Benefits Equilibrium - 2015 Plan Type Hybrid - Savings and Traditional combined Plan Operation - Hospitalisation 100% of Scheme negotiated Tariff - Day-to-day Limited Savings and additional Scheme Benefit (SB) Overall Annual Maximum Unlimited, up to 100% of Agreed Tariff Hospital Benefit 1 Private Hospital Care Any Private Hospital, subject to DSP Specialists 2 Co-payment R1240 - Oral surgery and MRI/CT scans 3 Oncology Limited to R117 000 per family 4 Organ Transplants Unlimited, PMB conditions only, DSP hospitals 5 Dialysis Unlimited, PMB conditions only, DSP hospitals 6 Maternity - Natural Birth Unlimited - Elective Ceasarean Unlimited 7 To take home medication R400 per beneficiary per admission 8 Psychiatric Hospitalisation Limited to R14 800 per family Radiology/Pathology/Prosthesis 1 Basic Radiology Unlimited Essence - 2015 Gold - 2015 Traditional limited 100% of Scheme negotiated Tariff Limited benefits: Scopes, Dentistry, Appliances, OTC Medicine Unlimited, up to 100% of Agreed Tariff Hybrid - Savings and Traditional combined 100% of Scheme negotiated Tariff Any Private Hospital, subject to DSP Specialists R1240 - Oral surgery and MRI/CT scans Limited to R117 000 per family Unlimited, PMB conditions only, DSP hospitals Unlimited, PMB conditions only, DSP hospitals Unlimited Unlimited R400 per beneficiary per admission Limited to R14 800 per family Any Private Hospital, subject to DSP Specialists R1240 - Oral surgery and MRI/CT scans Limited to R300 000 per family Unlimited, PMB conditions only, DSP hospitals Unlimited, PMB conditions only, DSP hospitals Unlimited Unlimited R400 per beneficiary per admission Limited to R30 300 per family Unlimited Unlimited R12 400 p/f, R1240 co-payment, PET limited to R13 700 and 2 p/b Unlimited Limited to R35 000 subject to DSP, sublimits and protocols, case management Included in above, Hearing Aids - R12 000 p/f per 4 years, DSP Limited Savings and additional Scheme Benefit (SB) Unlimited, up to 100% of Agreed Tariff 2 MRI, CT & PET Scans R12 400 p/f, R1240 co-payment. No PET Scan benefit R12 400 p/f, R1240 co-payment. No PET Scan benefit 3 Pathology Unlimited Unlimited 4 Internal Prosthesis Limited to PMB/Trauma conditions only, sublimits apply Limited to PMB/Trauma conditions only, sublimits apply Limited to PMB/Trauma conditions only, sublimits apply Limited to PMB/Trauma conditions only, sublimits apply Limited to PMB conditions Combined with Hospice benefit Unlimited - Netcare 911 Limited to PMB conditions Combined with Hospice benefit Unlimited - Netcare 911 Limited to R30 000 per family, R9900 wound care Combined with Hospice benefit Unlimited - Netcare 911 Unlimited - DSP & Formulary, 30% co-pay at non-DSP DSP. 90% - Children under 21 - 3 conditions (Acne/Rhinitis/ADHD) Unlimited - DSP & Formulary, 30% co-pay at non-DSP Unlimited - DSP & Formulary, 15% co-pay at non-DSP No benefit No benefit 5 External Appliances/Prosthesis Sub Acute Facilities 1 Hospice 2 Nursing 3 Ambulance Services Chronic Benefit 27 CDL chronic conditions Additional chronic conditions Day-to-day Benefit N/a N/a N/a Savings plus Scheme Benefit (SB) of PM R3725, AD R2770, CD R885 Any GP, Specialist, Pharmacy(except Chronic), DENIS PM: R3960, AD: R2676, C: R768+ SB:PM R3725, AD R2770, CD R885 N/a N/a N/a Subject to MSA and Scheme Benefit limit Subject to MSA and Scheme Benefit limit Subject to MSA and Scheme Benefit limit Subject to MSA and Scheme Benefit limit No benefit No benefit No benefit Limited to R350 per beneficiary Subject to MSA and Scheme Benefit limit Subject to MSA and Scheme Benefit limit Subject to MSA and Scheme Benefit limit R1515 p/f, Subject to MSA and Scheme Benefit Subject to MSA and Scheme Benefit limit Combined with In-hospital benefit limit No benefit, except PMB