2014 Healthcare Arrangements Presented by Nicolette du Toit AGENDA - - PowerPoint PPT Presentation

Volkswagen Group South Africa 2014 Healthcare Arrangements

Presented by Nicolette du Toit

AGENDA

• Who is Alexander Forbes?
• FAIS Requirements
• 2014 VWSA Healthcare Arrangements
• General
• On-site Assistance
• Scheme Administration
• Waiting Periods and Penalties
• Medical Schemes Options for 2014
• Top-up/Gap Cover Insurance offering
• Overview of Schemes/Plans
• Bonitas Medical Fund
• Medihelp Unify
• Discovery Health (Managers and Supervisors Only)
• Contact Details for Assistance

Alexander Forbes Health’s Commitment to You

As Healthcare Consultants to VWSA we provide the following services

• On-Site Assistance – Monthly visits
• Telephone/E-mail Assistance: Consultant and Member Service Unit.
• Assistance in choosing the correct medical scheme option, based on your needs
• Monthly Induction sessions upon employment at VWSA; promotion (to supervisor/managerial level).
• Annual Helpdesks during the option change period (October – November).
• Clarification of benefits and the escalation of any unresolved medical scheme queries.
• Liaison with your medical scheme on your behalf to ensure you are treated fairly and correctly, based
• n your benefit entitlements.
• Industry updates that could affect the business and members.
• Annual Evaluation of Medical Schemes available in the Market.
• Strategic consulting to VWSA as a whole.

FAIS Requirements

• Alexander Forbes Health is an approved Financial Services Provider - FSP

33471

• Alexander Forbes Health is accredited by Council for Medical Schemes - ORG

3064

• General Disclosure and Product Supplier disclosures are available upon

request

• Alexander Forbes Health are appointed brokers to Administrators and Open

Medical Schemes (actuarial and consulting services)

• All information provided in this presentation is factual and NO advice is

provided

• All information provided in this presentation has been customized according to

the VWSA Healthcare offering for 2014

General

• Medical Aid Compulsory for all VWSA employees
• Employer Subsidy – 50% of total contribution
• Relatives and Children charged at the Adult Dependant Rates are not

subsidised. On-site Assistance (Medical Aid Office in the HR Benefits Department)

• Rosalind Lourens - Administration / Applications
• Medical Schemes/Service Providers:
• Bonitas – 11h00 to 15h00 - Tuesday & Wednesday
• Udipa – Every day
• Alexander Forbes – 11h00 to 14h00 – Thursday

Scheme Administration

• All changes in personal status, i.e. marriage, new-borns etc. must be advised

within 30 days of the event.

• Termination of dependants requires one month’s notice.
• Members joining during the year – benefits will be pro-rated.

2014 HEALTHCARE ARRANGEMENTS

Waiting Periods & Penalties

• No waiting periods will be applied to any new employee and dependants who join

a VWSA Scheme at date of employment.

• No waiting periods will be applied when changing options within your Scheme or

if you change Schemes (at the end of the year). Medical Schemes & Options for 2014 (All Employees)

• Bonitas
• Standard Option
• Primary Option
• Medihelp
• Unify Option
• Discovery Health (Managers & Supervisors only)
• Classic Comprehensive
• Essential Comprehensive
• Classic Priority
• Classic Saver
• Essential Saver
• Coastal Saver

2014 HEALTHCARE ARRANGEMENTS

Separate Insurance product – Administered by Guardrisk

• Membership is VOLUNTARY
• Covers the GAP for in hospital expenses up to a maximum of 5 times the Admed Tariff
• Additional benefits:

 Stated benefit – R20 000

• can be used for In-hospital deductibles/co-payments on specified procedures
• includes Breast cancer & prostate cancer benefit on 1st diagnosis post policy

 Oncology co-payment cover up to R250 000  Personal accident cover  RoadCover

• Waiting periods and Exclusions apply
• A calendar months notice is required in order to terminate the policy
• Admed Gap must be claimed within 6 months of the date of admission to hospital
• Cost: R 123 per month – payment via Debit Order

*Please refer to the Admed brochure in your induction pack for further detail

AdmedAdd+*

2014 HEALTHCARE ARRANGEMENTS

AND

Summary of the 2014 Schemes/Plans

PLANS Primary Standard Unify Type of Plan Offers members who do not need extensive chronic medicine benefits, with affordable cover and limited day-to-day benefits. Provides comprehensive cover with extended chronic medicine cover and generous day-to-day benefits. a Managed Care plan where the selected GP acts as the “gatekeeper” to the required health services, and provides primary health benefits for the full year as medically required. Ambulance ER 24 – 084 124 Overall Annual Limit None None None HOSPITALS Private Hospitals Pre-authorisation [at least 48 hours prior to hospitalisation ] Unlimited 100% of Bonitas Rate Sub-limits apply & deductibles on listed procedures Unlimited 100% of Bonitas Rate Sub-limits apply Unlimited 100% of Medihelp Rate Sub-limits apply Cuyler Clinic: Uithge Mercantile: PE & Others

