd
mol
ars)
• D
irect
and
indi
rect
pul
p ca
ppin
g
pr
oced
ures
Sche
me
excl
usio
ns:
• Ro
ot ca
nal t
hera
py o
n pr
imar
y (m
ilk) t
eeth
• Ro
ot ca
nal t
hera
py o
n w
isdom
teet
h
(3rd
mol
ars)
• D
irect
and
indi
rect
pul
p ca
ppin
g
pr
oced
ures
PLAS
TIC
DEN
TURE
S AN
DAS
SOCI
ATED
LA
BORA
TORY
CO
STS
1 se
t of p
last
ic d
entu
res (
an u
pper
and
a
low
er) p
er b
enefi
ciar
y in
a 4
year
per
iod.
Bene
fit is
subj
ect t
o m
anag
ed ca
re
prot
ocol
s.
Cove
red
at th
e BD
T**
1 se
t of p
last
ic d
entu
res (
an u
pper
and
a
low
er) p
er b
enefi
ciar
y in
a 4
year
per
iod
Bene
fit is
subj
ect t
o m
anag
ed ca
re
prot
ocol
s.
Cove
red
at th
e BD
T
1 se
t of p
last
ic d
entu
res (
an u
pper
and
a
low
er) p
er b
enefi
ciar
y in
a 4
year
per
iod
Bene
fit is
subj
ect t
o m
anag
ed ca
re
prot
ocol
s.
Cove
red
at th
e BD
T
1 se
t of p
last
ic d
entu
res (
an u
pper
and
a
low
er) p
er b
enefi
ciar
y in
a 4
year
per
iod
Ben
efit i
s sub
ject
to m
anag
ed ca
repr
otoc
ols.
Co
vere
d at
the
BDT
Benefits 2014 Page 39
DEN
TAL
BEN
EFIT
TA
BLE
BON
COM
PREH
ENSI
VEBO
NCL
ASSI
CST
AND
ARD
BO
NSA
VE A
ND
PRI
MAR
Y
PLAS
TIC
DEN
TURE
S AN
DAS
SOCI
ATED
LA
BORA
TORY
CO
STS
Bene
fit is
not
ava
ilabl
e fo
r the
clin
ical
fe
e of
den
ture
repa
irs,
den
ture
too
th
repl
acem
ents
and
the
add
itio
n of
a s
oft
base
to
new
den
ture
s; t
he la
bora
tory
fe
e w
ill b
e co
vere
d.Be
nefit
is n
ot a
vaila
ble
for t
he
labo
rato
ry fe
e of
mou
thgu
ards
; th
e cl
inic
al fe
e w
ill b
e co
vere
dSc
hem
e ex
clus
ions
:•
Dia
gnos
tic
dent
ures
and
ass
ocia
ted
la
bora
tory
cos
ts•
Snor
ing
appl
ianc
es a
nd a
ssoc
iate
d
la
bora
tory
cos
ts
• H
igh
impa
ct a
cryl
ic•
The
cost
of g
old,
pre
ciou
s m
etal
,
sem
i-pre
ciou
s m
etal
and
pla
tinu
m fo
il•
Labo
rato
ry d
eliv
ery
fees
• Pr
ovis
iona
l den
ture
s an
d as
soci
ated
labo
rato
ry c
osts
Plea
se n
ote:
Bene
fit fo
r pla
stic
den
ture
s an
d as
soci
ated
labo
rato
ry c
osts
is p
ayab
le
from
the
ava
ilabl
e Co
nser
vati
ve
dent
istr
y lim
it.
Bene
fit is
not
ava
ilabl
e fo
r the
clin
ical
fe
e of
den
ture
repa
irs,
den
ture
too
th
repl
acem
ents
and
the
add
itio
n of
a s
oft
base
to
new
den
ture
s; t
he la
bora
tory
fe
e w
ill b
e co
vere
d.Be
nefit
is n
ot a
vaila
ble
for t
he
labo
rato
ry fe
e of
mou
thgu
ards
; th
e cl
inic
al fe
e w
ill b
e co
vere
d.Sc
hem
e ex
clus
ions
:•
Dia
gnos
tic
dent
ures
and
ass
ocia
ted
la
bora
tory
cos
ts•
Snor
ing
appl
ianc
es a
nd a
ssoc
iate
d
la
bora
tory
cos
ts
• H
igh
impa
ct a
cryl
ic•
The
cost
of g
old,
pre
ciou
s m
etal
,
sem
i-pre
ciou
s m
etal
and
pla
tinu
m fo
il•
Labo
rato
ry d
eliv
ery
fees
• Pr
ovis
iona
l den
ture
s an
d as
soci
ated
labo
rato
ry c
osts
Bene
fit is
not
ava
ilabl
e fo
r the
clin
ical
fe
e of
den
ture
repa
irs,
den
ture
too
th
repl
acem
ents
and
the
add
itio
n of
a s
oft
base
to
new
den
ture
s; t
he la
bora
tory
fe
e w
ill b
e co
vere
d.Be
nefit
is n
ot a
vaila
ble
for t
he
labo
rato
ry fe
e of
mou
thgu
ards
; th
e cl
inic
al fe
e w
ill b
e co
vere
dSc
hem
e ex
clus
ions
:•
Dia
gnos
tic
dent
ures
and
ass
ocia
ted
la
bora
tory
cos
ts•
Snor
ing
appl
ianc
es a
nd a
ssoc
iate
d
la
bora
tory
cos
ts
• H
igh
impa
ct a
cryl
ic•
The
cost
of g
old,
pre
ciou
s m
etal
,
sem
i-pre
ciou
s m
etal
and
pla
tinu
m fo
il•
Labo
rato
ry d
eliv
ery
fees
• Pr
ovis
iona
l den
ture
s an
d as
soci
ated
labo
rato
ry c
osts
Bene
fit is
not
ava
ilabl
e fo
r the
clin
ical
fe
e of
den
ture
repa
irs,
den
ture
too
th
repl
acem
ents
and
the
add
itio
n of
a s
oft
base
to
new
den
ture
s; t
he la
bora
tory
fe
e w
ill b
e co
vere
d.Be
nefit
is n
ot a
vaila
ble
for t
he
labo
rato
ry fe
e of
mou
thgu
ards
; th
e cl
inic
al fe
e w
ill b
e co
vere
d.Sc
hem
e ex
clus
ions
:•
Dia
gnos
tic
dent
ures
and
ass
ocia
ted
la
bora
tory
cos
ts•
Snor
ing
appl
ianc
es a
nd a
ssoc
iate
d
la
bora
tory
cos
ts•
Hig
h im
pact
acr
ylic
• Th
e co
st o
f gol
d, p
reci
ous
met
al,
se
mi-p
reci
ous
met
al a
nd p
lati
num
foil
• La
bora
tory
del
iver
y fe
es•
Prov
isio
nal d
entu
res
and
asso
ciat
ed
la
bora
tory
cos
ts
PART
IAL
MET
AL F
RAM
E D
ENTU
RES
AND
AS
SOCI
ATED
LA
BORA
TORY
CO
STS
2 pa
rtia
l fra
mes
(an
uppe
r and
a lo
wer
) pe
r ben
efici
ary
in a
5 y
ear p
erio
d.Be
nefit
is s
ubje
ct to
man
aged
car
e pr
otoc
ols.
Cove
red
at t
he B
DT.
Sche
me
excl
usio
ns:
• Th
e m
etal
bas
e to
full
dent
ures
and
asso
ciat
ed la
bora
tory
cos
ts•
Hig
h im
pact
acr
ylic
• Th
e co
st o
f gol
d, p
reci
ous
met
al, s
emi-
pr
ecio
us m
etal
and
pla
tinu
m fo
il•
Labo
rato
ry d
eliv
ery
fees
2 pa
rtia
l met
al fr
ames
(an
uppe
r and
a
low
er) p
er b
enefi
ciar
y in
a 5
yea
r per
iod.
Bene
fit is
sub
ject
to m
anag
ed c
are
prot
ocol
s.Co
vere
d at
the
BD
T.Sc
hem
e ex
clus
ions
:•
The
met
al b
ase
to fu
ll de
ntur
es a
nd
as
soci
ated
labo
rato
ry c
osts
• H
igh
impa
ct a
cryl
ic•
The
cost
of g
old,
pre
ciou
s m
etal
, sem
i-
prec
ious
met
al a
nd p
lati
num
foil
• La
bora
tory
del
iver
y fe
es
1 pa
rtia
l met
al fr
ames
(an
uppe
r and
a
low
er) p
er b
enefi
ciar
y in
a 5
yea
r per
iod.
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Cove
red
at t
he B
DT.
Sche
me
excl
usio
ns:
• Th
e m
etal
bas
e to
full
dent
ures
and
asso
ciat
ed la
bora
tory
cos
ts•
Hig
h im
pact
acr
ylic
• Th
e co
st o
f gol
d, p
reci
ous
met
al,
se
mi-p
reci
ous
met
al a
nd p
lati
num
foil
• La
bora
tory
del
iver
y fe
es
No
bene
fit
CRO
WN
AN
D
BRID
GE*
AN
D
ASSO
CIAT
ED
LABO
RATO
RY
COST
S.A
BRID
GE
COM
PRIS
ES
2 O
R M
ORE
CR
OW
N U
NIT
S.
EACH
CRO
WN
IS
PAY
ABLE
FR
OM
TH
E AV
AILA
BLE
CRO
WN
AN
D B
RID
GE
BEN
EFIT
.
Pre-
auth
oris
atio
n is
requ
ired.
3
crow
ns p
er fa
mily
per
yea
r. Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.
Cove
red
at t
he B
DT.
Bene
fits
for c
row
ns w
ill b
e gr
ante
d on
ce p
er t
ooth
in a
5 y
ear p
erio
dA
trea
tmen
t pl
an a
nd X
-ray
s m
ay b
e
requ
este
d
Pre-
auth
oris
atio
n is
requ
ired.
1
crow
n pe
r fam
ily p
er y
ear.