conditions No benefit Combined with In-hospital benefit limit No benefit, except PMB conditions Subject to MSA and Scheme Benefit limit Combined with In-hospital benefit limit Subject to MSA and Scheme Benefit- 30% co-payment 100%, subject to DENIS protocols and sublimits Subject to MSA 100%, subject to DENIS protocols and sublimits No benefit, except maxillo-facial and oral surgery 100%, subject to DENIS protocols and sublimits Unlimited, subject to DENIS protocols and 20% co-payment 1 Examination Subject to MSA and Scheme Benefit limit No benefit 2 Lenses Subject to MSA and Scheme Benefit limit No benefit 3 Frames 4 Contact Lenses Auxilliary Services 1 Physiotherapy 2 Psychiatry 3 Psychology Subject to MSA and Scheme Benefit limit Subject to MSA and Scheme Benefit limit No benefit No benefit Subject to SB: R2340(OAL) p/b per 24 months: One test per 2 years Subject to OAL: 1 pair p/b every 2 years. Refractive surgery subject to OAL Subject to OAL: 1 pair p/b every 2 years: R740 limit Subject to OAL: R1110 p/b per annum Subject to MSA and Scheme Benefit limit Combined with In-hospital benefit, R6200 sublimit p/f Combined with Psychiatry benefit Unlimited, subject to case management, protocols and PMB entitlement in Private Hospitals No benefit No benefit No benefit Unlimited, subject to case management, protocols and PMB entitlement in Private Hospitals Subject to MSA and Scheme Benefit limit Combined with In-hospital benefit, R12 400 sublimit p/f Combined with Psychiatry benefit Unlimited, subject to case management, protocols and PMB entitlement in Private Hospitals December 31, 2013 Scheme - 36 019 This Option - 4 071 PMSA Medical Scheme Administrators (Pty) Ltd Average age- 42.6(31.9); Pensioner %- 20.1%(9.9%) 29.50% 2012- 10.4%, 2013- 11.3%, 2014- 8.9%, 2015- 6.9% December 31, 2013 Scheme - 36 019 This Option - 1 916 PMSA Medical Scheme Administrators (Pty) Ltd Average age- 42.6(34.3); Pensioner %- 20.1%(10.3%) 29.50% 2012- 10.4%, 2013- 11.3%, 2014- 8.9%, 2015- 6.9% December 31, 2013 Scheme - 36 019 This Option - 19 292 PMSA Medical Scheme Administrators (Pty) Ltd Average age- 42.6(44.3); Pensioner %- 20.1%(21.0%) 29.50% 2012- 10.4%, 2013- 11.3%, 2014- 8.9%, 2015- 6.9% Overall Annual Maximum Preferred Provider Medical Savings Account Annual Threshold Self Payment Gap Above Threshold Benefit GP's and medication 1 General Practitioners 2 Specialists 3 Prescribed Medication 4 Pharmacy Advised Medicine Radiology & Pathology 1 Basic Radiology 2 MRI, CT & PET Scans 3 Pathology Dental Benefit 1 Conservative Dentistry 2 Specialised Dentistry Optical Benefit HIV / AIDS Financial and Demographic 1 Date of information 2 Principal Members 3 Administrator 4 Scheme (Option) age profile 5 Solvency ratio 6 Past Scheme increases Contributions Savings plus Scheme Benefit (SB) of PM R1840, AD R1025, CD R555 Any GP, Specialist, Pharmacy(except Chronic), DENIS PM R1296, AD R780, C R396 + SB:PM R1840, AD R1025, CD R555 N/a N/a N/a Individual limits per service category MediKredit for Chronic, DENIS for dental N/a Salary Brackets All All All Principal Member 1487 1065 3302 Principal Member + Spouse 2384 1909 5534 Principal + Spouse + 1 Child 2839 2264 6181 Principal + Spouse + 2 Children 3294 2619 6828 Principal + Spouse + 3 Children 3749 2974 7475 E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail. Benefits Origin - 2015 Platinum - 2015 Plan Type Capitation (Designated Service Providers) Plan Operation - Hospitalisation Prime Cure contracted Private and Public Hospitals (DSP's) Traditional limited 100% of Scheme negotiated Tariff Any Private Hospital, subject to DSP Specialists R1240 - Oral surgery and MRI/CT scans Any Private Hospital, subject to DSP Specialists R1240 - Oral surgery and MRI/CT scans Unlimited, authorisation and