Marys Medicine

Untitled

Bonitas Medical Fund
¥ R2.2 billion reserves
¥ 35.7% solvency ratio
¥ A+ Global Credit Rating
¥ Administration cost only 9.2% of gross contribution income
Number of principal members DISTRIBUTION OF MEMBERS (August 2010)
¥ Free cover for the fourth and subsequent child dependants ¥ Child rates for students up to the age of 24 ¥ Unique set of dental benefits (DENIS) ¥ Customised Wellness days ¥ World class managed Care programmes ¥ Clinically approved HCT programmes ¥ Dedicated on site consultants 1 Audited Annual Financial Statements December 2009

Bonitas Benefit Structure and Options
In these times, affordable, quality health cover has become something of a necessity- rather than an option. Which is why our six solutions ensure you're well looked after.
Major Medical Benefit
So whatever your particular need is, we're serious enough about it to have an answer Covers medical expenses Covers medicine for in: BonComprehensive, BonEssential, BonSave, Standard, Primary and BonCap. Just
in hospital and major conditions that require say the word.
medication on anongoing basis We have categorized our benefits into four main categories illustrated in the diagram
on the right. When chosing your option, we would like you to consider your healthcare
Out of Hospital Benefit
needs in respect of the three main benefit categories listed below. Once you have
Covers out of hospital Additional benefits, made your selection we encourage you to look at the option you have selected in more detail, considering also the supplementary benefits provided.
incurred in or out ofhospital Major Medical Benefits
Major medical benefits cover medical expenses in hospital and major medical events. Hospital accounts are covered in full as per thenegotiated rates between Bonitas and the major hospital groups. Hospital admission is subject to pre-authorisation by Hospital Management,except in the case of emergencies.
Overall Annual Limit
Unlimited
Unlimited
Unlimited
R750 000 per
R500 000 per
family per annum family per annum Provider
Prime Cure hospital Chronic benefits cover medicine for conditions that require medication on an ongoing basis. Subject to pre-authorisation by ChronicMedicine Management.
R10 000 per beneficiary Prescribed Minimum Prescribed Minimum R6 900 per beneficiary Prescribed Minimum Prescribed Minimum R20 000 per family R13 800 per family Designated Service Designated Service Designated Service Designated Service Provider (26 conditions) Provider (26 conditions)
Provider (26 conditions) Provider (26 conditions)
Restrictive Formulary Restrictive Formulary Restrictive Formulary Prime Cure Medicine formulary in benefit.
Restrictive Formularywhen benefits areexceeded for PMBÕs Prime Cure Network Dispensing GP up to limit. PMBÕs unlimited atDSP thereafter Out of Hospital Benefits
Out of hospital benefits cover day to day medical expenses incurred out of hospital.
New Generation Options
Low Cost Capitation
A savings account A hospital plan and cover A savings account Out of hospital care is coordinated enables members to for PMB conditions enables members to through your general practitioner (GP). self-insure and manage self-insure and manage Visiting a contracted GP on the Bonitas their own out of hospital their own out of hospital GP Network ensures that you will not be financial limits by medical expenses.
medical expenses.
charged anything in excess of the Bonitas the Prime Cure GP.
Unspent savings are Unspent savings are Tariff. Acute medication, radiology and carried forward with carried forward with pathology etc. prescribed by your doctor interest. An insured is available from your Day to Day Benefit.
threshold benefit Specialist consultations are also payable provides additional from this benefit if referred by your GP.
peace of mind for highout of hospital expenses.
1 Reimbursement rate of healthcare practitioners in hospital e.g. medical specialists * Unlimited PMB cover

Unlimited consultations above threshold, major medical expenses at
300% of the Bonitas rate, covers lasik eye surgery, basic and advanced
dentistry - all covered by our BonComprehensive option. So in these
tough times, isnÕt it a treat to know thereÕs a solution that puts your mind
at ease.
Major Medical Benefits Major medical expenses are covered at 300% of Bonitas tariff. This benefitincludes major medical events. All hospital admissions, oncology treatmentplans and renal dialysis require pre-authorisation by Hospital Managementexcept in case of emergencies.
Overall Annual Limit
Benefits payable at 300% of the Bonitas Rate
Sub-limits applicable:
GP & Specialist Consultations
Unlimited, 300% Bonitas rate Pathology
Radiology (Specialised & General)
Paramedical Services (Allied Medical
Professions) e.g. speech therapy,
occupational therapy, audiology,
dietetics
Oncology3
R450 000 per family Biological drugs e.g. Herceptin
R150 000 per family,included in the above limit, subject to clinicalprotocols and 20% co-payment Organ Transplants
Chronic Renal Dialysis
Maxillo Facial Surgery
Unlimited, excluding orthognatic surgery Medication to take out (TTO)
R350 per beneficiary, per admission Physical Rehabilitation
R32 000 per family Chronic Medicine Benefits2
Covers medication for conditions that require medication on an ongoingbasis.
Covers 54 diseases. R10 000 per beneficiary, R20 000 per family, subjectto pre-authorisation. Biological drugs: R120 000 per family, subject toclinical protocols and 20% co-payment This Summary is for information purposes only and does not supersedethe Rules of the Fund. In the event of any discrepancy between theSummary and the Rules, the Rules will prevail.
1 Subject to pathology management programme2 Comprehensive formulary, refer to page 18 for a complete chronic disease list3 All members enrolled on clinical trials should inform the scheme *PMBÕs are covered

Out of Hospital
Savings & Threshold Additional Benefits 300% Bonitas Rate in or out of hospital Advanced Dentistry R20 000 per family Out of Hospital Benefits
Cover day to day medical expenses e.g. GP & specialist consultations, Additional benefits, medical expenses incurred in or acute medication, paramedical services, optometry, radiology, pathology etc.
Maternity Care per event
Unlimited hospitalisation (subject Per Month
Per Annum
(ante- and postnatal) to pre-authorisation) and midwifery services.
Antenatal classes to the value of R800 and private ward for Threshold Benefit
Threshold
Self Funding Gap
post-delivery12 antenatal consultations, Principal Member 2 X 2D scans and 4 postnatal consultations with midwife R11 000 per family at 100% Acute Medication &
Subject to savings and/or threshold Bonitas Rate, Subject to Pharmacy Advised Therapy The following limits apply:
Immune deficiency related
to HIV infection
Subject to Aid for AIDS (AfA) registration and clinical protocols Mental Health Benefits
R32 000 per family, subject topre-authorisation Sub-limit of (80% of the Bonitas rate accrues to threshold; 20% co-payment in threshold)
R10 600 for consultations in & out GP and Specialists
Subject to savings and/or threshold, 20% of hospital.
co-payment in threshold R22 000 per family General Radiology
Subject to savings and/or threshold, 20% (out of hospital) Subject to pre-authorisation co-payment in threshold Unlimited, subject to Pathology
Subject to savings and/or threshold, 20% co-payment in threshold Endoscopies in practitionersÕ
Unlimited, subject to Paramedical Services
Subject to savings and/or threshold, limited to R38 000 per family R5 500 per family and 20% co-payment in R38 000 per family Professions) e.g.