2014 In Hospital Deductibles applicable on the Primary plan

R1 000

Colonoscopy, Conservative back treatment, Cystoscopy, Facet joint injections, Flexible sigmoidoscopy, Functional nasal surgery, Gastroscopy, Umbilical hernia repair, Hysteroscopy (not Endometrial ablation), Myringotomy, Tonsillectomy and Adenoidectomy (except PMB’s), Varicose vein surgery

R2 500

Arthroscopy, Diagnostic laparoscopy, Hysterectomy (except cancer and PMB’s), Perutaneous Radiofrequency ablations, Percutaneous rhizotomies, Laparoscopic Appendectomy, Laparscopic Nephrectomy

R5 000

Nissan Fundoplication (reflux surgery), Back surgery including spinal fusion, Joint replacements e.g. hip & knee replacements (except PMB’s)Laparoscopic Pyeloplasty, Laparoscpic Radical Prostatectomy

PLANS Primary Standard Unify CHRONIC MEDICATION BENEFITS Chronic Medication 26 PMB conditions unlimited cover for PMB’s from DSP: Pharmacy Direct Telephonic Application Clinical Entry Criteria 26 PMB conditions 16 Additional conditions Paid from benefit limit

• f R7 400 pb /R14 800 pf

at ANY Provider (comprehensive formulary) thereafter unlimited cover for PMB’s from DSP: Pharmacy Direct Telephonic Application Clinical Entry Criteria 26 PMB conditions Subject to chosen GP or referred specialist and Network formulary Additional conditions Subject to chosen GP or referred specialist and Network formulary up to an Annual limit of R 6 600 pb All Chronic Medication must be obtained from Udipa’s Chronic Disease and Wellness Centre.

Summary of the 2014 Schemes/Plans

PLANS Primary Standard Unify TYPE OF COVER OUT OF HOSPITAL COVER

Day-to-Day non-hospital Specialists consultations (referral required), Acute medication, PAT(limits apply), Radiology, Pathology and certain auxiliary services are paid from the Day- to-Day fund. The funds belong to the Scheme No roll over/accumulation takes place Benefit limits applies to other disciplines

The member must use the selected Network GP for all Day- to-Day Doctors’ visits, Acute medication, Referral to Specialists, Radiology and Pathology. Preffered Providers: GP Network – Udipa/Ecipa Radiology – Visser & Erasmus Pathology - Pathcare

If requirements are met , above services will be covered for the full year.

OTC Medication up to R250 pfpa available from Udipa’s Chronic Disease and Wellness Centre.

Benefit limits applies to other disciplines

Day-to-Day fund Single Member : R1 600 Member+1 : R2 900 Member+2: R3 400 Member+3: R3 700 Member+4: R4 000 Day-to-Day fund Single Member : R3 600 Member+1 : R5 500 Member+2: R5 900 Member+3: R6 400 Member+4: R6 950

Summary of the 2014 Schemes/Plans

PLANS Primary Standard Unify DAY-TO-DAY/OUT OF HOSPITAL LIMITS GP Consultations & procedures

GP Network Benefit Limit

PM : R1 500; M+1 : R2 850; M+2: R3 300; M+3: R3 600; M+4+: R4 000

Non-Network Sub-Limit

PM : R500; M+1 : R950; M+2: R1 100; M+3: R1 200; M+4+: R1 350

GP Network Benefit Limit

PM : R3 200; M+1 : R4 400; M+2: R5 200; M+3: R5 500; M+4+: R5 900

Non-Network Sub-Limit

PM : R1 050; M+1 : R1 600; M+2: R1 750; M+3: R1 850; M+4+: R2 000

Required benefits for the full year from chosen GP Emergency Out of Network Benefit:

4 visits per family & R600 per family for medication

Member to pay and claim back from fund Also for 2nd Opinion

Specialist Consultations & procedures

Subject to Day-to-Day fund limit Specialist referral Management in all instances except: Gynaecologist: 1 visit per annum – female beneficiaries. Paediatrician visits: no referral required for children < 2 yr Oncologist visits Ophthalmologist visits Required benefits for full year; Subject to referral by chosen GP

Summary of the 2014 Schemes/Plans

PLANS Primary Standard Unify DAY-TO-DAY/OUT OF HOSPITAL LIMITS (continued) Optometry Either Spectacles or Contact Lenses, not both 1 Consultation: max R295 Lenses: (per lens) Clear single vision R150 Flat top Bifocal R325 Clear Multifocal R600 Frame limit: R300 Contact lenses: R750 Annual Family Limit: R3 880 2 Year Benefit Cycle for spectacles/ contact lenses

* If non-PPN Provider is used, member will be refunded and must ensure payment to the provider. Subject to available benefits.

1 Consultation: max R295 Lenses: (per lens) Clear single vision R150 Flat top Bifocal R325 Clear Multifocal R600 Frame limit: R800 Contact lenses: R1 550 Annual Family Limit: R5 180 2 Year Benefit Cycle for spectacles/ contact lenses

* If non-PPN Provider is used, member will be refunded and must ensure payment to the provider. Subject to available benefits.