case management apply Limited to R131 000 per family Unlimited, authorisation and case management apply Unlimited, authorisation and case management apply Unlimited Unlimited R400 per beneficiary per admission Limited to R44 500 per family Unlimited, PMB conditions only, DSP hospitals Unlimited, PMB conditions only, DSP hospitals Unlimited Unlimited R400 per beneficiary per admission Limited to R14 800 per family Unlimited R18 500 p/f, R1240 co-payment, PET limited to R13 700 and 2 p/b Unlimited Unlimited, subject to DSP, sublimits and protocols, case management Included in above, Hearing Aids - R26 000 p/f per 4 years, DSP Unlimited R11 000 p/f, subject to pre-auth and case management No benefit Unlimited - Netcare 911 Limited to R37 000 per family, R12 900 wound care Combined with Hospice benefit Unlimited - Netcare 911 Limited to R22 300 per family, R7150 wound care Combined with Hospice benefit Unlimited - Netcare 911 Unlimited - Preferred Provider & Formulary applies Unlimited - DSP & Formulary, 10% co-pay at non-DSP DSP. 90% - Single: R14 200, Family R29 000, 29 conditions Unlimited - DSP & Formulary, 30% co-pay at non-DSP - Day-to-day Member nominated Prime Cure GP Overall Annual Maximum Hospital Benefit 1 Private Hospital Care 2 Co-payment R500 000 perfamily 3 Oncology Designated Public and Private Hospital Network R5000 if no pre-authorisation obtained for elective admissions R110 000 p/f. PMB's only at DSP (pre-auth and case management apply) Limited to PMB conditions at DSP Hospitals Unlimited, PMB conditions only, DSP hospitals Unlimited at DSP Hospital. Unlimited at DSP. Subject to second opinion and case management Limited to 7 days supply per event PMB's only at DSP Hospital/Clinic 4 Organ Transplants 5 Dialysis 6 Maternity - Natural Birth - Elective Ceasarean 7 To take home medication 8 Psychiatric Hospitalisation Radiology/Pathology/Prosthesis 1 Basic Radiology R6600 p/f, subject to pre-authorisation 2 MRI, CT & PET Scans Included in Basic Radiology benefit 3 Pathology R21 000 p/f, subject to pre-authorisation 4 Internal Prosthesis R21 000 p/f, subject to OAL, protocols and motivation 5 External Appliances/Prosthesis Sub Acute Facilities 1 Hospice 2 Nursing 3 Ambulance Services Chronic Benefit 27 CDL chronic conditions Additional chronic conditions Silver - 2015 Traditional comprehensive 100% of Scheme negotiated Tariff Scheme Benefit, then Member funded portion and then Above Threshold Benefit Unlimited, up to 100% of Agreed Tariff No benefit No benefit Set benefit limits per service category Unlimited, up to 100% of Agreed Tariff R12 400 p/f, R1240 co-payment. No PET Scan benefit Unlimited Limited to PMB/Trauma conditions only, sublimits apply Limited to PMB/Trauma conditions only, sublimits apply No benefit Day-to-day Benefit Overall Annual Maximum Individual limits per service category Preferred Provider Yes - Prime Cure GP Network Medical Savings Account N/A Annual Threshold Self Payment Gap Above Threshold Benefit GP's and medication N/A N/A N/A Scheme Benefit, then Member funded portion and then Above Threshold Benefit Any GP, Specialist, Pharmacy(except Chronic), DENIS N/a - Scheme Benefit (SB) of PM: R8100, AD: R7855, C: R1920 PM: R10 935, AD: R10 380, C: R2850 PM: R2835, AD: R2525, C: R930 Various limits/co-payments per service category Scheme Benefit (SB) and additional benefits Any GP, Specialist, Pharmacy(except Chronic), DENIS N/a - Scheme Benefit (SB) of PM: R5760; AD: R4185, C: R1160 N/a N/a N/a 2 Specialists 12 visits p/b at nominated DSP GP. Pre-auth after 8th visit. PMB's only after 12th visit. 