Subject to pre-authorisation HIV test and Flu vaccine
Free, 1 per beneficiary per annum occupational therapy, audiology, dietetics General appliances R6 500 per family Optometry
Subject to savings and/or threshold, limited to Wheelchairs & large Included in the general R2 250 per beneficiary and 20% co-payment orthopaedic appliances Stoma products & CPAP4 May exceed general appliance In addition: Dental Benefits
R20 000 per family, biennial Basic Dentistry
Subject to clinical protocols & Bonitas Dental benefit (Jan 2010 - Dec 2011)
Oxygen: Home ventilation Unlimited, subject to pre- Advanced Dentistry
Subject to clinical protocols & Bonitas Dental authorisation by Hospital Principal Member
Adult Dependant
1 Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations, and subject to the use of the relevant Designated Service Provider 2 Subject to pathology management programme3 Comprehensive list of dental benefits (DENIS) pages 19 - 214 Subject to pre-authorisation * All benefits are per annum, unless otherwise stated

Are you young and vibrant? Are you looking for a hospital plan with a
difference Ð one that has chronic benefits, and is also affordable? Then
BonEssential is for you. Simple. So before you continue with your punching
bag, isnÕt it a treat to know in these tough times, thereÕs a solution that
is unique and wonÕt put you out of pocket?
Major Medical Benefits Major medical expenses are covered at 100% of Bonitas tariff.
This benefit includes major medical events. All hospital admissions,oncology treatment plans and renal dialysis require pre-authorisationby Hospital Management except in case of emergencies.
Overall Annual Limit
Benefits payable at 100% of the Bonitas Rate
Sub-limits applicable:
GP & Specialist Consultations
Unlimited, 100% Bonitas rate Pathology
Radiology (Specialised & General)
Paramedical Services (Allied Medical
Professions) e.g. speech therapy,
occupational therapy, audiology,
dietetics
Oncology2
R250 000 per family Organ Transplants
Chronic Renal Dialysis
Maxillo Facial Surgery
Unlimited, excluding orthognatic surgery Medication to take out (TTO)
R250 per beneficiary, per admission Physical Rehabilitation
R32 000 per family deductible
deductible
Nissen Fundoplication Conservative Back Diagnostic Laparoscopy (Reflux Surgery) Back Surgery including (except cancer and Facet Joint Injections Joint replacements Flexible sigmoidoscopy Functional Nasal Surgery Radiofrequency Umbilical Hernia Repair Hysteroscopy (but not endometrial ablation)MyringotomyTonsillectomy andAdenoidectomy(except PMBÕs)Varicose Vein Surgery 1 Subject to pathology management programme2 All members enrolled on clinical trials should inform the scheme * PMBÕs are covered Out of Hospital
PBMÕs only at DSP Additional Benefits 100% Bonitas Rate in or out of hospital Chronic Medicine Benefits2
Covers medication for conditions that require medication onan ongoing basis.
Chronic Disease List (CDL) as per the Prescribed Minimum Benefits (PMB),at the Designated Service Provider (DSP), subject to pre-authorisation Out of hospital Benefits
No benefits for out of hospital expenses, except for the diagnosis, treatmentand care of Prescribed Minimum Benefits where appropriate.
Additional benefits, medical expenses incurred in or out of hospital Maternity Care per event
Unlimited hospitalisation (subject topre-authorisation) and midwifery services.
12 antenatal consultations, 2 x 2D scansand 4 postnatal consultations with midwife Immune deficiency related
R22 000 per beneficiary to HIV infection
Subject to Aid for AIDS (AfA)registration and clinical protocols Mental Health Benefits
R21 200 per family, subject topre-authorisation Unlimited, subject to and External
HIV test
Free, 1 per beneficiary per annum This Summary is for information purposes only and does not supersedethe Rules of the Fund. In the event of any discrepancy between theSummary and the Rules, the Rules will prevail.
Principal Member
Adult Dependant
1 Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations, and subject to the use of the relevant Designated Service 2 Restrictive formulary, refer to page 18 for a complete chronic disease list3 Comprehensive list of dental benefits (DENIS) pages 19 - 21 * All benefits are per annum, unless otherwise stated Fit as a fiddle, you would like an option that offers you the flexibility of
managing your day to day benefits with a savings account, not so? Our
BonSave option, therefore, is for you. So in these tough times Ð and how
lucky you are to be in good health Ð isnÕt it a treat to know thereÕs an
option thatÕs as youthful as you are?
Major Medical Benefits Major medical expenses are covered at 150% of Bonitas tariff. This benefitincludes major medical events. All hospital admissions, oncology treatmentplans and renal dialysis require pre-authorisation by Hospital Managementexcept in case of emergencies.
Overall Annual Limit
Benefits payable at 150% of the Bonitas Rate
Sub-limits applicable:
GP & Specialist Consultations
Unlimited, 150% Bonitas rate Pathology
Radiology (Specialised & General)
Paramedical Services (Allied Medical
Professions)e.g. speech therapy,
occupational therapy, audiology,
dietetics
Oncology2
R250 000 per family Organ Transplants
Chronic Renal Dialysis
Maxillo Facial Surgery
Unlimited, excluding orthognaticsurgery Medication to take out (TTO)
R250 per beneficiary, peradmission Physical Rehabilitation
R32 000 per family deductible
deductible
Nissen Fundoplication Conservative Back Diagnostic Laparoscopy (Reflux Surgery) Back Surgery including (except cancer and Facet Joint Injections Joint replacements Flexible sigmoidoscopy Functional Nasal Surgery Radiofrequency Umbilical Hernia Repair Hysteroscopy (but not endometrial ablation)MyringotomyTonsillectomy andAdenoidectomy(except PMBÕs)Varicose Vein Surgery 1 Subject to pathology management programme2 All members enrolled on clinical trials must inform the scheme * PMBÕs are covered Out of Hospital
PBMÕs only at DSP Savings plus Basic & Additional Benefits; 150% Bonitas Rate Advanced Dentistry medical expensesincurred in or out ofhospital Chronic Medicine Benefits2
Covers medication for conditions that require medication on an ongoing Additional benefits, medical expenses incurred in or Chronic Disease List (CDL) as per the Prescribed Minimum Benefits (PMB), Maternity Care per event
Unlimited hospitalisation (subject (ante- and postnatal) to pre-authorisation) and at the Designated Service Provider (DSP), subject to pre-authorisation midwifery services. Antenatalclasses to the value of R800 and Out of hospital Benefits
private ward for post-delivery12 antenatal consultations, Covers day to day medical expenses e.g. GP & specialist consultations, 2 X 2D scans and 4 postnatal acute medication, paramedical(Allied Medical Professions), optometry, consultations with midwife radiology, pathology, etc.