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BD
T.Be
nefit
s fo
r cro
wns
will
be
gran
ted
once
per
too
th in
a 5
yea
r per
iod
A tr
eatm
ent
plan
and
X-r
ays
may
be
re
ques
ted
Pre-
auth
oris
atio
n is
requ
ired.
1
crow
n pe
r fam
ily p
er y
ear.
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BD
T.Be
nefit
s fo
r cro
wns
will
be
gran
ted
once
per
too
th in
a 5
yea
r per
iod
A tr
eatm
ent
plan
and
X-r
ays
may
be
re
ques
ted
No
bene
fit
Page 40 Benefits 2014
DEN
TAL
BEN
EFIT
TA
BLE
BON
COM
PREH
ENSI
VEBO
NCL
ASSI
CST
AND
ARD
BO
NSA
VE
AND
PR
IMAR
YCR
OW
N A
ND
BR
IDG
E* A
ND
AS
SOCI
ATED
LA
BORA
TORY
CO
STS
A BR
IDG
E CO
MPR
ISES
2
OR
MO
RE
CRO
WN
U
NIT
S. E
ACH
CR
OW
N IS
PA
YABL
E FR
OM
TH
E AV
AILA
BLE
CRO
WN
AN
D B
RID
GE
BEN
EFIT
.
Sche
me
excl
usio
ns:
• Cr
owns
or c
row
n re
tain
ers
on w
isdo
m
te
eth
(3rd
mol
ars)
• Po
ntic
s on
2nd
mol
ars
• Cr
own
and
brid
ge p
roce
dure
s for
cosm
etic
reas
ons
and
asso
ciat
ed
la
bora
tory
cos
ts•
Full
mou
th re
habi
litat
ions
and
asso
ciat
ed la
bora
tory
cos
ts•
Prov
isio
nal c
row
ns a
nd a
ssoc
iate
d
labo
rato
ry c
osts
• Po
rcel
ain
vene
ers
and
inla
ys a
nd
as
soci
ated
labo
rato
ry c
osts
• Em
erge
ncy
crow
ns t
hat
are
not
pl
aced
for t
he im
med
iate
pro
tect
ion
in
too
th in
jury
and
ass
ocia
ted
labo
rato
ry c
osts
.•
The
cost
of g
old,
pre
ciou
s m
etal
,
sem
i-pre
ciou
s m
etal
and
pla
tinu
m fo
il•
Labo
rato
ry d
eliv
ery
fees
Sche
me
excl
usio
ns:
• Cr
owns
or c
row
n re
tain
ers
on w
isdo
m
te
eth
(3rd
mol
ars)
• Po
ntic
s on
2nd
mol
ars
• Cr
own
and
brid
ge p
roce
dure
s for
cosm
etic
reas
ons
and
asso
ciat
ed
la
bora
tory
cos
ts•
Full
mou
th re
habi
litat
ions
and
as
soci
ated
labo
rato
ry c
osts
• Pr
ovis
iona
l cro
wns
and
ass
ocia
ted
labo
rato
ry c
osts
• Po
rcel
ain
vene
ers
and
inla
ys a
nd
as
soci
ated
labo
rato
ry c
osts
• Em
erge
ncy
crow
ns t
hat
are
not
pl
aced
for t
he im
med
iate
pro
tect
ion
in
too
th in
jury
and
ass
ocia
ted
labo
rato
ry c
osts
.•
The
cost
of g
old,
pre
ciou
s m
etal
,
sem
i-pre
ciou
s m
etal
and
pla
tinu
m fo
il•
Labo
rato
ry d
eliv
ery
fees
Sche
me
excl
usio
ns:
• Cr
owns
or c
row
n re
tain
ers
on w
isdo
m
te
eth
(3rd
mol
ars)
• Po
ntic
s on
2nd
mol
ars
• Cr
own
and
brid
ge p
roce
dure
s for
cosm
etic
reas
ons
and
asso
ciat
ed
la
bora
tory
cos
ts•
Full
mou
th re
habi
litat
ions
and
asso
ciat
ed la
bora
tory
cos
ts•
Prov
isio
nal c
row
ns a
nd a
ssoc
iate
d
la
bora
tory
cos
ts•
Porc
elai
n ve
neer
s an
d in
lays
and
asso
ciat
ed la
bora
tory
cos
ts•
Emer
genc
y cr
owns
tha
t ar
e no
t
plac
ed fo
r the
imm
edia
te p
rote
ctio
n
in t
ooth
inju
ry a
nd a
ssoc
iate
d
la
bora
tory
cos
ts.
• Th
e co
st o
f gol
d, p
reci
ous
met
al,
se
mi-p
reci
ous
met
al a
nd p
lati
num
foil
• La
bora
tory
del
iver
y fe
es
No
bene
fit
IMPL
ANTS
* AN
D
ASSO
CIAT
ED
LABO
RATO
RY
COST
S
Pre-
auth
oris
atio
n is
requ
ired.
2
impl
ants
per
ben
efici
ary
in a
5 y
ear p
erio
d.
Bene
fit is
sub
ject
to m
anag
ed c
are
prot
ocol
s.
Cove
red
at t
he B
DT.
Cost
of i
mpl
ant
com
pone
nts
is li
mit
ed to
R2
000
per
impl
ant.
Sc
hem
e ex
clus
ions
:•
Impl
ants
on
wis
dom
teet
h
(3rd
mol
ars)
• D
olde
r bar
s an
d as
soci
ated
abu
tmen
ts
on
impl
ants
incl
udin
g th
e as
soci
ated
labo
rato
ry c
osts
• La
bora
tory
del
iver
y fe
es
No
bene
fitN
o be
nefit
No
bene
fit
ORT
HO
DO
N-
TICS
*AN
D
ASSO
CIAT
ED
LABO
RATO
RY
COST
S
Pre-
auth
oris
atio
n is
requ
ired.
Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.O
n pr
e-au
thor
isat
ion,
cas
es w
ill b
e cl
inic
ally
as
sess
ed b
y us
ing
an o
rtho
dont
ic n
eeds
an
alys
is. B
enefi
t al
loca
tion
is s
ubje
ct t
o th
e ou
tcom
e of
the
nee
ds a
naly
sis
and
fund
ing
can
be g
rant
ed u
p to
100
% o
f BD
T
Pre-
auth
oris
atio
n is
requ
ired.
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
O
n pr
e-au
thor
isat
ion
case
s w
ill b
e cl
inic
ally
asse
ssed
by
usin
g an
ort
hodo
ntic
nee
ds
anal
ysis
.
Pre-
auth
oris
atio
n is
requ
ired.
Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.
On
pre-
auth
oris
atio
n ca
ses
will
be
clin
ical
ly a
sses
sed
by
usin
g an
ort
hodo
ntic
nee
ds a
naly
sis
No
bene
fit
Benefits 2014 Page 41
DEN
TAL
BEN
EFIT
TA
BLE
BON
COM
PREH
ENSI
VEBO
NCL
ASSI
CST
AND
ARD
BO
NSA
VE
AND
PR
IMAR
YO
RTH
OD
ON
-TI
CS*
AND
AS
SOCI
ATED
LA
BORA
TORY
CO
STS
Bene
fit fo
r ort
hodo
ntic
tre
atm
ent
will
be
gran
ted
whe
re fu
ncti
on is
impa
ired.
Be
nefit
will
not
be
gran
ted
whe
re
orth
odon
tic
trea
tmen
t is
requ
ired
for
cosm
etic
reas
ons.
The
asso
ciat
ed la
bora
tory
cos
ts w
ill a
lso
not
be c
over
ed.
Onl
y on
e fa
mily
mem
ber m
ay c
omm
ence
O
rtho
dont
ic t
reat
men
t in
a c
alen
dar y
ear.
Bene
fit is
lim
ited
to in
divi
dual
s you
nger
than
18
yea
rs o
f age
.Sc
hem
e ex
clus
ions
:•
Ort
hogn
athi
c (ja
w c
orre
ctio
n) a
nd o
ther
orth
odon
tic-
rela
ted
surg
ery
and
any
re
late
d ho
spit
al a
nd la
bora
tory
cos
ts
• In
visi
ble
reta
iner
mat
eria
l•
Labo
rato
ry d
eliv
ery
fees
• O
rtho
dont
ic re
-tre
atm
ent
and
any
rela
ted
labo
rato
ry c
ost
Bene
fit a
lloca
tion
is s
ubje
ct t
o th
e ou
tcom
e of
th
e ne
eds
anal
ysis
and
fund
ing
can
be g
rant
ed
up t
o 10
0% o
f BD
T.Be
nefit
for o
rtho
dont
ic t
reat
men
t w
ill b
e gr
ante
d w
here
func
tion
is im
paire
d.
Bene
fit w
ill n
ot b
e gr
ante
d w
here
orth
odon
tic
trea
tmen
t is
requ
ired
for
cosm
etic
reas
ons.
Th
e as
soci
ated
Lab
orat
ory
cost
s w
ill a
lso
not
be c
over
ed.
Onl
y on
e fa
mily
mem
ber m
ay c
omm
ence
or
thod
onti
c tr
eatm
ent
in a
cal
enda
r yea
r. Be
nefit
is li
mit
ed t
o in
divi
dual
s yo
unge
r tha
n 18
yea
rs o
f age
. Sc
hem
e ex
clus
ions
:•
Ort
hogn
athi
c (ja
w c
orre
ctio
n) a
nd
ot
her o
rtho
dont
ic re
late
d su
rger
y
and
any
rela
ted
hosp
ital
cos
t
incl
udin
g as
soci
ated
labo
rato
ry c
osts
•
Ort
hodo
ntic
re-t
reat
men
t an
d an
y
rela
ted
labo
rato
ry c
osts
• In
visi
ble
reta
iner
mat
eria
l•
Labo
rato
ry d
eliv
ery
fees
Bene
fit a
lloca
tion
is s
ubje
ct t
o th
e ou
tcom
e of
the
ne
eds
anal
ysis
and
fund
ing
can
be g
rant
ed u
p to
80%
of
BD
T.Be
nefit
for o
rtho
dont
ic t
reat
men
t w
ill b
e gr
ante
d w
here
func
tion
is im
paire
d.