Must use Network Optometrist 1 Test every year Spectacle & Contact Lens limits: M : R 954 M+1 : R 1 091 M+2 : R 1 219 M + 3 : R 1 749 Frame sub-limit: R439 2 Year Benefit Cycle for spectacles/ contact lenses

Summary of the 2014 Schemes/Plans

PLANS Primary Standard Unify DAY-TO-DAY/OUT OF HOSPITAL LIMITS (continued) Dentistry Basic cover only Subject to: clinical protocol Bonitas Dental Tariff Basic & Advanced Subject to: clinical protocol Bonitas Dental Tariff 20% co-payment applies to Orthodontic treatment Pre-authorisation required for Advanced Dental Services Must use Network Dentist Basic & Advanced limited to: M : R 2 332 M+ 1 : R 2 681 M+ 2 : R 2 915 M + 3 : R 3 148 M + 4 : R 3 381 M + 5 : R 3 604 M + 6 : R 3 964 Dentures included in above limits and limited to 1 set per beneficiary every 3 years.

Summary of the 2013 Schemes/Plans

PLANS Primary Standard Unify SUPPLIMENTARY BENEFITS Maternity Care

6 ante-natal consultations 2 x 2D scans 12 ante-natal consultations 2 x 2D scans R950 for ante-natal Classes Selected Network GP/referral to Specialist by Network GP 2 x 2D scans

Mental Health Benefits

R12 200 per family Pre-Authorisation Sub-limit of R7 400 for consultations in & out of Hospital R31 200 per family Pre-Authorisation Sub-limit of R12 200 for consultations in & out of Hospital Combined limit of R2 120 per family with Other Health Services

Infant Paediatric Benefit

1 consultation before the age

• f 1 pb pa

1 consultation between the ages of 1 to 2 pb pa 2 consultations before the age of 1 pb pa 1 consultation between the ages

• f 1 to 2 pb pa

Selected Network GP/referral to Specialist by Network GP

Childhood Illness Benefit

1 GP consultation pb pa between ages of 2 to 12 2 GP consultation pb pa between ages of 2 to 12 Selected Network GP

Summary of the 2014 Schemes/Plans

* On Bonitas the Supplementary Benefits are Additional Benefits that does not affect your Day-To-Day Benefit limits.

PLANS Primary Standard Unify DAY-TO-DAY/OUT OF HOSPITAL LIMITS (continued) Specialized Radiology: MRI/CT Scans

Joint limit with In-Hospital Scans R9 500 per family/year R20 100 per family/year 1 specialised investigation, i.e. MRI,CT scan or angiography to a max of R6 000 per family/year

Auxiliary Services

Subject to Day-to-Day fund limit: e.g. Chiropractors, Dieticians, Physiotherapy. Or Supplementary Benefits: e.g. Appliances, Prosthesis, Mental Health Benefits, Maternity Benefits. R2 120 Joint annual limit for services., Including clinical psychologists, physiotherapy speech therapy, podiatry, equipment and external prosthesis, subject to PMB

Summary of the 2014 Schemes/Plans

2014 Employee Contributions (50%)

ALL INCOME CATEGORIES Family Size PRIMARY PLAN DAY-to-DAY BENEFITS Network GP limit STANDARD PLAN DAY-to-DAY BENEFITS Network GP limit Member 706.00 1600 1500 1093.00 3600 3200 Member, Spouse 1258.50 2900 2850 2038.50 5500 4700 Member, Spouse, 1 Child 1483.50 3400 3300 2358.00 5900 5200 Member, Spouse, 2 Children 1708.50 3700 3600 2677.50 6400 5500 Member, Spouse, 3 Children + 1933.50 4000 4000 2997.00 6950 5900 Member, 1 Child 931.00 1600 2850 1412.50 5500 4700 Member, 2 Children 1156.00 3400 3300 1732.00 5900 5200 Member, 3 Children + 1381.00 3700 3600 2051.50 6400 5500 1 Un-subsidised Adult 1105.00 TBD TBD 1891.00 TBD TBD 2 Un-subsidised Adults 2210.00 TBD TBD 3782.00 TBD TBD

TBD: The day-to-day values and GP benefit limits are determined based on the overall family size and not per dependant Please note that these rate tables have been calculated up to the 3rd child.

• On the Bonitas Primary and Standard Plans you only pay for the first 3 children.
• The Child Dependant Rate is charged up to the age of 21, and may be extended up to age 24, provided the child is a full time Student,

and required proof is supplied annually.

2014 Employee Contributions (50%)

MONTHLY INCOME Family Size <= 3000 3001 to 5000 5001 to 7000 7001 to 9000 => 9001 Member 489.00 546.00 657.00 708.00 879.00 Member, Spouse 879.00 1056.00 1290.00 1368.00 1572.00 Member, Spouse, 1 Child 990.00 1179.00 1449.00 1536.00 1746.00 Member, Spouse, 2 Children 1101.00 1302.00 1608.00 1704.00 1920.00 Member, Spouse, 3 Children 1212.00 1425.00 1767.00 1872.00 2094.00 Member, 1 Child 600.00 669.00 816.00 876.00 1053.00 Member, 2 Children 711.00 792.00 975.00 1044.00 1227.00 Member, 3 Children 822.00 915.00 1134.00 1212.00 1401.00 1 Un-subsidised Adult 780.00 1020.00 1266.00 1320.00 1386.00 2 Un-subsidised Adults 1560.00 2040.00 2532.00 2640.00 2772.00

Please note that these rate tables have been calculated up to the 3rd child.