Immune deficiency related
R21 200 per beneficiary, Subject Per Month
Per Annum
to HIV infection
to Aid for AIDS (AfA)registration and clinical protocols Mental Health Benefits
R21 200 per family, subject to pre-authorisation Sub-limit of R10 600 for consultations in & outof hospital.
Acute Medication &
Subject to savings R16 000 per family subject to Pharmacy Advised Therapy
(out of hospital) GP and Specialists
Subject to savings Unlimited, subject to Netcare 911 General Radiology
Subject to savings Endoscopies in practitionersÕ
Unlimited, subject to Pathology
Subject to savings Paramedical Services
Subject to savings and External
HIV test and Flu vaccine
Free, 1 per beneficiary per annum Professions) e.g.
General appliances R4 800 per family occupational therapy, Wheelchairs & large Included in the general audiology, dietetics orthopaedic appliances Stoma products & CPAP4 May exceed general appliance In addition: Dental Benefits
Oxygen: Home ventilation Unlimited, subject topre-authorisation by Hospital Basic Dentistry
Subject to clinical protocols & Bonitas Dental Advanced Dentistry
Subject to clinical protocols & Bonitas Dental This Summary is for information purposes only and does not supersedethe Rules of the Fund. In the event of any discrepancy between theSummary and the Rules, the Rules will prevail.
Principal Member
Adult Dependant
1 Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations, and subject to the use of the relevant Designated Service 2 Restrictive formulary, refer to page 18 for a complete chronic disease list3 Comprehensive list of dental benefits (DENIS) pages 19 - 214 Subject to pre-authorisation * All benefits are per annum, unless otherwise stated The Standard option provides comprehensive hospital cover with generous
day-to-day benefits and aligned with our GP network Ð which provides
value based healthcare, without the nasty surprise of footing the bill for
unexpected expenses. This option has an unlimited overall annual limit
and additional chronic medicine benefits.
Major Medical Benefits Major medical expenses are covered at 100% of Bonitas tariff. This benefitincludes major medical events. All hospital admissions, oncology treatmentplans and renal dialysis require pre-authorisation by Hospital Managementexcept in case of emergencies.
Overall Annual Limit
Benefits payable at 100% of the Bonitas Rate
Sub-limits applicable:
GP & Specialist Consultations
Pathology
Radiology (Specialised & General)
Paramedical Services (Allied Medical
Professions)e.g. speech therapy,
occupational therapy, audiology,
dietetics
Oncology3
R225 000 per family Organ Transplants
R265 000 per family Chronic Renal Dialysis
R225 000 per family Maxillo Facial Surgery
Unlimited, excluding orthognaticsurgery Medication to take out (TTO)
R300 per beneficiary, peradmission Physical Rehabilitation
R32 000 per family Chronic Medicine Benefits2
Out of Hospital Benefits
Covers medication for conditions that require medication on an ongoing Cover day to day medical expenses e.g. GP & specialist consultations, acute medication, pathology, radiology,paramedical services (Allied Medical Professions), Limited to R6 900 per beneficiary and R13 800 per family, at any pharmacy optometry, dentistry etc.
or dispensing GP, subject to pre-authorisation. Once limit has beenexceeded, PMBÕs are unlimited at DSP subject to restrictive formulary.
GP Benefit
Only 42 chronic conditions covered.
A new benefit has been created specifically for out ofhospital general practitioner consultations empowering theGP to become your co-ordinator of care. By making use ofa GP in the network you are not only guaranteed that thedoctor will charge the Bonitas rate, but the benefit availableis more generous. A sub-limit applies to non-network visits,allowing you the flexibility to see any doctor when you are This Summary is for information purposes only and does not supersede away from home. To find a network doctor near you call 0860 the Rules of the Fund. In the event of any discrepancy between the 00 2108 or visit our website: Summary and the Rules, the Rules will prevail.
1 Subject to pathology management programme2 Comprehensive formulary, refer to page 18 for a complete chronic disease list3 All members enrolled on clinical trials should inform the scheme * PMBÕs are covered Out of Hospital
42 Chronic Conditions Additional Benefits 100% Bonitas Rate R6 900 per beneficiary Day to Day Benefit in or out of hospital R13 800 per family Basic & AdvancedDentistry, Optometry GP Benefit
In Network
Non Network
Benefit included in the Network benefit
Additional benefits, medical expenses incurred in or Maternity Care per event
Unlimited hospitalisation (subject (ante- and postnatal) to pre-authorisation) and midwifery services. 12 antenatal The Bonitas GP Network is the schemeÕs Designated Service Provider for consultations, 2 X 2D scans and the provision of Prescribed Minimum Benefits, A co-payment of 40% will 4 postnatal consultations withmidwife thus apply for out of network visits once limits are exhausted.
Immune deficiency related
R21 200 per beneficiary. Subject Day to day Benefit2
to HIV infection
to Aid for AIDS (AfA) registrationand clinical protocols The day to day benefit is the pool of benefits from which your GP can Mental Health Benefits
R26 500 per family, subject to prescribe the appropriate care to improve your health. This benefit covers pre-authorisation Sub-limit of acute medication, out of hospital radiology and pathology, paramedical R10 600 for consultations in & out services etc. Specialist consultations will only be payable on referral by of hospital.
R17 000 per family subject to (out of hospital) Day to Day Benefit
Unlimited, subject to Netcare 911 Sub limit of R530 per beneficiary and R1600 per Endoscopies in practitionersÕ
Unlimited, subject to family for pharmacy advised therapy. (PAT).
R29 000 per family and External
Subject to pre-authorisation HIV test and Flu vaccine
Free, 1 per beneficiary per annum The introduction of specialist referral management will require all General appliances R5 300 per family beneficiaries to obtain referral from a GP to consult with a specialist. The Wheelchairs & large Included in the general following exceptions apply: orthopaedic appliances Stoma products & CPAP4 May exceed general appliance Female beneficiaries, 1 visit per annum without referral.
No referral required for beneficiaries under age 2.
R11 700 per family, biennial No referral required benefit (Jan 2010 - Dec 2011) Oxygen: Home ventilation Unlimited, subject to pre-authorisation by Hospital Specialist referral by a GP is also required for Prescribed Minimum Benefit Conditions.
In addition to the day to day benefit the following is also provided:
Basic Dentistry
Subject to clinical protocols and Bonitas DentalTariff (BDT)3 Advanced
Subject to clinical protocols and Bonitas Dental Dentistry
Optometry
2-year benefit from anniversary of claiming,
per beneficiary (Jan 2011 - Dec 2012)
100% of cost at PPN optometrist or to a maximum of R235 at a non-network provider Frames & prescription R600 per beneficiarylenses/add-onsClear Single Vision R120 per lens or
Clear Aquity Flat-Top R275 per lens or
Bifocal
Clear Aquity Multifocal R500 per lens or
Contact lenses
R1 220 per beneficiary Principal Member
Adult Dependant
Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations, and subject to the use of the relevant Designated Service Provider Subject to pathology management programme Comprehensive list of dental benefits (DENIS) pages 19 - 21 Subject to pre-authorisation * All benefits are per annum, unless otherwise stated BonitasÕ Primary option is designed for members who donÕt
need extensive chronic medicine. With all major medical
expenses at 100% of our rate and an overall annual limit of
R750 000, the Primary option offers affordable cover with day
to day benefits. So in these tough times, isnÕt it a treat to have
a clean bill of health and a solution suited specifically
to you?