Bene
fit w
ill n
ot b
e gr
ante
d w
here
ort
hodo
ntic
tr
eatm
ent
is re
quire
d fo
r cos
met
ic re
ason
s.
The
asso
ciat
ed la
bora
tory
cos
ts w
ill a
lso
not
be
cove
red.
O
nly
one
fam
ily m
embe
r may
com
men
ce o
rtho
dont
ic
trea
tmen
t in
a c
alen
dar y
ear.
Bene
fit is
lim
ited
to
indi
vidu
als
youn
ger t
han
18 y
ears
of
age
. Sc
hem
e ex
clus
ions
:•
Ort
hogn
athi
c (ja
w c
orre
ctio
n) a
nd
ot
her o
rtho
dont
ic re
late
d su
rger
y
and
any
rela
ted
hosp
ital
and
labo
rato
ry c
osts
•
Ort
hodo
ntic
re-t
reat
men
t an
d an
y
rela
ted
labo
rato
ry c
osts
• In
visi
ble
reta
iner
mat
eria
l•
Labo
rato
ry d
eliv
ery
fees
No
bene
fit
PERI
OD
ON
TICS
*Pr
e-au
thor
isat
ion
is re
quire
d.
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BD
T**.
Bene
fit is
lim
ited
to
cons
erva
tive
, no
n-su
rgic
al t
hera
py o
nly
and
will
onl
y be
ap
plie
d to
mem
bers
who
are
regi
ster
ed o
n th
e Pe
riod
onta
l Pro
gram
me.
Sche
me
excl
usio
ns:
• Su
rgic
al p
erio
dont
ics
whi
ch
in
clud
es g
ingi
vect
omie
s,
pe
riod
onta
l fla
p su
rger
y, t
issu
e gr
afti
ng
an
d th
e he
mis
ecti
on o
f a t
ooth
• Pe
rio
chip
pla
cem
ent
Pre-
auth
oris
atio
n is
requ
ired.
Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.
Cove
red
at t
he B
DT.
Bene
fit is
lim
ited
to
cons
erva
tive
, non
-sur
gica
l th
erap
y on
ly a
nd w
ill o
nly
be a
pplie
d to
m
embe
rs w
ho a
re re
gist
ered
on
the
Peri
odon
tal P
rogr
amm
e.Sc
hem
e ex
clus
ions
:•
Surg
ical
per
iodo
ntic
s w
hich
incl
udes
ging
ivec
tom
ies,
peri
odon
tal f
lap
surg
ery,
tis
sue
graf
ting
and
the
hem
isec
tion
of a
too
th•
Peri
o ch
ip p
lace
men
t
Pre-
auth
oris
atio
n is
requ
ired.
Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.
Cove
red
at t
he B
DT.
Bene
fit is
lim
ited
to
cons
erva
tive
, non
-sur
gica
l the
rapy
on
ly a
nd w
ill o
nly
be a
pplie
d to
mem
bers
who
are
regi
s-te
red
on t
he P
erio
dont
al P
rogr
amm
e.Sc
hem
e ex
clus
ions
:•
Surg
ical
per
iodo
ntic
s w
hich
incl
udes
gin
give
ctom
ies,
peri
odon
tal f
lap
surg
ery,
tis
sue
graf
ting
and
the
hem
isec
tion
of a
too
th•
Peri
o ch
ip p
lace
men
t
No
bene
fit
Page 42 Benefits 2014
DEN
TAL
BEN
EFIT
TAB
LEBO
NCO
MPR
EHEN
SIVE
BON
CLAS
SIC
STAN
DAR
D
BON
SAVE
AN
D P
RIM
ARY
MAX
ILLO
-FAC
IAL
SURG
ERY
AND
O
RAL
PATH
OLO
GY
Surg
ery
in t
he d
enta
l cha
ir:
Bene
fit is
subj
ect t
o m
anag
ed c
are
prot
ocol
s.
Cove
red
at t
he B
DT*
*.Be
nefit
for T
empr
o-m
andi
bula
r Joi
nt
(TM
J) th
erap
y is
lim
ited
to n
on-s
urgi
cal
inte
rven
tion
/tre
atm
ents
.Th
e cl
aim
s for
ora
l pat
holo
gy
proc
edur
es (c
ysts
and
bio
psie
s, th
e su
rgic
al tr
eatm
ent o
f tum
ours
of t
he
jaw
and
soft
tiss
ue tu
mou
rs) w
ill o
nly
be c
over
ed if
supp
orte
d by
a la
bora
tory
re
port
that
con
firm
s dia
gnos
is.
Sche
me
excl
usio
ns:
• O
rtho
gnat
hic
(jaw
cor
rect
ion)
surg
ery
• Si
nus
lifts
• Bo
ne a
ugm
enta
tion
s•
Bone
and
tiss
ue re
gene
rati
on
pr
oced
ures
• Th
e co
st o
f bon
e re
gene
rati
on
m
ater
ial
• Th
e au
to-t
rans
plan
tati
on o
f tee
th
• Th
e cl
osur
e of
an
oral
-ant
ral o
peni
ng
(c
urre
ntly
cod
e 89
09) w
hen
clai
med
durin
g th
e sa
me
visi
t wit
h
im
pact
ed te
eth
(cur
rent
ly c
odes
8941
, 894
3 an
d 89
45) i
s a sc
hem
e
ex
clus
ion
Surg
ery
in h
ospi
tal;
See
Hos
pita
lisat
ion*
bel
ow
Surg
ery
in t
he d
enta
l cha
ir:
Bene
fit is
subj
ect t
o m
anag
ed c
are
prot
ocol
s.Co
vere
d at
the
BD
T.Be
nefit
for T
empr
o-m
andi
bula
r Joi
nt
(TM
J) th
erap
y is
lim
ited
to n
on-s
urgi
cal
inte
rven
tion
/tre
atm
ents
. Th
e cl
aim
s for
ora
l pat
holo
gy
proc
edur
es (c
ysts
and
bio
psie
s, th
e su
rgic
al tr
eatm
ent o
f tum
ours
of t
he
jaw
and
soft
tiss
ue tu
mou
rs) w
ill o
nly
be c
over
ed if
supp
orte
d by
a la
bora
tory
re
port
that
con
firm
s dia
gnos
is.
Sche
me
excl
usio
ns:
• O
rtho
gnat
hic
(jaw
cor
rect
ion)
surg
ery
• Si
nus
lifts
• Bo
ne a
ugm
enta
tion
s•
Bone
and
tiss
ue re
gene
rati
on
pr
oced
ures
• Th
e co
st o
f bon
e re
gene
rati
on
m
ater
ial
• Th
e au
to-t
rans
plan
tati
on o
f tee
th
• Th
e cl
osur
e of
an
oral
-ant
ral o
peni
ng
(c
urre
ntly
cod
e 89
09) w
hen
clai
med
durin
g th
e sa
me
visi
t wit
h
im
pact
ed te
eth
(cur
rent
ly c
odes
8941
, 894
3 an
d 89
45) i
s a sc
hem
e
ex
clus
ion
Surg
ery
in h
ospi
tal;
See
Hos
pita
lisat
ion*
bel
ow
Surg
ery
in t
he d
enta
l cha
ir:
Bene
fit is
subj
ect t
o m
anag
ed c
are
prot
ocol
s.Co
vere
d at
the
BD
T.Be
nefit
for T
empr
o-m
andi
bula
r Joi
nt
(TM
J) th
erap
y is
lim
ited
to n
on-s
urgi
cal
inte
rven
tion
/tre
atm
ents
.Th
e cl
aim
s for
ora
l pat
holo
gy
proc
edur
es (c
ysts
and
bio
psie
s, th
e su
rgic
al tr
eatm
ent o
f tum
ours
of t
he
jaw
and
soft
tiss
ue tu
mou
rs) w
ill o
nly
be c
over
ed if
supp
orte
d by
a la
bora
tory
re
port
that
con
firm
s dia
gnos
is.
Sche
me
excl
usio
ns:
• O
rtho
gnat
hic
(jaw
cor
rect
ion)
surg
ery
• Si
nus
lifts
• Bo
ne a
ugm
enta
tion
s•
Bone
and
tiss
ue re
gene
rati
on
pr
oced
ures
• Th
e co
st o
f bon
e re
gene
rati
on
m
ater
ial
• Th
e au
to-t
rans
plan
tati
on o
f tee
th
• Th
e cl
osur
e of
an
oral
-ant
ral o
peni
ng
(c
urre
ntly
cod
e 89
09) w
hen
clai
med
durin
g th
e sa
me
visi
t wit
h
im
pact
ed te
eth
(cur
rent
ly c
odes
8941
, 894
3 an
d 89
45) i
s a sc
hem
e
ex
clus
ion
Surg
ery
in h
ospi
tal;
See
Hos
pita
lisat
ion*
bel
ow
Surg
ery
in t
he d
enta
l cha
ir:
Bene
fit is
subj
ect t
o m
anag
ed c
are
prot
ocol
s.Co
vere
d at
the
BD
T.Be
nefit
for T
empr
o-m
andi
bula
r Joi
nt
(TM
J) th
erap
y is
lim
ited
to n
on-s
urgi
cal
inte
rven
tion
/tre
atm
ents
.Th
e cl
aim
s for
ora
l pat
holo
gy
proc
edur
es (c
ysts
and
bio
psie
s, th
e su
rgic
al tr
eatm
ent o
f tum
ours
of t
he
jaw
and
soft
tiss
ue tu
mou
rs) w
ill o
nly
be c
over
ed if
supp
orte
d by
a la
bora
tory
re
port
that
con
firm
s dia
gnos
is.