• On the Medihelp Unify Option you will pay a contribution for each child and should you have more than 3 children you would have

to add a further contribution in respect to each additional child i.e.

• The Child Dependant Rate is charged up to the age of 24; however note that “Special dependants” who qualifies, e.g. a grand

child, is charged a rate equal to the adult dependant rate, even if they are under the age of 24.

MONTHLY INCOME <= 3000 3001 to 5000 5001 to 7000 7001 to 9000 => 9001 Per additional Child (50%) 111.00 123.00 159.00 168.00 174.00

COMPREHENSIVE PRIORITY SAVER

Overview of DH benefit structure – Saver Options

HOSPITAL BENEFIT

• Covers approved hospitalisation with no overall limit

– clinical protocols are followed

• If using network specialist, the specialist fees will be

covered in full

• If not, the cover for specialist fees will be limited to:

Classic: 200% of DH Rate Essential: 100% of DH Rate Coastal: 100% of DH Rate DEDUCTABLES apply to In-Hospital Dentistry CO-PAYMENTS apply to specified In-Hospital Scopes / Out-of-Hospital MRI/CT Scans and In- Hospital MRI/CT Scans related to conservative back/neck treatment

VitalityCheck & other

screenings Tests covered from risk benefit at DH rate

CHRONIC ILLNESS BENEFIT

• All plans cover 26 (CDL) PMB Conditions
• Subject to Medicine Formulary or CDA
• Subject to clinical entry criteria

TRAUMA RECOVERY BENEFIT*

*refer to detailed TREB outline for detail Encourage healthy behavior, through access to wellness facilities and incentive structures proven to drive positive changes in behavior

INSURED NETWORK BENEFIT (INB)*

• Additional Network GP visits on All plans*
• Maternity Benefit on Classic Plan only

*refer to detailed INB outline for detail

MEDICAL SAVINGS ACCOUNT (MSA)

Classic & Coastal: 25% of Total Contrib. Essential: 15% of Total Contrib.

• Used to pay day-to-day medical

expenses

• Unused funds accumulate year-on-year
• Full year’s MSA available upon

joining, Pro-Rated in line with your/your dependants’ join date

• Unused funds will be paid out

after 4 months if you resign/join an

• ption that does not have a savings

component

• If you resign/terminate a dependant, the

Scheme may claw-back funds used, but not yet paid

all expense your

• wn responsibility

Overview of DH benefit structure – Classic Priority Option

HOSPITAL BENEFIT

• Covers approved hospitalisation with no overall limit

– clinical protocols are followed

• If using network specialist, the specialist fees will be

covered in full

• If not the cover for specialist fees will be limited to:

Classic: 200% of DH Rate DEDUCTABLES apply to defined list of procedures as well as In-Hospital Dentistry CO-PAYMENTS apply to Out-of-Hospital MRI/CT Scans and In-Hospital MRI/CT Scans related to conservative back/neck treatment

VitalityCheck & other

screenings Tests covered from risk benefit at DH rate

CHRONIC ILLNESS BENEFIT

• All plans cover 26 (CDL) PMB Conditions
• Subject to Medicine Formulary or CDA
• Subject to clinical entry criteria

TRAUMA RECOVERY BENEFIT*

*refer to detailed TREB outline for detail Encourage healthy behavior, through access to wellness facilities and incentive structures proven to drive positive changes in behavior

INSURED NETWORK BENEFIT (INB)

• Network GP visits throughout SPG*
• Maternity Benefit on Classic Plan only
• Unlimited Pathology @ Network Providers
• Selected External Medical Items

*refer to detailed INB outline for detail

your own responsibility

SELF PAYMENT GAP (SPG)*

*refer to SPG outline for detail

MEDICAL SAVINGS ACCOUNT (MSA) Classic: 25% of Total Contrib.

• Used to pay day-to-day medical

expenses

• Unused funds accumulate year-on-year
• Full year’s MSA available upon joining, Pro-Rated

in line with your/your dependants’ join date

• Unused funds will be paid out after 4 months if you

resign/join an option that does not have a savings component

• If you resign/terminate a dependant, the Scheme may

claw-back funds used, but not yet paid

ABOVE THRESHOLD BENEFIT (ATB)

• Limited ‘Safety-net’ for day-to-day expenses subject to

certain sub-limits, and overall ATB limit

• Paid by Discovery at the DH Rate once day-to-day claims

reach certain level Classic:

• Threshold level - Member:

R9 990 Adult: R7 510 Child: R3 270

• Overall limit -

Member: R8 500 Adult: R6 050 Child: R2 920

Overview of DH benefit structure – Comprehensive Options

HOSPITAL BENEFIT

• Covers approved hospitalisation with no overall limit

– clinical protocols are followed

• If using network specialist, the specialist fees will be

covered in full

• If not the cover for specialist fees will be limited to:

Classic: 200% of DH Rate Essential: 100% of DH Rate DEDUCTABLES apply to In-Hospital Dentistry CO-PAYMENTS apply to specified In-Hospital Scopes / Out-of-Hospital MRI/CT Scans and In- Hospital MRI/CT Scans related to conservative back/neck treatment

VitalityCheck & other

screenings Tests covered from risk benefit at DH rate

CHRONIC ILLNESS BENEFIT

• Cover 26 (CDL) PMB Conditions Plus 34

additional (ADL) Conditions

• Subject to Medicine Formulary or CDA
• Subject to clinical entry criteria

TRAUMA RECOVERY BENEFIT*

*refer to detailed TREB outline for detail Encourage healthy behavior, through access to wellness facilities and incentive structures proven to drive positive changes in behavior

INSURED NETWORK BENEFIT (INB)*

• Network GP visits throughout SPG – both plans*
• Maternity Benefit ; Unlimited Pathology @

Network Providers; Preferred Medicine List Medication from Network Pharmacies on Classic Plan only

• Selected External Medical Items – both plans

*refer to detailed INB outline for detail

ATB exclusions and benefits exceeded for your cost

SELF PAYMENT GAP (SPG)*

*refer to SPG outline for detail

MEDICAL SAVINGS ACCOUNT (MSA) Classic: 25% of Total Contrib

Essential: 15% of Total Contrib.

• Used to pay day-to-day medical

expenses

• Unused funds accumulate year-on-year
• Full year’s MSA available upon joining, Pro-Rated

in line with your/your dependants’ join date

• Unused funds will be paid out after 4 months if you

resign/join an option that does not have a savings component

• If you resign/terminate a dependant, the Scheme may

claw-back funds used, but not yet paid

ABOVE THRESHOLD BENEFIT (ATB)

• ‘Safety-net’ for day-to-day expenses subject to certain

sub-limits

• Paid by Discovery at the DH Rate once day-to-day

claims reach certain level Classic & Essential:

• Threshold level - Member:

R11 350 Adult: R11 350 Child: R2 150

Deductibles

A deductible is the amount a member has to pay from his / her own pocket when they go for a specific procedure.

• The Classic Priority plan deductibles range from R2 150 to R10 500
• The deductibles for in-hospital dentistry on all VWSA plans are:

Deductibles 2014 Conservative back and neck treatment, myringotomy (grommets), tonsillectomy, adenoidectomy R2 150 Colonoscopy, Proctoscopy, Sigmoidoscopy, Cystoscopy and Gastroscopy R2 850 Arthroscopy, functional nasal procedures, hysterectomy (except for pre-

• peratively diagnosed cancer), endometrial ablation, laparoscopy, hysteroscopy

R5 150 Reflux surgery, spinal (back and neck) surgery and joint replacements R10 500 Category of members Hospital Day Clinic 2014 2014 Member younger than 13 R1 550 R750 Member older than 13 R4 000 R2 600

• Endoscopic Procedures
• MRI/CT Scans

Co-Payments

Plan Series In-Hospital Out-of-Hospital (in the doctor’s rooms) Hospital account Related accounts Comprehensive

First R2 500 paid from MSA/ATB/your pocket Balance Paid by Discovery Paid by Discovery Paid by Discovery

Priority

First R2 850 / R5 150 is a deductible. (Refer List

• f deductibles)

Balance Paid by Discovery

Saver

First R3 100 paid from MSA /ATB/your pocket Balance Paid by Discovery

A co-payment is the amount a member can pay from his savings when they go for a specific procedure, and which accumulates to the ATB on the Threshold plans

Please note: While the co-payment is payable from your savings, some service providers, Hospitals in particular, may insist on you paying upfront and claiming the amount back from Discovery Health, subject to your available benefits.

All VWSA Plans

In Hospital Out-of-Hospital Paid by Discovery

* However, first R2 450 paid from MSA/ATB/your pocket if related to admission for conservative back or neck treatment.

First R2 450 paid from MSA/ATB Balance Paid by Discovery

Trauma Recovery Extender Benefit

Cover is extended until the end of the subsequent year Trauma

Cover for all day-today expenses related to qualifying events:

• Crime-related injuries
• Conditions resulting from a near-

drowning

• Poisoning
• Severe anaphylactic reaction
• Paraplegia
• Quadriplegia
• Severe burns
• External and internal head

injuries

• Loss of limbs as a result of a

traumatic event covered up to R50,000 per family

2014 2015

2014 Benefit

Chronic Illness Benefit (CIB)

DHMS will fund telemetric glucometers for all diabetic members

Tracking data will be visible to healthcare professionals in HealthID Glucose tracking linked to online Health and Vitality profile –

providing members access to additional management tools

Ability to export test results with date, time and notes to Excel Ability to share data with loved

• ne’s via

Facebook

• r email

iFora app available for download for iOS and Android devices

(development for Blackberry)

Available 01 Jan 2014 via MedXpress

• Cover 26 (CDL) PMB Conditions on ALL plans PLUS 34 additional (ADL) Conditions on