Major Medical Benefits Major medical expenses are covered at 100% of Bonitas tariff. This benefitincludes major medical events. All hospital admissions, oncology treatmentplans and renal dialysis require pre-authorisation by Hospital Managementexcept in case of emergencies.
Overall Annual Limit (OAL)
R750 000 per family
Benefits payable at 100% of the Bonitas Rate
Sub-limits applicable:
GP & Specialist Consultations
Unlimited; subject to overall annuallimit Pathology
Unlimited; subject to overall annuallimit1 Unlimited; subject to overall annuallimit Paramedical Services (Allied Medical Subject to overall annual limit
Professions)e.g. speech therapy,
occupational therapy, audiology,
dietetics
Oncology3
R110 000 per family, subject to OAL Organ Transplants
PMBÕs at public hospitals only Chronic Renal Dialysis
PMBÕs at public hospitals only Maxillo Facial Surgery
Unlimited, subject to overall annuallimit, excluding orthognatic surgery Medication to take out (TTO)
R250 per beneficiary, per admission Physical Rehabilitation
R32 000 per family, subject to OAL Chronic Medicine Benefits2
Out of Hospital Benefits
Covers medication for conditions that require medication on an ongoing Cover day to day medical expenses e.g. GP & specialist consultations, acute medication, pathology, radiology,paramedical services (Allied Medical Professions) optometry, Chronic Disease List (CDL) as per the Prescribed Minimum Benefits (PMB), dentistry, etc.
at the Designated Service Provider (DSP), subject to pre-authorisation GP Benefit
A new benefit has been created specifically for out ofhospital general practitioner consultations, empowering theGP to become your co-ordinator of care. By making use ofa GP in the network you are not only guaranteed that thedoctor will charge the Bonitas rate, but the benefit availableis more generous. A sub-limit applies to non-network visits,allowing you the flexibility to see any doctor when you are This Summary is for information purposes only and does not supersede away from home. To find a network doctor near you call 0860 the Rules of the Fund. In the event of any discrepancy between the 00 2108 or visit our website: Summary and the Rules, the Rules will prevail.
1 Subject to pathology management programme2 Restrictive formulary, refer to page 18 for a complete chronic disease list3 All members enrolled on clinical trials should inform the scheme * PMBÕs are covered Out of Hospital
PMBÕs only at DSP Additional Benefits Day to Day Benefit in or out of hospital 100% Bonitas rate GP Benefit
In Network
Non Network
Benefit included in the network benefit
Additional benefits, medical expenses incurred in or Maternity Care per event
Unlimited hospitalisation (subject (ante- and postnatal) to pre-authorisation and OAL), and midwifery services The Bonitas GP Network is the schemeÕs Designated Service Provider for 12 antenatal consultations, the provision of Prescribed Minimum Benefits. A co-payment of 40% will 2 X 2D scans and 4 postnatalconsultations with midwife thus apply for out of network visits once limits are exhausted.
Immune deficiency related
R16 000 per beneficiary, subject Day to day Benefit
to HIV infection
to Aid for AIDS (AfA) registrationand clinical protocols. Subject to 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 Mental Health Benefits
R10 500 per family, subject to covers acute medication, out of hospital radiology and pathology, pre-authorisation, Sub-limit of paramedical services, etc. Specialist consultations will only be payable R6 400 for consultations in & out on referral by your GP.
of hospital.
R8 500 per family, subject to Day to Day Benefit
(joint limit in & out of hospital) pre-authorisation and OAL Unlimited, subject to Netcare 911 Sub limit of R320 per beneficiary and R950 per family for pharmacy advised therapy. (PAT).
Endoscopies in practitionersÕ
Subject to overall annual limit R17 500 per family, subject to OAL and External
and pre-authorisation HIV test and Flu vaccine
1 per beneficiary per annum The introduction of specialist referral management will require all beneficiaries to obtain referral from a GP to consult with a specialist. The General appliances R4 800 per family, subject to OAL following exceptions apply: Wheelchairs & large Included in the general orthopaedic appliances Female beneficiaries, 1 visit per annum without referral.
Stoma products & CPAP4 May exceed general appliance No referral required for beneficiaries under age 2.
No referral required R6 900 per family, biennial benefit (Jan 2010 - Dec 2011) Oxygen: Home ventilation Subject to overall annual limit and Specialist referral by a GP is also required for Prescribed Minimum pre-authorisation by Hospital Benefit Conditions.
In addition to the day to day benefit the following is also provided:
Basic Dentistry
Subject to clinical protocols and Bonitas DentalTariff (BDT)3 Optometry
2-year benefit from anniversary of claiming,
per beneficiary (Jan 2011 - Dec 2012)
100% of cost at PPN optometrist or to a maximum of R235 at a non-network provider Frames & prescription R150 per beneficiary at a network providerlenses/add-ons No benefit at a non-network provider Clear Single Vision R120 per lens or
Clear Aquity Flat-Top R275 per lens or
Bifocal
Clear Aquity Multifocal R275 per lens or
(Up to bifocal limit)
Contact lenses
R395 per beneficiary Principal Member
Adult Dependant
1 Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations, and subject to the use of the relevant Designated Service Provider2 Subject to pathology management programme3 Comprehensive list of dental benefits (DENIS) pages 19 - 214 Subject to pre-authorisation * All benefits are per annum, unless otherwise stated Choosing the right medical scheme
Medical scheme brokers generally agree that a medical scheme's key indicators (its solvency ratio, average beneficiary
age, pensioner ratio and expense ratios) provide a reliable indication of a medical scheme's long-term viability, financial
stability and value for money.
Bonitas Key Indicators
The table below sets out the key indicators for Bonitas compared to the open scheme average based on the latest annual
report from the Council for Medical Schemes:
Open Scheme Average
Average beneficiary age 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 The law requires that medical schemes maintain a solvency ratio of at least 25% to ensure the scheme has the ability tomeet its financial commitments. A medical scheme's solvency ratio is therefore the most reliable indication of its financialsoundness and ability to pay claims.
Fact: Bonitas' projected solvency ratio for 2010 is 35.7% - one of the highest in the industry and a comfortable 10% higher
than the required minimum of 25%.
Average beneficiary age and pensioner ratio
As people age, their medical costs rise and this tends to increase contributions. It therefore makes sense to choose amedical scheme with a relatively young beneficiary age and low pensioner ratio to ensure you get value for money.
Fact: The average beneficiary age and pensioner ratio for Bonitas are much lower than those of the vast majority of open
schemes in the industry.