Sche
me
excl
usio
ns:
• O
rtho
gnat
hic
(jaw
cor
rect
ion)
surg
ery
• Si
nus
lifts
• Bo
ne a
ugm
enta
tion
s•
Bone
and
tiss
ue re
gene
rati
on
pr
oced
ures
• Th
e co
st o
f bon
e re
gene
rati
on
m
ater
ial
• Th
e au
to-t
rans
plan
tati
on o
f tee
th
• Th
e cl
osur
e of
an
oral
-ant
ral o
peni
ng
(c
urre
ntly
cod
e 89
09) w
hen
clai
med
durin
g th
e sa
me
visi
t wit
h
im
pact
ed te
eth
(cur
rent
ly c
odes
8941
, 894
3 an
d 89
45) i
s a sc
hem
e
ex
clus
ion
Surg
ery
in h
ospi
tal;
See
Hos
pita
lisat
ion*
bel
ow
Benefits 2014 Page 43
DEN
TAL
BEN
EFIT
TAB
LEBO
NCO
MPR
EHEN
SIVE
BON
CLAS
SIC
STAN
DAR
D
BON
SAVE
AN
D P
RIM
ARY
HOSPITALISATON AND ANAESTHETIC
HO
SPIT
ALIS
ATIO
N
(GEN
ERAL
AN
AEST
HET
IC) *
Pre-
auth
oris
atio
n is
requ
ired.
Adm
issi
on p
roto
cols
app
ly.
Gen
eral
ana
esth
etic
ben
efits
are
av
aila
ble
for c
hild
ren
unde
r the
ag
e of
5 y
ears
for e
xten
sive
den
tal
trea
tmen
t.
Gen
eral
ana
esth
etic
ben
efits
are
av
aila
ble
for t
he re
mov
al o
f im
pact
ed
teet
h. B
enefi
t is
sub
ject
to
man
aged
ca
re p
roto
cols
.Th
e ho
spit
al a
nd a
naes
thet
ist
clai
ms
for t
he fo
llow
ing
proc
edur
es w
ill n
ot
be c
over
ed w
hen
perf
orm
ed u
nder
ge
nera
l ana
esth
esia
. The
pay
men
t of
the
den
tal p
roce
dure
will
be,
de
pend
ent
on a
vaila
ble
bene
fits
and
paya
ble
at B
DT
tari
ffs:
• Ap
icec
tom
ies
• D
ente
ctom
ies
• Fr
enec
tom
ies
• Im
plan
tolo
gy a
nd a
ssoc
iate
d
surg
ical
pro
cedu
res
• Co
nser
vati
ve d
enta
l tre
atm
ent
(filli
ngs,
ext
ract
ions
and
root
cana
l the
rapy
) for
adu
lts
• Pr
ofes
sion
al o
ral h
ygie
ne
proc
edur
es•
Surg
ical
too
th e
xpos
ures
for
or
thod
onti
c re
ason
sSc
hem
e ex
clus
ions
: •
Whe
re t
he o
nly
reas
on fo
r
ad
mis
sion
to
hosp
ital
is d
enta
l
fear
and
anx
iety
•
Mul
tipl
e ho
spit
al a
dmis
sion
s•
Whe
re t
he o
nly
reas
on fo
r the
adm
issi
on re
ques
t is
for a
ste
rile
faci
lity
• Th
e co
st o
f den
tal m
ater
ials
for
pr
oced
ures
per
form
ed u
nder
gen
eral
anae
sthe
sia
Pre-
auth
oris
atio
n is
requ
ired.
Adm
issi
on p
roto
cols
app
ly.
Gen
eral
ana
esth
etic
ben
efits
are
av
aila
ble
for c
hild
ren
unde
r the
ag
e of
5 y
ears
for e
xten
sive
den
tal
trea
tmen
t.
Gen
eral
ana
esth
etic
ben
efits
are
av
aila
ble
for t
he re
mov
al o
f im
pact
ed
teet
h. B
enefi
t is
sub
ject
to
man
aged
ca
re p
roto
cols
.Th
e ho
spit
al a
nd a
naes
thet
ist
clai
ms
for t
he fo
llow
ing
proc
edur
es w
ill n
ot
be c
over
ed w
hen
perf
orm
ed u
nder
ge
nera
l ana
esth
esia
. The
pay
men
t of
the
den
tal p
roce
dure
will
be
depe
nden
t on
ava
ilabl
e be
nefit
s an
d pa
yabl
e at
BD
T ra
tes:
• Ap
icec
tom
ies
• D
ente
ctom
ies
• Fr
enec
tom
ies
• Im
plan
tolo
gy a
nd a
ssoc
iate
d
surg
ical
pro
cedu
res
• Co
nser
vati
ve d
enta
l tre
atm
ent
(filli
ngs,
ext
ract
ions
and
root
cana
l the
rapy
) for
adu
lts
• Pr
ofes
sion
al o
ral h
ygie
ne
proc
edur
es•
Surg
ical
too
th e
xpos
ures
for
or
thod
onti
c re
ason
sSc
hem
e ex
clus
ions
: •
Whe
re t
he o
nly
reas
on fo
r
ad
mis
sion
to
hosp
ital
is d
enta
l
fear
and
anx
iety
•
Mul
tipl
e ho
spit
al a
dmis
sion
s•
Whe
re t
he o
nly
reas
on fo
r the
adm
issi
on re
ques
t is
for a
ste
rile
faci
lity
• Th
e co
st o
f den
tal m
ater
ials
for
pr
oced
ures
per
form
ed u
nder
gen
eral
anae
sthe
sia
Pre-
auth
oris
atio
n is
requ
ired.
Adm
issi
on p
roto
cols
app
ly.
Gen
eral
ana
esth
etic
ben
efits
are
av
aila
ble
for c
hild
ren
unde
r the
ag
e of
5 y
ears
for e
xten
sive
den
tal
trea
tmen
t.
Gen
eral
ana
esth
etic
ben
efits
are
av
aila
ble
for t
he re
mov
al o
f im
pact
ed
teet
h. B
enefi
t is
sub
ject
to
man
aged
ca
re p
roto
cols
.Th
e ho
spit
al a
nd a
naes
thet
ist
clai
ms
for t
he fo
llow
ing
proc
edur
es w
ill n
ot
be c
over
ed w
hen
perf
orm
ed u
nder
ge
nera
l ana
esth
esia
. The
pay
men
t of
the
den
tal p
roce
dure
will
be,
de
pend
ent
on a
vaila
ble
bene
fits
and
paya
ble
at B
DT
tari
ffs:
• Ap
icec
tom
ies
• D
ente
ctom
ies
• Fr
enec
tom
ies
• Im
plan
tolo
gy a
nd a
ssoc
iate
d
surg
ical
pro
cedu
res
• Co
nser
vati
ve d
enta
l tre
atm
ent
(filli
ngs,
ext
ract
ions
and
root
cana
l the
rapy
) for
adu
lts
• Pr
ofes
sion
al o
ral h
ygie
ne
proc
edur
es•
Surg
ical
too
th e
xpos
ures
for
or
thod
onti
c re
ason
sSc
hem
e ex
clus
ions
: •
Whe
re t
he o
nly
reas
on fo
r
ad
mis
sion
to
hosp
ital
is d
enta
l
fear
and
anx
iety
•
Mul
tipl
e ho
spit
al a
dmis
sion
s•
Whe
re t
he o
nly
reas
on fo
r the
adm
issi
on re
ques
t is
for a
ste
rile
faci
lity
• Th
e co
st o
f den
tal m
ater
ials
for
pr
oced
ures
per
form
ed u
nder
gen
eral
anae
sthe
sia
Pre-
auth
oris
atio
n is
requ
ired.
Adm
issi
on p
roto
cols
app
ly.
Gen
eral
ana
esth
etic
ben
efits
are
av
aila
ble
for c
hild
ren
unde
r the
ag
e of
5 y
ears
for e
xten
sive
den
tal
trea
tmen
t.
Gen
eral
ana
esth
etic
ben
efits
are
av
aila
ble
for t
he re
mov
al o
f im
pact
ed
teet
h. B
enefi
t is
sub
ject
to
man
aged
ca
re p
roto
cols
.Th
e ho
spit
al a
nd a
naes
thet
ist
clai
ms
for t
he fo
llow
ing
proc
edur
es w
ill n
ot
be c
over
ed w
hen
perf
orm
ed u
nder
ge
nera
l ana
esth
esia
. The
pay
men
t of
the
den
tal p
roce
dure
will
be
depe
nden
t on
ava
ilabl
e be
nefit
s an
d pa
yabl
e at
BD
T ra
tes:
• Ap
icec
tom
ies
• D
ente
ctom
ies
• Fr
enec
tom
ies
• Im
plan
tolo
gy a
nd a
ssoc
iate
d
surg
ical
pro
cedu
res
• Co
nser
vati
ve d
enta
l tre
atm
ent
(filli
ngs,
ext
ract
ions
and
root
cana
l the
rapy
) for
adu
lts
• Pr
ofes
sion
al o
ral h
ygie
ne
proc
edur
es•
Surg
ical
too
th e
xpos
ures
for
or
thod
onti
c re
ason
sSc
hem
e ex
clus
ions
: •
Whe
re t
he o
nly
reas
on fo
r
ad
mis
sion
to
hosp
ital
is d
enta
l
fear
and
anx
iety
•
Mul
tipl
e ho
spit
al a
dmis
sion
s•
Whe
re t
he o
nly
reas
on fo
r the
adm
issi
on re
ques
t is
for a
ste
rile
faci
lity
• Th
e co
st o
f den
tal m
ater
ials
for
pr
oced
ures
per
form
ed u
nder
gen
eral
anae
sthe
sia
Page 44 Benefits 2014
ADD
ITIO
NAL
SCH
EME
EXCL
USI
ON
S:•
Elec
trog
nath
ogra
phic
reco
rdin
gs, p
anto
grap
hic
reco
rdin
gs a
nd o
ther
suc
h el
ectr
onic
ana
lyse
s•
Nut
riti
onal
and
tob
acco
cou
nsel
ling
• Ca
ries
sus
cept
ibili
ty a
nd m
icro
biol
ogic
al t
ests
• Fi
ssur
e se
alan
ts o
n pa
tien
ts 1
6 ye
ars
and
olde
r•
Pulp
tes
ts•
Cost
of M
iner
al T
riox
ide
• Co
st o
f pre
scri
bed
toot
hpas
tes,
mou
thw
ashe
s (e
.g. C
orso
dyl)
and
oint
men
ts•
Appo
intm
ent
not
kept
•
Spec
ial r
epor
t•
Den
tal t
esti
mon
y in
clud
ing
Den
to-le
gal f
ees
• Tr
eatm
ent
pla
n co
mpl
eted
(cur
rent
ly c
ode
8120
)•
Enam
el m
icro
abra
sion
• Be
havi
our m
anag
emen
t•
Intr
amus
cula
r or s
ubcu
tane
ous
inje
ctio
n•
Proc
edur
es t
hat
are
defin
ed a
s un
usua
l circ
umst
ance
s an
d pr
oced
ures
tha
t ar
e de
fined
as
unlis
ted
proc
edur
es
DEN
TAL
BEN
EFIT
TAB
LEBO
NCO
MPR
EHEN
SIVE
BON
CLAS
SIC
STAN
DAR
D
BON
SAVE
AN
D P
RIM
ARY
Laug
hing
gas
in d
enta
l ro
oms
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BD
T
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BD
T
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BD
T
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BD
T
IV c
onsc
ious
sed
atio
n in
room
s*Pr
e-au
thor
isat
ion
is re
quire
d.