Comprehensive plans

• Subject to clinical entry criteria, submission and approval of CIB Application form
• Subject to CIB medicine list/Medicine Formulary or Chronic Drug Amount
• CIB medicine list and CDA’s are updated annually to reflect price changes
• Implemented for existing registrations in July of each year; for new registrations 1 January of each year

Chronic Illness Benefit - All plans - According to Formulary and CDA 26 Chronic Disease List/Prescribed Minimum Benefit Conditions

1 Addison’s disease 14 Epilepsy 2 Asthma 15 Glaucoma 3 Bronchiectasis 16 Haemophilia 4 Bipolar Mood Disorder 17 HIV/AIDS 5 Cardiac Failure 18 Hyperlipedaemia (High Cholesterol) 6 Cardiomyopathy 19 Hypertension (High Blood Pressure) 7 Chronic Obstructive Pulmonary Disease/Emphysema 20 Hypothyroidism (Inactive Thyroid Gland) 8 Chronic Kidney Disease 21 Multiple Sclerosis 9 Coronary Artery Disease 22 Parkinson’s Disease 10 Crohn's disease 23 Rheumatoid Arthiritis 11 Diabetes Insipidus 24 Schizophrenia 12 Diabetes Mellitus (Type 1 & 2) 25 Systemic Lupus Erythomatosis 13 Dysrhythmia (Irregular Heartbeat) 26 Ulcertative Colitis

34 Additional Disease List - on Comprehensive Plans only

• Ankylosing spondylitis
• Behcet’s disease
• Connective Tissue disorder
• Cushing’s disease
• Cystic fibrosis
• Delusional disorder
• Dermatopolymyositis
• Generalised anxiety disorder
• Hungtington’s disease
• Hypoparathyrodism
• Major depression
• Motor neurone disease
• Muscular dystrophy and other inherited

myopathies

• Myasthenia gravis
• Obsessive compulsive disorder
• Organ transplatation
• Osteporosis
• Paget’s disease
• Panic disorder
• Paraplegia
• Pemphigus
• Peripheral artherioschlerotic

disease

• Pituitary microadenomas
• Polyarteritis Nodosa
• Post traumatic stress disorder
• Psoriatic arthritis
• Pulmonary interstitial fibrosis
• Quadriplegia
• Sjogren’s syndrome
• Stroke
• Systemic sclerosis
• Thrombocytopaenia purpura
• Valvular heart disease
• Wegener’s granumatosis

So what is SELF PAYMENT GAP (SPG)?

• Originates as a result of your Annual MSA being lower than your Above Threshold Level and

is impacted on by your claims behavior.

• Know the size of your SPG at the beginning of the year
• Understand how items accumulate to your Threshold
• Claim within your benefit limits
• Use the Discovery networks whenever possible
• Once your MSA is depleted you must pay cash for services & continue to submit your claims to Discovery
• To monitor your SPG movement during the year :

 Check your statement/claims transaction history  Phone the Call Centre: 0860 99 88 77  Discovery’s website: www.discovery.co.za The SPG Tracker provides detailed information on what has contributed towards your Self Payment Gap, without the need to request this information through a different channel

GP Consultation (Network) – R320 GP consultation (Network) + R320

ACCUMULATION OF CLAIMS TO ABOVE THRESHOLD LEVEL

Rate Claims Accumulate to Threshold Claims being paid from MSA AT COST

• Based on a single member on the Classic Comprehensive Option
• Above Threshold Level = R11,350 and MSA for the year = R10,080
• Rates are examples

‘Automatic’ SPG = R1,270



SPG Increased To R4,673

Non –preferred Medicine List Medication + R639 Premier Rate Specialist Consultation + R498 X-rays (DH Rate) + R1,200 (Non-network) Glasses + R3,500 OTC medication (S 0,1 or 2) + R0 Non-Premier Rate Specialist Consultation (DH Rate) + R520 Non -preferred Medicine List Medication – R852 Premier Rate Specialist Consultation – R498 X-rays – R1,200 Glasses – R5,780 OTC Medication (S 0, 1 or 2) – R630

• Non-Premier Rate Specialist
• Consultation – R800

Medical Savings Account

• f R10,080 for the year

DEPLETED Balance = R 0 Total Value of Claims Accumulated to Threshold = R6,677

Discovery Health pays for claims from the ATB

• Benefit limits vary per option
• If Benefit Limit is exceeded, member is liable for full settlement of account

Annual Benefit Limits apply to In-Hospital/Major Medical services

Option Limits applies to the following In-of-Hospital/Major Medical services All VWSA Options

• Oncology
• Chronic Dialysis
• Dental appliances, their placement and orthodontic treatment
• Nerve stimulators, Cochlear implants, Auditory brain implants

and processors

• Internal Prosthesis, including devices used for spinal surgery, as

well as hip, knee and shoulder joint prostheses

• Mental Health
• Compassionate care

Annual Benefit Limits apply to day-to-day benefits irrespective of whether you are in your MSA, SPG and/or ATB

Option Limits applies to the following Out-of-Hospital services Classic Comprehensive Essential Comprehensive Classic Priority