Non Healthcare expense ratios
Expense ratios are an important indicator of whether a scheme offers value for money or not. Inevitably medical schemeshave expenses (such as administration fees and broker commission) and the higher these Ònon healthcareÓ costs, the lessthere is available to pay claims. Schemes with higher than average expense ratios are generally not offering good valuefor money.
Fact: Bonitas' expense ratios are lower than the market average.
Size of the medical scheme
In the medical scheme industry, there is safety in numbers. The larger the scheme's membership base, the better its abilityto spread the risk of high claims.
Fact: With over 270 000 principal members and 600 000 beneficiaries covered, Bonitas is the second largest open medical
scheme in South Africa.
Value for money
Bonitas exists for the benefit of its members. We believe that one of the most important considerations when designing andcosting benefit options is value-for-money, particularly during these difficult financial times.
This is not only demonstrated by the indicators shown above but also by the introduction of innovations such as the BonitasGP Network which: ¥ eliminates the need for co-payments on GP visits¥ ensures that members receive quality, cost-effective healthcare.
Above all, Bonitas is serious about providing an excellent product at an affordable price.
TO OUR MEMBERS
Call Centre: 0860 002 108
Does BonCapÕs requirement of cover with a preferred provider not faze
you? If the answer is yes, then youÕre well-poised for BonCapÕs generous
rewards. With unlimited GP and generous specialist consultations at
100% of our rates and value-based healthcare through our GP network,
BonCap also covers medical expenses incurred while in hospital, as
well as major medical events. So in these tough times, isnÕt it a treat to
know thereÕs a solution that wonÕt hurt your pocket?
Major Medical Benefits Major medical expenses are covered at 100% of Bonitas tariff. This benefitincludes major medical events. All hospital admissions, oncology treatmentplans and renal dialysis require pre-authorisation by Prime Cure exceptin case of emergencies.
Overall Annual Limit
R500 000 per family
Benefits payable at 100% of the Prime Cure agreed rate
Sub-limits applicable:
GP & Specialist Consultations
Unlimited; subject to overall annuallimit and Prime Cure Provider Pathology
Limited to R19 000, except for PMBÕs Unlimited; subject to overall annuallimit Physiotherapy &
R3 000, subject to overall annual limit and Prime Cure Provider Oncology
Organ Transplants
PMBÕs only, subject to pre-authorisation and Prime CureProvider Chronic Renal Dialysis
PMBÕs only, subject to pre-authorisation and Prime CureProvider Medication to take out (TTO)
7 days supply per beneficiary,per admission Alternatives to hospitalisation
Limited to R10 000 per family per (Step down or home nursing) annum, pre-authorisation required Chronic Medicine Benefits1
Covers medication for conditions that require medication on an ongoingbasis.
Chronic Disease List (CDL) as per the Prescribed Minimum Benefits (PMB),at the Designated Service Provider (DSP) i.e. Prime Cure, accreditedpharmacies and Medipost Courier Pharmacy. Subject to preauthorisationand Prime Cure medicine formulary This Summary is for information purposes only and does not supersedethe Rules of the Fund. In the event of any discrepancy between theSummary and the Rules, the Rules will prevail.
1 Chronic Disease List as per PMBÕs page 16, Prime Cure medicine formulary * PMBÕs are covered Out of Hospital
PMBÕs at Prime Cure Additional Benefits in or out of hospital 100% of the Prime through Prime Cure Cure agreed tariff Out of hospital Benefits
Cover day to day medical expenses e.g. GP & specialist consultations, Additional benefits, medical expenses incurred in or acute medication, pathology, radiology, paramedical services (Allied Medical Professions) optometry, dentistry etc.
Maternity Care per event
Day to Day Benefit
(ante- and postnatal)Neonatal Care R32 000 per family, except PMBÕs These benefits cover out of hospital expenses which are accessed Immune deficiency related
Clinical protocol and subject to through the Prime Cure Network providers and are listed below.
to HIV infection
registration on the HIV/AIDSprogramme.
GP Consultations2
Unlimited PMB, eight consultations per beneficiary.
Mental Health Benefits
Pre-authorisation is required after the eighth. R8 000 per family, included in the consultation only for PMBÕs. 20% co-payment will (joint limit in & out of hospital) OAL and subject to apply for the use of non DSP.
Out of network
One visit per beneficiary or two visits per family to Unlimited, subject to OAL.
a maximum of R700 and 20% co-payment Emergency
Unlimited subject to pre-authorisation R19 000 per family, included in theOAL and subject to pre- authorisation Acute Medication3
Prime Cure accredited pharmacy and subject to medicine formulary Over the Counter3
Three events per beneficiary per annum limited to (Includes general appliances, R3 000 per family, included in the R180 per beneficiary, maximum of R60 per event wheelchairs, stoma products, OAL and subject to Specialist
Three visits or R2 200 per beneficiary, up to five visits CPAP, hearing aids) or R3 200 per family, included in OAL. No benefit Oxygen Therapy & Home Referral by a Prime Cure GP and without Network GP referral subject to overall annual limitand pre-authorisation & Physiotherapy
General Radiology
Referral by a Prime Cure GP. Approved black andwhite X-rays and soft tissue ultrasounds Pathology
Subject to the contracted Provider Basic Dentistry
List of approved codes, subject to Prime Cure Provider limited to:One consultation per beneficiary, per annumOne preventative treatment per beneficiary per annum e.g. cleaning, polishing, fillings, extractions,pain and sepsis treatment and X-rays4 Emergency Dentistry
Out of network emergency dentistry is lmited to one episode per beneficiary Plastic Dentures
One set of dentures per family over a 24-month period applicable over the age of 21 (20% co-payment applies) Optometry
One pair of spectacles every 24 months, subject tonetwork provider One optometric examination per beneficiary, limited to contracted provider Every 24 months, subject to contracted Provider Subject to contracted Provider Principal Member
Adult Dependant
R0 - R4 800
R4 801 - R7 800
1 Prescribed Minimum Benefits are provided on all options in accordance with the Medical Schemes Act and Regulations, and subject to the use of the relevant Designated Service Provider2 Pre-authorisation required after patientÕs 8th visit for PMBÕs (in a 12 month-cycle)3 Prime Cure medicine formulary4 Basic Dentistry is subject to Prime Cure protocols5 All benefits are per annum, unless otherwise stated The Bonitas GP Network Ð the next generation in quality,
affordable healthcare provision
The benefits
¥ By visiting a Bonitas Network GP members are guaranteed not to be charged more than the Bonitas Tariff¥ Network GPs are incentivised to adhere to the best clinical guidelines in treating your chronic conditions¥ Network doctors are incentivised to take extra care of your health with a goal of reducing avoidable hospital admissions¥ Network doctors are incentivised to practice cost-effectively¥ Improved health outcomes leads to lower cost overall¥ Prevention of duplication of tests, ensures continuity of healthcare¥ On Standard and Primary members can access generous GP benefits if they make use of a network doctor¥ Should you exhaust your Òout of hospitalÓ benefits Prescribed Minimum Benefits can be accessed above limits through the network without any member co-payment How to find a network Dr
¥ Search for a doctor in your suburb on our website: http://www.bonitasmedicalfund.co.za
¥ Call us on 0860 002 108
The Network is growing daily
¥ If your family doctor is not yet on our network encourage him/her to join Ð all registered practitioners are welcome
¥ Contact our call centre 0860 002 108 and give your doctorÕs name, practice number, contact details, and our team will
Empowering the GP as the coordinator of care Ð Specialist Referral Management System
¥ One doctor equals one picture of health. Our network of doctors is dedicated to promoting quality care to Bonitas members.