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Cove
red
at t
he B
DT.
Bene
fit is
lim
ited
to
exte
nsiv
e de
ntal
tr
eatm
ent
Pre-
auth
oris
atio
n is
requ
ired.
Bene
fit is
sub
ject
to
man
aged
car
e pr
otoc
ols.
Co
vere
d at
the
BD
T.Be
nefit
is li
mit
ed t
o ex
tens
ive
dent
al
trea
tmen
t
Pre-
auth
oris
atio
n is
requ
ired.
Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.
Cove
red
at t
he B
DT.
Bene
fit is
lim
ited
to
exte
nsiv
e de
ntal
tr
eatm
ent
Pre-
auth
oris
atio
n is
requ
ired.
Be
nefit
is s
ubje
ct t
o m
anag
ed c
are
prot
ocol
s.
Cove
red
at t
he B
DT.
Bene
fit is
lim
ited
to
exte
nsiv
e de
ntal
tr
eatm
ent
Benefits 2014 Page 45
NEW
GEN
ERAT
ION
MAJ
OR
MED
ICAL
BEN
EFIT
SBO
NCO
MPR
EHEN
SIVE
BO
NCL
ASSI
CBO
NSA
VEBO
NES
SEN
TIAL
OVE
RALL
AN
NU
AL L
IMIT
Unl
imit
edU
nlim
ited
Unl
imit
edU
nlim
ited
REIM
BURS
EMEN
T RA
TESu
rgic
al p
roce
dure
s an
d co
nsul
tati
ons
at 3
00%
Bon
itas
Rat
e10
0% B
onit
as R
ate
150%
Bon
itas
Rat
e10
0% B
onit
as R
ate
PRO
VID
ERAn
y ho
spit
alAn
y ho
spit
alAn
y ho
spit
alAn
y ho
spit
al
GPs
AN
D S
PECI
ALIS
TS, P
ATH
OLO
GY
AND
RAD
IOLO
GY,
PAR
AMED
ICAL
SE
RVIC
ES
Unl
imit
edU
nlim
ited
Unl
imit
edU
nlim
ited
ON
COLO
GY
- CH
EMO
AN
D
RAD
IATI
ON
R475
000
per
fam
ilyR3
15 0
00 p
er fa
mily
R264
500
per
fam
ilyR2
64 5
00 p
er fa
mily
ON
COLO
GY
- BIO
LOG
ICAL
DRU
GS
INCL
UD
ED IN
TH
E O
NCO
LOG
Y LI
MIT
R200
000
(10%
co-
paym
ent)
pe
r fam
ilyN
o be
nefit
No
bene
fitN
o be
nefit
ORG
AN T
RAN
SPLA
NTS
Unl
imit
ed, s
ubje
ct t
o pr
e-au
thor
isat
ion
Subj
ect
to p
re-a
utho
risa
tion
Unl
imit
ed, s
ubje
ct t
o pr
e-au
thor
isat
ion
Unl
imit
ed, s
ubje
ct t
o pr
e-au
thor
isat
ion
REN
AL D
IALY
SIS
Unl
imit
ed, s
ubje
ct t
o pr
e-au
thor
isat
ion
Subj
ect
to p
re-a
utho
risa
tion
PMBs
onl
yPM
Bs o
nly
MED
ICAT
ION
TO
TAK
E O
UT
R420
per
ben
efici
ary
per a
dmis
sion
R360
per
ben
efici
ary
per a
dmis
sion
R290
per
ben
efici
ary
per a
dmis
sion
R290
per
ben
efici
ary
per a
dmis
sion
AT A GLANCE
CHRO
NIC
BON
COM
PREH
ENSI
VE O
PTIO
NBO
NCL
ASSI
C O
PTIO
NBO
NSA
VE O
PTIO
NBO
NES
SEN
TIAL
OPT
ION
• 53
Chr
onic
Con
diti
ons
Co
mpr
ehen
sive
For
mul
ary
• R1
0 60
0 pe
r ben
efici
ary,
R21
150
pe
r fam
ily
• 63
con
diti
ons
R8 7
00 p
er
be
nefic
iary
, R18
000
pe
r fam
ily, p
er a
nnum
•• Re
stri
ctiv
e Fo
rmul
ary
at D
SP,
40
% c
o-pa
ymen
t ap
ply
at
no
n-D
SP
• 26
PM
Bs o
nly
• Re
stri
ctiv
e Fo
rmul
ary
at D
SP,
40
% c
o-pa
ymen
t ap
ply
at
no
n-D
SP
• 26
PM
Bs o
nly
• Re
stri
ctiv
e Fo
rmul
ary
at D
SP,
40
% c
o-pa
ymen
t ap
ply
at
no
n-D
SP
OU
T O
F H
OSP
ITAL
BEN
EFIT
S BON
COM
PREH
ENSI
VEBO
NCL
ASSI
CBO
NSA
VEBO
NES
SEN
TIAL
Savi
ngs
Thre
shol
d m
embe
rSe
lf-fu
ndin
g ga
pSa
ving
sSa
ving
sN
o be
nefit
MEM
BER
R6 4
92R7
400
R908
R3 0
24R3
180
-
MEM
BER
+AR1
2 62
4R1
4 10
0R1
476
R5 6
16R5
640
-
MEM
BER
+A +
CR1
3 94
4R1
6 05
0R2
106
R6 3
60R6
600
-
Page 46 Benefits 2014
OU
T O
F H
OSP
ITAL
BEN
EFIT
S BON
COM
PREH
ENSI
VEBO
NCL
ASSI
CBO
NSA
VEBO
NES
SEN
TIAL
N
o be
nefit
S EX
CEPT
PM
Bs
MEM
BER
+A +
2CR1
5 26
4R1
8 00
0R2
736
R7 1
04R
7 56
0-
MEM
BER
+A +
3CR1
6 58
4R1
9 95
0R3
366
R7 8
48R
8 52
0
-
GP
CON
SULT
ATIO
NS
Subj
ect
to s
avin
gs a
nd/o
r thr
esho
ld, 2
5% c
o-pa
ymen
t in
thr
esho
ldSu
bjec
t to
sav
ings
Subj
ect
to s
avin
gs, o
nce
savi
ngs
exha
uste
d 3
visi
ts p
er b
enefi
ciar
y, u
p to
a m
axim
um o
f 6 v
isit
s pe
r fam
ily
No
bene
fit
SPEC
IALI
STS
CON
SULT
ATIO
NSu
bjec
t to
sav
ings
and
/or t
hres
hold
, 25%
co-
paym
ent
in t
hres
hold
Subj
ect
to s
avin
gsSu
bjec
t to
sav
ings
No
bene
fit
RAD
IOLO
GY,
PAT
HO
LOG
YSu
bjec
t to
sav
ings
and
/or t
hres
hold
GEN
ERAL
RAD
IOLO
GY:
R2
400
per
ben
efici
ary
limit
ed t
o R3
700
per
fam
ily
Path
olog
y R2
400
per
ben
efici
ary,
R5 3
00 p
er fa
mily
Subj
ect
to s
avin
gsN
o be
nefit
PARA
MED
ICAL
SER
VICE
SSu
bjec
t to
sav
ings
and
/or t
hres
hold
. 25%
co-
paym
ent
in t
hres
hold
Mem
ber =
R2
300
Mem
ber +
1 =
R3
500
Mem
ber +
2 =
R4
050
Mem
ber +
3 =
R4
300
Mem
ber +
4+
= R4
600
Subj
ect
to s
avin
gsN
o be
nefit
OPT
OM
ETRY
Subj
ect
to s
avin
gs a
nd/o
r thr
esho
ld, l
imit
ed t
o R2
450
per
ben
efici
ary.
25
% c
o-pa
ymen
t in
thr
esho
ld
R5 2
60 p
er fa
mily
, per
ann
umEy
e ex
amin
atio
n 10
0% o
f cos
t.Fr
ames
/len
s add
ons
R70
0 p.
b.Si
ngle
vis
ion
lens
R18
5 pe
r len
s, p
.b.
Bifo
cal l
ens
R430
per
lens
, p.b
. M
ulti-
foca
l lens
es R
750
per l
ens,
p.b
. Co
ntac
t le
ns R
1 63
5 p.
b.
Subj
ect
to s
avin
gsN
o be
nefit
ACU
TE M
EDIC
ATIO
NS
AND
PAT
Subj
ect
to s
avin
gs a
nd/o
r thr
esho
ld, 1
00%
of B
onit
as ra
tes
accr
ues
to t
hres
hold
, 25
% c
o-pa
ymen
t in
thr
esho
ldSu
bjec
t to
sav
ings
Subj
ect
to s
avin
gsN
o be
nefit
DEN
TIST
RY
BASI
C D
ENTI
STRY
Subj
ect
to s
avin
gs a
nd/o
r thr
esho
ld. 2
5% c
o-pa
ymen
t in
thr
esho
ld.