1 out-of-network visit p/b and 2 p/f 5 visits p/f, maximum of 3 p/b. Limited to R2400 p/b and R3500 p/f 3 Prescribed Medication Unlimited at DSP, Formulary applies 4 Pharmacy Advised Medicine Radiology & Pathology 1 Basic Radiology 2 MRI, CT & PET Scans 3 Pathology Dental Benefit 1 Conservative Dentistry Limited to 3 events p/b, R210 p/b and R70 per event Subject to Scheme Beneft/ATB - 90% Unlimited in ATB Subject to Scheme Benefit limit 100%. Subject to SB & ATB. Sublimit PM R6680, AD Subject to Scheme Benefit limit R3030, C R1480 Subject to SB and R2275 per family Limited to R1245 per family and Scheme Benefit Specific list of black & white x-rays Combined with In-hospital benefit limit Specific list of tests, protocols apply Subject to SB limits - 90% Unlimited in ATB Combined with In-hospital benefit limit Subject to SB and ATB, 20% co-payment Subject to Scheme Benefit limit Combined with In-hospital benefit limit Limited to Scheme Benefit limit - 30% co-payment Unlimited at DSP - basic services only No benefit 100%, subject to DENIS protocols and sublimits 80%, subject to DENIS & 20% co-pay, R3100 for implants 100%, subject to DENIS protocols and sublimits 2 Specialised Dentistry Subject to SB. R3900(OAL) p/b per 24 months: One test per 2 years 1 pair p/b per 2 years, R7900 limit for refractive surgery One pair p/b every 24 months, R1170 limit R1850 per beneficiary per annum Subject to SB: R1170(OAL) p/b per 24 mths, 1 test p/b every 24 mths Subject to OAL: 1 pair p/b every 2 years Subject to OAL: R390 sublimit p/b every 24 mths Subject to OAL: R520 sublimit p/b every 24 mths Scheme Beneft & ATB - 90% Unlimited in ATB Combined with In-hospital benefit, R18 500 sublimit p/f Combined with Psychiatry benefit Unlimited, subject to case management, protocols and PMB entitlement in Private Hospitals Subject to Scheme Benefit limit Combined with In-hospital benefit, R6200 sublimit p/f Combined with Psychiatry benefit Unlimited, subject to case management, protocols and PMB entitlement in Private Hospitals December 31, 2013 Scheme - 36 019 This Option - 4 941 PMSA Medical Scheme Administrators (Pty) Ltd Average age- 42.6(57.5); Pensioner %- 20.1%(42.4%) 29.50% 2012- 10.4%, 2013- 11.3%, 2014- 8.9%, 2015- 6.9% December 31, 2013 Scheme - 36 019 This Option - 5 301 PMSA Medical Scheme Administrators (Pty) Ltd Average age- 42.6(38.2); Pensioner %- 20.1%(14.8%) 29.50% 2012- 10.4%, 2013- 11.3%, 2014- 8.9%, 2015- 6.9% 1 General Practitioners Subject to Scheme Beneft/ATB - 90% Unlimited in ATB Subject to Scheme Benefit limit, 2 additional visits p/f No benefit, except maxillo-facial and oral surgery Optical Benefit 1 Examination One consultation per member per 12 months 2 Lenses 3 Frames 4 Contact Lenses Auxilliary Services 1 Physiotherapy 2 Psychiatry 3 Psychology One basic set every 24 months One basic set every 24 months No benefit HIV / AIDS Unlimited, subject to registration, DSP Hospitals Financial and Demographic 1 Date of information 2 Principal Members 3 Administrator 4 Scheme (Option) age profile 5 Solvency ratio 6 Past Scheme increases Contributions December 31, 2013 Scheme - 36 019 This Option - 498 PMSA Medical Scheme Administrators (Pty) Ltd Average age- 42.6(28.7); Pensioner %- 20.1%(0.1%) 29.50% 2012- 10.4%, 2013- 11.3%, 2014- 8.9%, 2015- 6.9% Limited to PMB's Limited to PMB's Limited to PMB's Salary Brackets R0 R500 R501 R3500 Principal Member 440 607 Principal Member + Spouse 880 1177 Principal + Spouse + 1 Child R3501 R5000 R5001 R7500 R7501 R10000 All All 647 806 1112 1260 1510 5475 2487 2065 9313 3824 1095 1442 1545 1851 2451 10467 4342 Principal + Spouse + 2 Children 1310 1707 1830 2192 2837 11621 4860 Principal + Spouse + 3 Children 1525 1972 2115 2533 3223 12775 5378 E&OE. Although care is taken to represent the benefits correctly, errors and omissions could occur. In case of any conflict, the Rules of the affected Scheme prevail.
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