In the event of chronic disease flare ups or in the case of emergencies, members can feel assured that all of their healthinformation can be found at one place.
¥ All specialist visits for Standard and Primary members will need to be referred by their GP¥ Your GP will create an authorisation for you to visit a specialist by using our IVR (interactive voice recording) system, the provider call centre or our website. Members should remind their GPs to obtain an authorisation ¥ This rule will apply to all specialist visits whether you make use of the network of GPs or not¥ Remember to contact your GP to create a new authorisation if one specialist refers you to another specialist¥ Your GP can create a referral that is valid for up to 6 months.
¥ Paediatrician visits for children under 2¥ 1 visit per annum for female beneficiaries to the Gynaecologist¥ Maternity Care¥ In-hospital care¥ Emergencies requiring a specialist visit - provided GP creates authorisation within 72 working hours¥ Ophthamology¥ Oncology What happens if you run out of benefits?
¥ The Bonitas GP Network is the Designated Service Provider of the scheme for the provision of Prescribed Minimum Benefits on Standard and Primary i.e. your GP is the key to accessing treatment in respect of Prescribed Minimium Benefit Conditions should you use up your out of hospital benefits ¥ The GP will still be able to refer you to a specialist, if appropriate, should you exhaust your day to day benefits¥ The GP will also be able to prescribe medication or send you for appropriate radiology and pathology tests above limits¥ If you choose to see a GP out of the network once your non-network GP benefit has run out, a co-payment of 40% will apply Chronic Disease Lists
26 PMBÕs
PMBÕs as per Chronic Disease List
In addition to the 26 PMB conditions
In addition to the 26 PMB conditions the
including 270 Diagnosis and
the following 27 diseases are covered:
following 16 diseases are covered:
treatment Pairs (DTP) as indicated
in regulation 29.(1) (0) of the
Medical Schemes Act.
2 Allergic Rhinitis 2 Allergic Rhinitis 3 Ankylosing Spondylitis 3 Ankylosing Spondylitis 1 AddisonÕs Disease 4 Attention Deficit Disorder 4 Attention Deficit Disorder 5 BehcetÕs Disease 5 BarrettÕs Oesophagus 3 Bipolar Mood Disorder 6 BarrettÕs Oesophagus 6 BehcetÕs Disease 5 Cardiac Failure 9 Generalized Anxiety Disorder 9 Gastro-Oesaphageal Reflux (GORD) 7 Chronic Renal Disease 10 Gastro-Oesophageal Reflux (GORD) 8 Chronic Obstructive Pulmonary 12 HuntingtonÕs Disease 12 Obsessive Compulsive Disorder 9 Coronary Artery Disease 13 Hypoparathyroidism 13 Panic Disorder 10 CrohnÕs Disease 14 Myaesthenia Gravis 14 Post-Traumatic Stress Syndrome 11 Diabetes Insipidus 15 TouretteÕs Syndrome 12 Diabetes Mellitus Type 1 16 Zollinger-Ellison Syndrome 13 Diabetes Mellitus Type 2 17 Obsessive Compulsive Disorder 26 PMBÕs
19 PagetÕs Disease 20 Panic Disorder 18 Hyperlipidaemia 22 Polyarteritis Nordosa 23 Post-Traumatic Stress Syndrome 20 Hypothyroidism 24 Pulmonary Interstitial Fibrosis 21 Multiple Sclerosis 25 Systemic Sclerosis 22 ParkinsonÕs Disease 26 TouretteÕs Syndrome 23 Rheumatoid Arthritis 27 Zollinger-Ellison Syndrome 24 Schizophrenia25 Systemic Lupus Erythematosus 26 PMBÕs
26 Ulcerative Colitis Chronic Medicine Management
To apply for chronic medicine authorisation the member, doctor or pharmacist can call chronic medicine management on 0860100608.
Alternatively members, doctors or pharmacists may apply for chronic medication online by logging onto the Medscheme websitehttp://www.medscheme.co.za Designated Service Provider for chronic medication - Pharmacy Direct
To 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.
* Prescribed Minimum Benefit conditions, coverd on more comprehensive formulary on BonComprehensive and Standard options Dental benefits are paid at the Bonitas Dental tariff* (BDT). Co-payments for Orthodontics exist on the Standard and BonSave options. All specialised dentistry and hospitalisation must be pre-authorised**. If no pre-authorisation is obtained or if pre-authorisation is applied for after the treatment has been done, a 20% penalty will apply. This does not apply to emergency hospital admission. Dental benefits are subject to clinical protocols and Managed Care Interventions which may include the requirement of treatment plans and/or radiographs prior to benefit application. Scheme exclusions apply to dental benefits. In the event of a dispute, the rules of the scheme prevail.
Standard and
2 annual check-ups per beneficiary. Benefit 2 annual check-ups per beneficiary. Benefit 2 annual check-ups per beneficiary. Benefit is subject to clinical protocols*.
is subject to clinical protocols*.
is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
¥ Electrognathographic recordings
¥ Electrognathographic recordings ¥ Electrognathographic recordings 1 per beneficiary in a 3 year period. Benefit 1 per beneficiary in a 3 year period. Benefit 1 per beneficiary in a 3 year period. Benefit is subject to clinical protocols*.
is subject to clinical protocols*. Additional is subject to clinical protocols*. Additional benefit may be considered where specialised benefit may be considered where specialiseddental treatment is required.
dental treatment is required.
Oral Hygiene
2 annual scale and polish treatments per 2 annual scale and polish treatments per 2 annual scale and polish treatments per beneficiary. Benefit is subject to clinical beneficiary. Benefit is subject to clinical beneficiary. Benefit is subject to clinical protocols*. Benefit for fissure sealants is limited protocols*. Benefit for fissure sealants is limited protocols*. Benefit for fissure sealants is limited to individuals younger than 16 years of age. to individuals younger than 16 years of age. to individuals younger than 16 years of age.
¥ Oral hygiene instructions ¥ Oral hygiene instructions ¥ Oral hygiene instructions ¥ Oral hygiene evaluation ¥ Oral hygiene evaluation ¥ Oral hygiene evaluation ¥ Professionally applied adult fluoride ¥ Professionally applied adult fluoride ¥ Professionally applied adult fluoride ¥ Dental bleaching ¥ Dental bleaching ¥ Dental bleaching Benefit for re-treatment of a tooth is subject Benefit for re-treatment of a tooth is subject Benefit for re-treatment of a tooth is subject to clinical protocols*.
to clinical protocols*.
to clinical protocols*.