Cove
red
acco
rdin
g to
DEN
IS C
linic
al P
roto
cols
and
Bon
itas
Den
tal T
ariff
R3 6
00 p
er fa
mily
per
ann
um
Subj
ect
to c
linic
al p
roto
cols
and
Bo
nita
s D
enta
l Tar
iff (B
DT)
1
Cove
red
acco
rdin
g to
D
ENIS
Clin
ical
Pro
toco
ls
and
Boni
tas
Den
tal T
ariff
No
bene
fit
ADVA
NCE
D D
ENTI
STRY
Subj
ect
to s
avin
gs a
nd/o
r thr
esho
ld. 2
5% c
o-pa
ymen
t in
thr
esho
ld.
Cove
red
acco
rdin
g to
DEN
IS C
linic
al P
roto
cols
and
Bon
itas
Den
tal T
ariff
R4 3
00 p
er fa
mily
per
ann
um
Subj
ect
to c
linic
al p
roto
cols
and
Bo
nita
s D
enta
l Tar
iff (B
DT)
1
No
bene
fitN
o be
nefit
Benefits 2014 Page 47
SUPP
LEM
ENTA
RY
BEN
EFIT
SBO
NCO
MPR
EHEN
SIVE
BON
CLAS
SIC
BON
SAVE
BON
ESSE
NTI
AL
MAT
ERN
ITY
CARE
12 a
nte-
nata
l con
sult
atio
ns, 2
x 2
D
scan
s, 4
pos
t-na
tal c
onsu
ltat
ions
wit
h a
mid
wif
e. A
nte-
nata
l cla
sses
R1
000
and
post
con
finem
ent
in a
pri
vate
war
d
R980
for a
nte-
nata
l cla
sses
. 12
ante
-na
tal c
onsu
ltat
ions
, 2 X
2D
sca
ns a
nd 4
po
st-n
atal
con
sult
atio
ns w
ith
a m
idw
ife
6 an
te-n
atal
con
sult
atio
ns, 2
x 2
D
scan
s, 4
pos
t-na
tal c
onsu
ltat
ions
wit
h a
mid
wif
e. A
nte-
nata
l cla
sses
R95
0
6 an
te-n
atal
con
sult
atio
ns, 2
x 2
D
scan
s, 4
pos
t-na
tal c
onsu
ltat
ions
wit
h a
mid
wif
e
REFR
ACTI
VE S
URG
ERY
R15
900
per f
amily
No
bene
fitN
o be
nefit
No
bene
fit
HIV
Unl
imit
ed s
ubje
ct t
o Ai
d fo
r AID
S re
gist
rati
onPM
Bs o
nly
Subj
ect
to A
id fo
r AID
S re
gist
rati
onR2
4 80
0 pe
r ben
efici
ary
subj
ect
to A
id
for A
IDS
regi
stra
tion
R24
800
per b
enefi
ciar
y su
bjec
t to
Aid
fo
r AID
S re
gist
rati
onM
ENTA
L H
EALT
H
(SU
BJEC
T TO
PRE-
AUTH
ORI
SATI
ON
BY
HBM
)
R36
000
per f
amily
, sub
-lim
it o
f R12
000
in
and
out
of h
ospi
tal c
onsu
ltat
ions
R31
700
per f
amily
. R12
400
sub
-lim
it
for c
onsu
ltat
ions
in a
nd o
ut o
f hos
pita
l. R2
4 80
0 pe
r fam
ily, s
ub-li
mit
of R
12 1
50
in a
nd o
ut o
f hos
pita
l con
sult
atio
nsR2
4 80
0 pe
r fam
ily. I
n ho
spit
al o
nly
SPEC
IALI
SED
RAD
IOLO
GY
(SU
BJEC
T TO
PRE-
AUTH
ORI
SATI
ON
BY
HBM
)
R24
000
per f
amily
(o
ut o
f hos
pita
l onl
y)R2
2 20
0 in
and
out
of h
ospi
tal
Incl
uded
in t
he h
ospi
tal b
enefi
tR1
7 00
0 pe
r fam
ily
(out
of h
ospi
tal o
nly)
No
bene
fit
AMBU
LAN
CE -
EMER
GEN
CYER
24ER
24ER
24ER
24
END
OSC
OPI
ES IN
D
OCT
ORS
RO
OM
S*U
nlim
ited
Unl
imit
ed, s
ubje
ct t
o pr
e-au
thor
isat
ion
Unl
imit
edN
o be
nefit
PRO
STH
ESES
INTE
RNAL
R42
300
per f
amily
R42
000
per f
amily
, sub
ject
to
pre-
auth
oris
atio
nPM
Bs o
nly
PMBs
onl
y
PRO
STH
ESES
EXT
ERN
ALR4
2 30
0 pe
r fam
ilyIn
clud
ed in
the
inte
rnal
pro
sthe
sis
PMBs
onl
yPM
Bs o
nly
COCH
LEAR
IMPL
ANTS
R158
000
per
fam
ilyR1
58 0
00 p
er fa
mily
No
bene
fitN
o be
nefit
INTE
RNAL
NER
VE
STIM
ULA
TORS
R127
000
per
fam
ilyN
o be
nefit
No
bene
fitN
o be
nefit
HIV
TES
T AN
D F
LU
VACC
INE
1 ea
ch p
er b
enefi
ciar
y, p
er a
nnum
1 ea
ch p
er b
enefi
ciar
y, p
er a
nnum
1 ea
ch p
er b
enefi
ciar
y, p
er a
nnum
1 ea
ch p
er b
enefi
ciar
y, p
er a
nnum
INFA
NT
PAED
IATR
IC
BEN
EFIT
3 co
nsul
tati
ons
befo
re t
he a
ge o
f 1 y
ear.
2 co
nsul
tati
ons
betw
een
the
ages
of 1
an
d 2
year
sN
o be
nefit
2 co
nsul
tati
ons
befo
re t
he a
ge o
f 1 y
ear.
1 co
nsul
tati
on b
etw
een
the
ages
of 1
an
d 2
year
sN
o be
nefit
CHIL
DH
OO
D IL
LNES
S BE
NEF
ITN
o be
nefit
1 G
P co
nsul
tati
on b
etw
een
the
ages
of
2 an
d 12
yea
rs1
GP
cons
ulta
tion
bet
wee
n th
e ag
es o
f 2
and
12 y
ears
1 G
P co
nsul
tati
on b
etw
een
the
ages
of 2
an
d 12
yea
rs
WO
MEN
’S H
EALT
H
• 1
mam
mog
ram
eve
ry 3
yea
rs fo
r
fem
ales
age
d 50
to
74
year
s•
1 pa
p sm
ear e
very
3 y
ears
for f
emal
es
age
21 t
o 65
yea
rs
No
bene
fitN
o be
nefit
No
bene
fit
AT A GLANCE
Page 48 Benefits 2014
NEW
GEN
ERAT
ION
PREV
ENTA
TIVE
CAR
E BE
NEF
ITBO
NCO
MPR
EHEN
SIVE
BON
CLAS
SIC
BON
SAVE
BON
ESSE
NTI
AL
CARD
IAC
HEA
LTH
• 1
full
lipog
ram
per
ben
efici
ary
No
bene
fitN
o be
nefit
No
bene
fit
ELD
ERLY
HEA
LTH
• 1
Pneu
moc
coca
l vac
cina
tion
abo
ve
age
65 y
ears
• 1
Faec
al o
ccul
t bl
ood
test
p.b
.p.a
be
twee
n th
e ag
es o
f 50
and
75 y
ears
• 1
Bone
Den
sito
met
ry S
cree
ning
tes
t
fo
r fem
ales
abo
ve t
he a
ge o
f 65
year
s
No
bene
fitN
o be
nefit
No
bene
fit
CHIL
DRE
N’S
HEA
LTH
• 1
TSH
tes
t fo
r inf
ants
bel
ow 1
mon
th
of a
ge•
Imm
unis
atio
n fo
r chi
ldre
n up
to
age
12,
as
spec
ified
in t
he E
xten
ded
Pr
ogra
mm
e on
Imm
unis
atio
n (E
PI)
No
bene
fitN
o be
nefit
No
bene
fit
GEN
ERAL
APP
LIAN
CES
APPL
IAN
CES
R6 8
00 p
er fa
mily
R6 3
00 p
er fa
mily
R5 6
00 p
er fa
mily
No
bene
fit, e
xcep
t PM
Bs
WH
EELC
HAI
RS A
ND
LA
RGE
ORT
HO
APAE
DIC
AP
PLIA
NCE
SIn
clud
ed in
Gen
eral
App
lianc
e lim
itIn
clud
ed in
G
ener
al A
pplia
nce
limit
Incl
uded
in G
ener
al A
pplia
nce
bene
fitN
o be
nefit
, exc
ept
PMBs
STO
MA
PRO
DU
CTS
AND
CP
AP*
SU
BJEC
T TO
PR
E-AU
THO
RISA
TIO
N
May
exc
eed
Gen
eral
App
lianc
e lim
it
by R
4 75
0In
clud
ed in
the
G
ener
al A
pplia
nce
limit
May
exc
eed
Gen
eral
App
lianc
e by
R5
000
No
bene
fit
HEA
RIN
G A
IDS
R21
000
Bien
nial
per
fam
ilyR1
3 80
0 pe
r fam
ily p
er a
nnum
ove
r a 3
ye
ar c
ycle
(cyc
le c
omm
ence
d
(1 Ja
n 20
13 -
31 D
ec 2
015)
No
bene
fitN
o be
nefit
OXY
GEN
: HO
ME
VEN
TILA
TIO
NU
nlim
ited
sub
ject
to
pre-
auth
oris
atio
n by
Hos
pita
l Ben
efit
Man
agem
ent
Incl
uded
in t
he G
ener
al A
pplia
nce
limit
Unl
imit
ed s
ubje
ct t
o pr
e-au
thor
isat
ion
by H
ospi
tal B
enefi
t M
anag
emen
tN
o be
nefit
, exc
ept
PMBs
AT A GLANCE
CON
TRIB
UTI
ON
SBO
NCO
MPR
EHEN
SIVE
BO
NCL
ASSI
CBO
NSA
VEBO
NES
SEN
TIAL
MEM
BER
R3 6
07R2
513
R1 5
58R1
085
MEM
BER
+ A
R7 0
09R4
671
R2 7
65R1
915
MEM
BER
+A +
CR7
743
R5 2
91R3
233
R2 2
33
MEM
BER
+ A
+2C
R8 4
77R5
911
R3 7
01R2
551
MEM
BER
+ A
+3C
R9 2
11R6
531
R4 1
69R2
869
Benefits 2014 Page 49
TRAD
ITIO
NAL
OPT
ION
S
MAJ
OR
MED
ICAL
BEN
EFIT
SST
AND
ARD
PRIM
ARY
OVE
RALL
AN
NU
AL L
IMIT
Unl
imit
edU
nlim
ited
REIM
BURS
EMEN
T RA
TE10
0% B
onit
as R
ate
100%
Bon
itas
Rat
e
PRO
VID
ERAn
y ho
spit
alAn
y ho
spit
al
GPs
AN
D S
PECI
ALIS
TS, P
ATH
OLO
GY
AND
RAD
IOLO
GY,
PA
RAM
EDIC
AL S
ERVI
CES
Unl
imit
edU
nlim
ited
ON
COLO
GY
- CH
EMO
AN
D R
ADIA
TIO
NR2
64 5
00 p
er fa
mily
R127
000
per
fam
ily
ORG
AN T
RAN
SPLA
NTS
, REN
AL D
IALY
SIS
Unl
imit
edPM
Bs, c
over
ed a
s pe
r sta
te p
roto
col
MED
ICAT
ION
TO
TAK
E O
UT
R360
per
ben
efici
ary
per a
dmis
sion
R290
per
ben
efici
ary
per a
dmis
sion
CHRO
NIC
STAN
DAR
DPR
IMAR
Y
• 42
Chr
onic
Con
diti
ons
R7 4
00 p
.b. o
r R14
800
p.f.