• Allied and therapeutic healthcare services
• Antenatal Classes
• Dental appliances and orthodontic treatment
• Prescribed medicine (over schedule 3)
• External medical items
• Hearing aids
• Optical
• Benefit limits vary per option
• If Benefit Limit is exceeded, member is liable for full settlement of account

How Discovery Health pays for Acute Medicine – Schedule >3 Preferred List Medication

OPTION/PLAN DESCRIPTION OF COVER Classic Comprehensive

100% of DHMR is paid from MSA first, once MSA is depleted it is paid from the Insured Network Benefit, up to the point where you enter the ATB, provided that:

• you obtain your medication from a Network Pharmacy
• the medication is listed on the Preferred Medicine List

If obtained from a Non-Network Pharmacy/Provider once MSA is depleted, it is paid from your pocket up to the point where you enter the ATB. Subject to the Acute Medicine Benefit limit per plan and family size

Essential Comprehensive

100% of DHMR is paid from MSA first, once MSA is depleted paid from your pocket

up to the point where you enter the ATB.

Subject to the Acute Medicine Benefit limit per plan and family size

Classic Priority

100% of DHMR is paid from MSA first, once MSA is depleted paid from your pocket

up to the point where you enter the ATB.

If the Annual ATB limit is reached, medication is again paid from your pocket Subject to the Acute Medicine Benefit limit per plan and family size

Saver

100% of DHMR is paid from MSA first, and once MSA is depleted paid from your

pocket

Please note: On the Threshold plans the cost accumulates to Threshold @ 100% of the DH Medication Rate The Preferred Medicine List includes mainly generic medication, but also offers appropriate branded medication

How Discovery Health pays for Acute Medicine – Schedule >3 Non-Preferred List Medication

OPTION/PLAN DESCRIPTION OF COVER Classic Comprehensive

75% of DHMR Paid from MSA first, once MSA is depleted paid from your pocket up

to the point where you enter the ATB.

Subject to the Acute Medicine Benefit limit per plan and family size

Essential Comprehensive

75% of DHMR Paid from MSA first, once MSA is depleted paid from your pocket up

to the point where you enter the ATB.

Subject to the Acute Medicine Benefit limit per plan and family size

Classic Priority

75% of DHMR Paid from MSA first, once MSA is depleted paid from your pocket up

to the point where you enter the ATB.

If the Annual ATB limit is reached, medication is again paid from your pocket Subject to the Acute Medicine Benefit limit per plan and family size

Saver

75% of DHMR Paid from MSA first, and once MSA is depleted paid from your

pocket

Please note: On the Threshold plans the cost accumulates to Threshold @ 75% of the DH Medication Rate

How Discovery Health pays for Acute Medicine – Schedule 0, 1 & 2 & OTC Medication

OPTION/PLAN DESCRIPTION OF COVER Classic Comprehensive

Either 100% or 75% of DHMR Paid from MSA first, depending on whether listed on the PML or not, and once MSA is depleted, paid from your pocket

NO cover in ATB!

Subject to the Acute Medicine Benefit limit per plan and family size

Essential Comprehensive

Either 100% or 75% of DHMR Paid from MSA first, depending on whether listed on the PML or not, and once MSA is depleted, paid from your pocket

NO cover in ATB!

Subject to the Acute Medicine Benefit limit per plan and family size

Classic Priority

Either 100% or 75% of DHMR Paid from MSA first, depending on whether listed on the PML or not, and once MSA is depleted, paid from your pocket

NO cover in ATB!

Subject to the Acute Medicine Benefit limit per plan and family size

Saver

Either 100% or 75% of DHMR Paid from MSA first, depending on whether listed on the PML or not, and once MSA is depleted, paid from your pocket

Please note: On the Threshold plans the cost DOES NOT accumulate to Threshold, i.e. it will increase your SPG!

INSURED NETWORK BENEFIT (INB)

GP consultations

Unlimited visits on:

Comprehensive Classic Priority

Defined number of visits:

Classic & Coastal Saver – 3 per beneficiary & maximum of 6 per family Essential Saver – 2 per beneficiary & maximum of 4 per family Discovery Health GP Network

Pathology

Unlimited on:

Classic Comprehensive Classic Priority Network of independent pharmacies and laboratories

Day-to-Day Preferred Medicine List

(schedule 3 and above) Unlimited on:

Classic Comprehensive Network of independent pharmacies

Maternity

Unlimited antenatal consults and two 2D scans through the Insured Network Benefit

Classic Comprehensive Classic Priority 8 antenatal consults and two 2D scans Classic Saver Gynaecologists and

• bstetricians on Direct

Payment Arrangements

Selected external medical items

Covered in full through the Insured Network Benefit

Comprehensive Classic Priority Wheelchairs, walkers, insulin pumps & CPAP machines via a Preferred supplier network

MedSaver

Save up to 25% on the purchase of schedule 1 and 2 medicines

ChroniCare

Save up to 25% on ChroniCare products at Dis-Chem pharmacies

Optometry

Save up to 20% on frames and lenses through our optometry network

Optometry network Stem cell cryogenics

Save up to 25% on umbilical cord blood and tissue stem cell cryogenics with Netcells Biosciences