¥ Fillings to restore teeth damaged due to ¥ Fillings to restore teeth damaged due to ¥ Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and toothbrush abrasion, attrition, erosion and toothbrush abrasion, attrition, erosion and ¥ Resin bonding for restorations that are ¥ Resin bonding for restorations that are ¥ Resin bonding for restorations that are charged as a separate procedure to the charged as a separate procedure to the charged as a separate procedure to the ¥ The polishing of restorations ¥ The polishing of restorations ¥ The polishing of restorations ¥ Gold foil restorations ¥ Gold foil restorations ¥ Gold foil restorations Root Canal Therapy
Benefit is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
¥ Direct and indirect pulp capping ¥ Direct and indirect pulp capping ¥ Direct and indirect pulp capping Plastic Dentures and
1 set of plastic dentures (an upper and a 1 set of plastic dentures (an upper and a 1 set of plastic dentures (an upper and a lower) per beneficiary in a 4 year period.
lower) per beneficiary in a 4 year period.
lower) per beneficiary in a 4 year period.
Benefit is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
Benefit is not available for the clinical fee of Benefit is not available for the clinical fee of Benefit is not available for the clinical fee of denture repairs, denture tooth replacements denture repairs, denture tooth replacements denture repairs, denture tooth replacements and the addition of a soft base to new and the addition of a soft base to new and the addition of a soft base to new dentures; the laboratory fee will be covered. dentures; the laboratory fee will be covered. dentures; the laboratory fee will be covered.
Benefit is not available for the laboratory fee Benefit is not available for the laboratory fee Benefit is not available for the laboratory fee of mouthguards; the clinical fee will be of mouthguards; the clinical fee will be of mouthguards; the clinical fee will be ¥ Diagnostic dentures and associated ¥ Diagnostic dentures and associated ¥ Diagnostic dentures and associated laboratory costs ¥ Snoring appliances and associated ¥ Snoring appliances and associated ¥ Snoring appliances and associated ¥ High impact acrylic ¥ High impact acrylic ¥ High impact acrylic ¥ The cost of gold, precious metal, ¥ The cost of gold, precious metal, ¥ The cost of gold, precious metal, semi-precious metal and platinum foil semi-precious metal and platinum foil semi-precious metal and platinum foil ¥ Laboratory delivery fees ¥ Laboratory delivery fees ¥ Laboratory delivery fees Partial Metal Frame
1 partial frame (an upper or a lower) per 2 partial frames (an upper and a lower) per beneficiary in a 5 year period. Benefit is beneficiary in a 5 year period. Benefit is subject to clinical protocols*.
subject to clinical protocols*.
¥ The metal base to full dentures and ¥ The metal base to full dentures and associated laboratory costs associated laboratory costs ¥ High impact acrylic ¥ High impact acrylic ¥ The cost of gold, precious metal, semi- ¥ The cost of gold, precious metal, semi- precious metal and platinum foil precious metal and platinum foil ¥ Laboratory delivery fees ¥ Laboratory delivery fees Crown and Bridge** and No benefit
Pre-authorisation is required. 2 crowns per Pre-authorisation is required.3 crowns per family per year. Benefit is subject to clinical family per year. Benefit is subject to clinical * Bonitas Dental Tariff** Pre-authorisation required Standard and
Crown and Bridge** and
¥ Crown and bridge procedures for ¥ Crown and bridge procedures for cosmetic reasons and associated cosmetic reasons and associated A bridge comprises of 2 ¥ Full mouth rehabilitations and associated ¥ Full mouth rehabilitations and associated or more crowns. Each crown is payable from ¥ Provisional crowns and associated ¥ Provisional crowns and associated the available Crown and Bridge benefit. ¥ Porcelain veneers and inlays and ¥ Porcelain veneers and inlays and associated laboratory costs associated laboratory costs ¥ Emergency crowns that are not placed ¥ Emergency crowns that are not placed for the immediate protection in tooth for the immediate protection in tooth injury and associated laboratory costs.
injury and associated laboratory costs.
¥ The cost of gold, precious metal, semi- ¥ The cost of gold, precious metal, precious metal and platinum foil semi-precious metal and platinum foil ¥ Laboratory delivery fees ¥ Laboratory delivery fees Pre-authorisation is required. 2 implants per beneficiary in a 5 year period. Cost of implant components is limited to R1500 per implant.
Benefit is subject to clinical protocols*.
Scheme exclusions:
¥ Dolder bars and associated
abutments on implants including the associated laboratory costs ¥ Laboratory delivery fees Pre-authorisation is required for Removable Pre-authorisation is required for Removable appliance therapy, Functional appliance appliance therapy, Functional appliance therapy, Partial fixed appliance therapy (Pre- therapy, Partial fixed appliance therapy (Pre-liminary treatment) and Comprehensive fixed liminary treatment) and Comprehensive fixedappliance therapy.
appliance therapy.
Benefit is subject to clinical protocols. A 25% Benefit is subject to clinical protocols*.
co-payment of the BDT exists.
On pre-authorisation cases will be clinically On pre-authorisation cases will be clinicallyassessed using orthodontic indices.
assessed using orthodontic indices.
Benefit for Orthodontic treatment will be Benefit for Orthodontic treatment will be granted where function is impaired. Benefit granted where function is impaired. Benefitwill not be granted where Orthodontic will not be granted where Orthodontic treatment is required for cosmetic reasons. treatment is required for cosmetic reasons.
The associated Laboratory costs will also not The associated Laboratory costs will also notbe covered.
Only one family member may commence Only one family member may commence Orthodontic treatment in a calendar year.
Orthodontic treatment in a calendar year.
Benefit is limited to individuals younger than Benefit is limited to individuals younger than18 years of age.
18 years of age.
¥ Orthodontic re-treatment and any ¥ Orthodontic re-treatment and any related Laboratory costs related Laboratory costs ¥ Orthognathic (jaw correction) ¥ Orthognathic (jaw correction) surgery and any related Hospital and surgery and any related Hospital and Laboratory costs ¥ Invisible retainer material ¥ Invisible retainer material ¥ Laboratory delivery fees ¥ Laboratory delivery fees Pre-authorisation is required. Benefit is subject Pre-authorisation is required. Benefit is subjectto clinical protocols*.
to clinical protocols*.
Benefit is limited to conservative, non-surgical Benefit is limited to conservative, non-surgicaltherapy only (root planing) and will only be therapy only (root planing) and will only beapplied to members who are registered on applied to members who are registered onthe Periodontal Programme.
the Periodontal Programme.