Com
preh
ensi
ve F
orm
ular
y in
ben
efit
limit
• Re
stri
ctiv
e fo
rmul
ary
whe
n be
nefit
s ar
e ex
ceed
ed fo
r PM
Bs o
nly
at D
SP
• 40
% c
o-pa
ymen
t ap
plie
s at
a n
on-D
SP
• 26
PM
Bs
• Re
stri
ctiv
e Fo
rmul
ary
at D
SP, 4
0% c
o-pa
ymen
t ap
ply
at n
on-D
SP
OU
T O
F H
OSP
ITAL
BEN
EFIT
SST
AND
ARD
PRIM
ARY
GP
CON
SULT
ATIO
NIN
-NET
WO
RKO
UT-
OF-
NET
WO
RK: S
UB-
LIM
IT
INCL
UD
ED IN
NET
WO
RKIN
-NET
WO
RKO
UT-
OF-
NET
WO
RK: S
UB-
LIM
IT IN
CLU
DED
IN
NET
WO
RK
MEM
BER
R3 2
00R1
050
R1 5
00R5
00
MEM
BER
+1R4
700
R1 6
00R2
850
R950
MEM
BER
+A+C
R5 2
00R1
750
R3 3
00R1
100
MEM
BER
+A+2
CR5
500
R1
850
R3 6
00R1
200
MEM
BER
+A+3
CR5
900
R2 0
00R4
000
R1 3
50
Page 50 Benefits 2014
AT A GLANCE O
UT
OF
HO
SPIT
AL B
ENEF
ITS
STAN
DAR
DPR
IMAR
Y
DAY
-TO
-DAY
LIM
ITD
AY-T
O-D
AY L
IMIT
DAY
-TO
-DAY
LIM
IT
MEM
BER
R3 6
00R1
600
MEM
BER
+ A
R5 5
00R2
900
MEM
BER
+A+C
R5 9
00R3
400
MEM
BER
+A+2
CR6
400
R3 7
00
MEM
BER
+A+3
CR6
950
R4 0
00
ACU
TE M
EDIC
ATIO
N
AND
PAT
SPEC
IALI
STS
CON
SULT
ATIO
NS,
RAD
IOLO
GY,
PAT
HO
LOG
Y,
PARA
MED
ICAL
SER
VICE
S, A
CUTE
M
EDIC
ATIO
N
Phar
mac
y Ad
vise
d Th
erap
y su
b-lim
it o
f R62
0 p.
b. a
nd R
1 90
0 p.
f. Al
l are
sub
ject
to
day-
to-d
ay b
enefi
t
Subj
ect
to d
ay-t
o-da
y be
nefit
PAT
sub-
limit
of R
380
p.b.
and
R1
100
per f
amily
. All
are
subj
ect
to d
ay-t
o-da
y be
nefit
Subj
ect
to d
ay-t
o-da
y be
nefit
OPT
OM
ETRY
: 2 Y
EAR
BEN
EFIT
FRO
M A
NN
IVER
SARY
OF
CLAI
MIN
G P
.B.
OPT
OM
ETRI
C EX
AMIN
ATIO
N10
0% o
f cos
t at
a n
etw
ork
prov
ider
, or R
295
at a
non
-net
wor
k pr
ovid
er.
100%
of c
ost
at n
etw
ork
prov
ider
, or R
295
at a
non
-net
wor
k pr
ovid
er
FRAM
ES A
ND
PRE
SCRI
PTIO
N
LEN
SES/
ADD
-ON
SR8
00 p
er b
enefi
ciar
yR3
00 p
er b
enefi
ciar
y at
a n
etw
ork
prov
ider
CLEA
R SI
NG
LE V
ISIO
NR1
50 p
er le
ns o
rR1
50 p
er le
ns o
r
CLEA
R AQ
UIT
Y FL
AT-T
OP
BIFO
CAL
R325
per
lens
or
R325
per
lens
or
CLEA
R AQ
UIT
Y M
ULT
IFO
CAL
(U
P TO
BIF
OCA
L LI
MIT
)R6
00 p
er le
ns o
rR6
00 p
er le
ns o
r
CON
TACT
LEN
SES
R1 5
50 p
er b
enefi
ciar
yR7
50 p
er b
enefi
ciar
y
DEN
TIST
RY
CON
SERV
ATIV
E D
ENTI
STRY
Bene
fits
are
subj
ect
to D
ENIS
clin
ical
pro
toco
ls.
Cove
red
at t
he B
DT*
(Bon
itas
Den
tal T
ariff
)Be
nefit
s ar
e su
bjec
t to
DEN
IS c
linic
al p
roto
cols
Co
vere
d at
the
BD
T* (B
onit
as D
enta
l Tar
iff)
SPEC
IALI
SED
DEN
TIST
RYBe
nefit
s ar
e su
bjec
t to
DEN
IS c
linic
al p
roto
cols
. Co
vere
d at
the
BD
T* (B
onit
as D
enta
l Tar
iff)
No
bene
fit
Benefits 2014 Page 51
INFA
NT
PAED
IATR
IC B
ENEF
IT2
cons
ulta
tion
s be
fore
the
age
of 1
yea
r.
1 co
nsul
tati
ons b
etw
een
the
ages
of
1 an
d 2
year
s per
ben
efici
ary,
per
ann
um1
cons
ulta
tion
bef
ore
the
age
of 1
yea
r. 1
cons
ulta
tion
bet
wee
n th
e ag
es o
f 1 a
nd 2
yea
rs p
er b
enefi
ciar
y, p
er a
nnum
CHIL
DH
OO
D IL
LNES
S BE
NEF
IT2
GP
cons
ulta
tion
s be
twee
n th
e ag
es o
f 2 a
nd 1
2 ye
ars
1 G
P co
nsul
tati
on b
etw
een
the
ages
of 2
and
12
year
s
APPL
IAN
CES
GEN
ERAL
APP
LIAN
CES
R 6
200
per f
amily
R5 5
50 p
er fa
mily
WH
EELC
HAI
RS A
ND
LAR
GE
ORT
HAP
AED
IC A
PPLI
ANCE
SIn
clud
ed in
Gen
eral
App
lianc
es li
mit
Incl
uded
in G
ener
al A
pplia
nces
lim
it
STO
MA
PRO
DU
CTS
AND
CPA
P*M
ay e
xcee
d G
ener
al A
pplia
nces
lim
it b
y R5
000
May
exc
eed
Gen
eral
App
lianc
es l
imit
by
R5 0
00
HEA
RIN
G A
IDS
R13
000
Bien
nial
per
fam
ily
R7 4
00 B
ienn
ial p
er fa
mily
OXY
GEN
: HO
ME
VEN
TILA
TIO
NU
nlim
ited
sub
ject
to
pre-
auth
oris
atio
n by
HBM
Unl
imit
ed s
ubje
ct t
o pr
e-au
thor
isat
ion
by H
BM
SUPP
LEM
ENTA
RY B
ENEF
ITS
STAN
DAR
DPR
IMAR
Y
MAT
ERN
ITY
CARE
12 a
nte-
nata
l con
sult
atio
ns, 2
x 2
D s
cans
, 4 p
ost-
nata
l co
nsul
tati
ons
wit
h a
mid
wif
e. A
nte-
nata
l cla
sses
R95
06
ante
-nat
al c
onsu
ltat
ions
, 2 x
2D
sca
ns, 4
pos
t-na
tal
cons
ulta
tion
s w
ith
a m
idw
ife
HIV
R24
900
per b
enefi
ciar
y su
bjec
t to
Aid
for A
IDS
regi
stra
tion
R19
000
per b
enefi
ciar
y su
bjec
t to
Aid
for A
IDS
regi
stra
tion
MEN
TAL
HEA
LTH
R31
200
per f
amily
, sub
-lim
it o
f R12
200
in
and
out
of h
ospi
tal c
onsu
ltat
ions
R12
200
per f
amily
, sub
-lim
it o
f R7
400
in a
nd o
ut o
f hos
pita
l con
sult
atio
ns
SPEC
IALI
SED
RAD
IOLO
GY
R20
100
per f
amily
, sub
ject
to
pre-
auth
oris
atio
n. O
ut o
f hos
pita
l lim
itR9
500
per
fam
ily (j
oint
lim
it in
and
out
of h
ospi
tal),
sub
ject
to
pre-
auth
oris
atio
n
AMBU
LAN
CE –
EM
ERG
ENCY
ER24
ER24
END
OSC
OPI
ES IN
D
OCT
ORS
RO
OM
S*U
nlim
ited
Unl
imit
ed
PRO
STH
ESES
INTE
RNAL
AN
D
EXTE
RNAL
R33
900
per f
amily
PMBs
onl
y
COCH
LEAR
IMPL
ANTS
R158
000
per
fam
ilyN
o be
nefit
INTE
RNAL
NER
VE S
TIM
ULA
TORS
R127
000
per
fam
ilyN
o be
nefit
HIV
TES
T AN
D F
LU V
ACCI
NE
1 ea
ch p
er b
enefi
ciar
y, p
er a
nnum
1 ea
ch p
er b
enefi
ciar
y, p
er a
nnum
Page 52 Benefits 2014
CON
TRIB
UTI
ON
S
MEM
BER
R2 1
86R1
412
MEM
BER
+ A
R4 0
77R2
517
MEM
BER
+ C
R2 8
25R1
862
MEM
BER
+A +
CR4
716
R2 9
67
MEM
BER
+ A
+ 2C
R5 3
55R3
417
MEM
BER
+ A
+ 3C
R5 9
94R3
867
Benefits 2014 Page 53
AT A GLANCE BO
NCA