Discovery Health Service Provider Partner Discounts

2011 Vitality

• Encourage healthy behavior
• Access to wellness facilities
• Incentive structures proven to drive positive changes in behavior
• Tangible reduction in healthcare costs

*Refer to brochure and website for more information

2014 Employee Contributions (50%) – THRESHOLD PLANS

Classic Comprehensive Essential Comprehensive Classic Priority Family Size

Member Portion: Monthly Contribution Annual MSA Compulsory Self Payment Gap Annual Threshold Level Member Portion: Monthly Contribution Annual MSA Compulsory Self Payment Gap Annual Threshold Level Member Portion: Monthly Contribution Annual MSA Compulsory Self Payment Gap Annual Threshold Level Member

1 681.00 10 080 1 270 11 350 1 412.50 5 057 6 293 11 350 1 127.00 6 756 3 234 9 990

Member, Spouse

3 271.00 19 620 3 080 22 700 2 747.50 9 876 12 824 22 700 2 014.00 12 072 5 428 17 500

Member, Spouse, 1 Child

3 606.00 21 624 3 226 24 850 3 031.50 10 896 13 954 24 850 2 465.00 14 772 5 998 20 770

Member, Spouse, 2 Children

3 941.00 23 628 3 372 27 000 3 315.50 11 916 15 084 27 000 2 916.00 17 472 6 568 24 040

Member, Spouse, 3 Children +

4 276.00 25 632 3 518 29 150 3 599.50 12 936 16 214 29 150 3 367.00 20 172 7 138 27 310

Member, 1 Child

2 016.00 12 084 1 416 13 500 1 696.50 6 096 7 404 13 500 1 578.00 9 456 3 804 13 260

Member, 2 Children

2 351.00 14 088 1 562 15 650 1 980.50 7 116 8 534 15 650 2 029.00 12 156 4 374 16 530

Member, 3 Children +

2 686.00 16 092 1 708 17 800 2 264.50 8 136 9 664 17 800 2 480.00 14 856 4 944 19 800

1 Un-subsidised Adult Other

3 180.00 9 540 TBD TBD 2 670.00 4 800 TBD TBD 1 774.00 5 316 TBD TBD

2 Un-subsidised Adults Other

6 360.00 19 080 TBD TBD 5 340.00 9 600 TBD TBD 3 548.00 10 632 TBD TBD

TBD: The MSA and ATB levels are determined based on the overall family size and not per dependant Please note that these rate tables have been calculated up to the 3rd child.

• On the Discovery Health Plans you only pay for the first 3 children.
• The Child Dependant Rate is charged up to the age of 21, thereafter the adult rate applies.

Single M+1 M+2+ R 84.50 R 99.50 R 112.50

2014 Employee Contributions (50%) – SAVER PLANS

TBD: The MSA levels are determined based on the overall family size and not per dependant Please note that these rate tables have been calculated up to the 3rd child.

• On the Discovery Health Plans you only pay for the first 3 children.
• The Child Dependant Rate is charged up to the age of 21, thereafter the adult rate applies.

Single M+1 M+2+ R 84.50 R 99.50 R 112.50 Classic Saver Essential Saver Coastal Saver

Family Size Member Portion: Monthly Contribution Annual MSA Member Portion: Monthly Contribution Annual MSA Member Portion: Monthly Contribution Annual MSA Member

988.00 5 928 785.00 2 820 778.00 4 668

Member, Spouse

1766.00 10 596 1372.50 4 932 1361.00 8 160

Member, Spouse, 1 Child

2161.00 12 960 1686.50 6 060 1673.50 10 032

Member, Spouse, 2 Children

2556.00 15 324 2000.50 7 188 1986.00 11 904

Member, Spouse, 3 Children+

3367.00 17 688 2314.50 8 316 2298.50 13 776

Member, 1 Child

1383.00 8 292 1099.00 3 948 1090.50 6 540

Member, 2 Children

1778.00 10 656 1413.00 5 076 1403.00 8 412

Member, 3 Children +

2173.00 13 020 1727.00 6 204 1715.50 10 284

1 Un-subsidised Adult Other

1556.00 4 668 1175.00 2 112 1666.00 3 492

2 Un-subsidised Adults Other

3112.00 9 336 2350.00 4 224 3332.00 6 984

When you need assistance:

Contact your dedicated Alexander Forbes consultants: Nicolette du Toit and Felicia Gounder Give us a call on (041) 392 8329 and (041) 392 8304 or Email us at dutoitni@aforbes.co.za and gounderf@aforbes.co.za EC Client Specialist Division: or Let us call You! Tel: (041) 392 8304 SMS the word “medical aid ec” to 31768 E-mail: afhealthec@aforbes.co.za and one of our consultants will call you back. (sms charged at standard rates) Visit your dedicated Alexander Forbes Website: http://www.afhealth.co.za/vwsa Contact your Scheme Directly: Bonitas 0860 00 21 08 (24 hrs) or access their website at www.bonitasmedicalfund.co.za Medihelp 0860 10 06 78 (24 hrs) or access their website at www.medihelp.co.za

Discovery Health 0860 99 88 77 (24 hrs) or access their website at www.discovery.co.za

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