P
MAJ
OR
MED
ICAL
BEN
EFIT
SBO
NCA
P
OVE
RALL
AN
NU
AL L
IMIT
Unl
imit
ed
REIM
BURS
EMEN
T RA
TE10
0% B
onCa
p Ra
te
PRO
VID
ERBo
nCap
Net
wor
k
GPs
AN
D S
PECI
ALIS
TSU
nlim
ited
PATH
OLO
GY
Lim
ited
to
R19
500,
exc
ept
for P
MBs
GEN
ERAL
RAD
IOLO
GY
Unl
imit
ed
SURG
ICAL
PRO
CED
URE
SLi
mit
ed t
o R1
3 50
0 pe
r fam
ily, p
er a
nnum
BLO
OD
TRA
NSF
USI
ON
Lim
ited
to
R14
200
per f
amily
, per
ann
um
PHYS
IOTH
ERAP
Y AN
D O
CCU
PATI
ON
AL T
HER
APY
ON
COLO
GY
- CH
EMO
AN
D R
ADIO
LOG
YO
RGAN
TRA
NSP
LAN
TSCH
RON
IC R
ENAL
DIA
LYSI
S
PMBs
onl
y
MAX
ILLO
-FAC
IAL
SURG
ERY
R13
500
per f
amily
, inc
lude
d in
sur
gica
l pro
cedu
res
MED
ICAT
ION
TO
TAK
E O
UT
(TTO
)R2
90 p
er b
enefi
ciar
y, p
er a
dmis
sion
ALTE
RNAT
IVES
TO
HO
SPIT
ALIS
ATIO
NLi
mit
ed t
o R1
1 00
0 p
er fa
mily
per
ann
um, p
re-a
utho
risa
tion
requ
ired
PHYS
ICAL
REH
ABIL
ITAT
ION
PMBs
onl
y
CHRO
NIC
BEN
EFIT
S
CHRO
NIC
26 P
MBs
Pha
rmac
y D
irect
is t
he D
SP fo
r the
dis
trib
utio
n of
chr
onic
med
icat
ion
OU
T O
F H
OSP
ITAL
BEN
EFIT
S
GP
CON
SULT
ATIO
NS
12 c
onsu
ltat
ions
per
ben
efici
ary
per a
nnum
sub
ject
to
the
BonC
ap G
P ne
twor
k. A
utho
risa
tion
is
requ
ired
afte
r the
12t
h vi
sit.
PM
B on
ly a
fter
the
12t
h vi
sit,
sub
ject
to
man
aged
car
e pr
otoc
ols
OU
T-O
F-N
ETW
ORK
CO
NSU
LTAT
ION
S1
visi
t pe
r ben
efici
ary
or 2
vis
its
per f
amily
to
a m
axim
um o
f R80
0 an
d 20
% c
o-pa
ymen
t (e
xcep
t em
erge
ncie
s). N
o be
nefit
for f
acili
ty fe
esAC
UTE
MED
ICAT
ION
Subj
ect
to t
he B
onCa
p Ac
ute
Med
icin
e Fo
rmul
ary
OVE
R-T
HE-
COU
NTE
R M
EDIC
ATIO
NLi
mit
ed t
o R2
05 p
er b
enefi
ciar
y, p
er a
nnum
, max
imum
of R
70 p
er e
vent
SPEC
IALI
ST C
ON
SULT
ATIO
NS
3
visi
ts p
er b
enefi
ciar
y lim
ited
to
R2 4
00 o
r 5 v
isit
s pe
r fam
ily li
mit
ed t
o R3
550
. Su
bjec
t to
refe
rral
from
a n
etw
ork
GP
and
pre-
auth
oris
atio
nO
CCU
PATI
ON
AL T
HER
APY
AND
PH
YSIO
THER
APY
PMBs
onl
y, o
n re
ferr
al fr
om a
net
wor
k G
P
GEN
ERAL
RAD
IOLO
GY
List
of a
ppro
ved
inve
stig
atio
ns
On
refe
rral
from
a n
etw
ork
GP
Page 54 Benefits 2014
AT A GLANCE BO
NCA
P
OU
T O
F H
OSP
ITAL
BEN
EFIT
S
PATH
OLO
GY
List
of a
ppro
ved
inve
stig
atio
ns o
n re
ferr
al fr
om a
net
wor
k G
P
BASI
C D
ENTI
STRY
Su
bjec
t to
DEN
IS m
anag
ed c
are
prot
ocol
s an
d ap
prov
ed c
odes
. Cov
ered
at
Boni
tas
dent
al ra
te
SPEC
IALI
SED
DEN
TIST
RY
No
bene
fit
OPT
OM
ETRY
2
year
ben
efit.
Ben
efit
com
men
ced
1 Ja
n 20
13
SUPP
LEM
ENTA
RY B
ENEF
ITS
MAT
ERN
ITY
CARE
Subj
ect
to B
onCa
p G
P ne
twor
kN
eona
tal c
are
limit
ed t
o R3
5 00
0 pe
r fam
ily
IMM
UN
E D
EFIC
IEN
CY R
ELAT
ED
TO H
IV IN
FECT
ION
Su
bjec
t to
man
aged
car
e pr
otoc
ols
and
regi
stra
tion
on
the
BonC
ap H
IV/A
IDS
prog
ram
me
MEN
TAL
HEA
LTH
BEN
EFIT
S PM
Bs o
nly
SPEC
IALI
SED
RAD
IOLO
GY
(JO
INT
LIM
IT IN
AN
D O
UT
OF
HO
SPIT
AL)
R8 9
00 p
er fa
mily
and
sub
ject
to
pre-
auth
oris
atio
n
EMER
GEN
CY M
EDIC
AL T
RAN
SPO
RTAT
ION
Su
bjec
t to
ER2
4 au
thor
isat
ion
PRO
STH
ESES
INTE
RNAL
(IN
HO
SPIT
AL)
PMBs
onl
y
PRO
STH
ESES
EXT
ERN
ALN
o be
nefit
HIV
TES
T AN
D F
LU V
ACCI
NE
1 ea
ch p
er b
enefi
ciar
y, p
er a
nnum
APPL
IAN
CES
GEN
ERAL
APP
LIAN
CES
R4 2
00 p
er fa
mily
WH
EELC
HAI
RS, S
TOM
A PR
OD
UCT
S,
CPA
P*, H
EARI
NG
AID
S, E
TC.
Join
t lim
it w
ith
Gen
eral
App
lianc
es
OXY
GEN
TH
ERAP
Y AN
D H
OM
E VE
NTI
LATI
ON
Subj
ect
to p
re-a
utho
risa
tion
by
Hos
pita
l Ben
efit
Man
agem
ent
Benefits 2014 Page 55
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INTERNATIONAL TRAVEL BENEFIT:E-mail: [email protected] 991 8000/9000
DENTISTRY:08h00-16h30 Mon-FriE-mail: [email protected]: 086 677 0336Web:www.denis.co.za0860 336 346
CENTRE FOR DIABETES AND ENDOCRINOLOGY (CDE):08h30-17h00 Mon-FriFax: 011 712 6000 / 011 728 6661E-mail: [email protected]: www.cdecentr.co.za
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CONTACT US: 0860 002 108
BLOEMFONTEIN: Shop C7, 1st Floor, Middestad Centre, C/O Charles and West Burger Street, BloemfonteinCAPE TOWN: Medscheme, Atterbury House, 15th Floor, 9 Riebeek Street, Cape Town DURBAN: 3rd Floor, 67 Old Fort Road, DurbanLEPHALALE: Onverwacht Business, Mienie Building, Block C, Walter Sisulu Avenue, LephalaleKATHU: 6 Rietbok Street, Kathu, Northern CapeNORTHAM: 180 Botha Steet, NorthamPORT ELIZABETH: Block 6, Greenacres Office Park, 2nd Avenue, Newton Park, Port ElizabethPOLOKWANE: Ground Floor, Bonitas House, 22 Hans van Rensburg Street, PolokwanePRETORIA: Ground Floor, Benstra Building, 473B Church Street, Arcadia, PretoriaROODEPOORT: 37 Conrad Road, Florida North, RoodepoortRUSTENBURG: 141 Fatima Bhayat Street, RustenburgSECUNDA: Grand Palace, Unit 82, 2302 Heinis Street, SecundaVEREENIGING: 36 Merriman Avenue, Ground floor, Vereeniging JOHANNESBURG: Mathomo Mall, 115 Main Street, Marshalltown, Johannesburg EAST LONDON: BSB Building, 7 Settlers Way, Gately Township, East LondonPRETORIA: Exxaro Corporate Centre, C/O Roger Dayson and Voortrekker Road, Pretoria West
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