¥ Surgical periodontics which includes ¥ Surgical periodontics which includes gingivectomies, periodontal flap surgery gingivectomies, periodontal flap surgery tissue grafting and the hemisection of a tissue grafting and the hemisection of a ¥ Periodontal chip placement ¥ Periodontal chip placement Surgery in the dental chair:
Surgery in the dental chair:
Surgery in the dental chair:
and Oral Pathology
Benefit is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
Benefit for Temporo-mandibular Joint (TMJ) Benefit for Temporo-mandibular Joint (TMJ) Benefit for Temporo-mandibular Joint (TMJ)therapy is limited to non-surgical therapy is limited to non-surgical therapy is limited to non-surgical The claims for oral pathology procedures The claims for oral pathology procedures The claims for oral pathology procedures (cysts and biopsies, the surgical treatment (cysts and biopsies, the surgical treatment (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours) of tumours of the jaw and soft tissue tumours) of tumours of the jaw and soft tissue tumours)will only be covered if supported by a will only be covered if supported by a will only be covered if supported by a laboratory report that confirms diagnosis.
laboratory report that confirms diagnosis.
laboratory report that confirms diagnosis.
* Bonitas Dental Tariff ** Pre-authorisation required Standard and
and Oral Pathology
¥ Orthognathic (jaw correction) surgery ¥ Orthognathic (jaw correction) surgery ¥ Orthognathic (jaw correction) surgery ¥ Bone augmentations ¥ Bone augmentations ¥ Bone augmentations ¥ Bone and tissue regeneration procedures ¥ Bone and tissue regeneration procedures ¥ Bone and tissue regeneration procedures¥ The cost of bone regeneration material ¥ The cost of bone regeneration material ¥ The cost of bone regeneration material¥ The auto-transplantation of teeth ¥ The auto-transplantation of teeth ¥ The auto-transplantation of teeth ¥ The closure of an oral-antral opening ¥ The closure of an oral-antral opening ¥ The closure of an oral-antral opening (currently code 8909) when claimed (currently code 8909) when claimed (currently code 8909) when claimed during the same visit with impacted during the same visit with impacted during the same visit with impacted teeth (currently codes 8941, 8943 and teeth (currently codes 8941, 8943 and teeth (currently codes 8941, 8943 and 8945) is a scheme exclusion.
8945) is a scheme exclusion.
8945) is a scheme exclusion.
Surgery in hospital:
Surgery in hospital:
Surgery in hospital:
See Hospitalisation* below See Hospitalisation* below See Hospitalisation* below Pre-authorisation is required. Admission Pre-authorisation is required.
Pre-authorisation is required.
(general anaesthetic) ** protocols apply.
Admission protocols apply.
Admission protocols apply.
General anaesthetic benefits are only General anaesthetic benefits are available General anaesthetic benefits are available available for the removal of impacted teeth; (for children under five years) for extensive (for children under five years) for extensive benefit will be granted where the impacted dental treatment.
dental treatment.
teeth are covered by bone.
General anaesthetic benefits are available General anaesthetic benefits are availablefor the removal of impacted teeth; benefit for the removal of impacted teeth; benefit will be granted where the teeth are covered will be granted where the teeth are coveredby bone.
The Hospital and anaesthetist claims for the The Hospital and anaesthetist claims for the The Hospital and anaesthetist claims for thefollowing procedures will not be covered following procedures will not be covered following procedures will not be covered when performed under general anaesthesia. when performed under general anaesthesia. when performed under general anaesthesia.
The payment of the dental procedure will The payment of the dental procedure will The payment of the dental procedure will be dependent on available benefits and be dependent on available benefits, and be dependent on available benefits and payable at BDT tariffs: payable at BDT tariffs: payable at BDT tariffs: ¥ Soft tissue impactions ¥ Soft tissue impactions ¥ Soft tissue impactions ¥ Implantology and associated ¥ Implantology and associated surgical ¥ Implantology and associated surgical surgical procedures ¥ Conservative dental treatment (fillings, ¥ Conservative dental treatment (fillings, ¥ Conservative dental treatment (fillings, extractions and root canal therapy) for extractions and root canal therapy) for extractions and root canal therapy) for children and adults ¥ Professional oral hygiene procedures ¥ Professional oral hygiene procedures ¥ Professional oral hygiene procedures Hospitalisation and Anaesthetics**
¥ Surgical tooth exposure for orthodontic ¥ Surgical tooth exposures for orthodontic ¥ Surgical tooth exposures for orthodontic ¥ Where the only reason for admission to ¥ Where the only reason for admission to ¥ Where the only reason for admission to hospital is dental fear and anxiety hospital is dental fear and anxiety hospital is dental fear and anxiety ¥ Multiple hospital admissions ¥ Multiple hospital admissions ¥ Multiple hospital admissions ¥ Where the only reason for the admission ¥ Where the only reason for the admission ¥ Where the only reason for the admission request is for a sterile facility request is for a sterile facility request is for a sterile facility ¥ The cost of dental materials for ¥ The cost of dental materials for ¥ The cost of dental materials for procedures performed under general procedures performed under general procedures performed under general Laughing gas in dental
Benefit is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
Benefit is subject to clinical protocols*.
IV conscious
Pre-authorisation is required. Benefit is subject Pre-authorisation is required. Benefit is subject Pre-authorisation is required. Benefit is subject sedation in rooms**
to clinical protocol*.Benefit is limited to to clinical protocol*.Benefit is limited to to clinical protocol*.Benefit is limited to extensive dental treatment.
extensive dental treatment.
extensive dental treatment.
Additional scheme exclusions:
¥ Nutritional and tobacco counselling¥ Caries susceptibility and microbiological tests¥ Cost of Mineral Trioxide¥ Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments¥ Appointment not kept¥ Special report¥ Dental testimony¥ Enamel microabrasion¥ Behaviour management¥ Intramuscular or subcutaneous injection¥ Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures * Bonitas Dental Tariff** Pre-authorisation required mulary, medication at R500 000 per family 100% Bonitas Rate Prime Cure Network Prime Cure Provider PMBÕs at Contracted Provider Subject to Prime Cure Provider Prime Cure Medicine or Medipost Courier Phar R750 000 per family 100% Bonitas Rate R110 000 per family PMB's at Public Hospitals PMB's at Public Hospitals R32 000 per family includin Traditional
Standard
100% Bonitas Rate R225 000 per family R300 PB, per admission R32 000 per family 42 Chronic Conditions R6 900 pb or R13 800 per family, Comprehensive For benefit. Restrictive formulary when benefits are exceeded for PMBÕs 150% Bonitas Rate R250 000 per family R250 PB, per admission R32 000 per family 40% co-payment applies at New Generation
100% Bonitas Rate R250 000 per family R250 PB, per admission R32 000 per family co-payment applies at non DSP 300% Bonitas Rate R450 000 per family R150 000 (20%co-pay) per family R350 PB, per admission R32 000 per family 54 Chronic Conditions Comprehensive For per beneficiary, R20 000 per family Biological drugs R120 000 per family, 20% co-payment Major Medical Benefit
Reimbursement Rate GP's & Specialists Pathology & Radiology Paramedical services Oncology - Chemo & Radiation Oncology - Biological Drugs Physical Rehabilitation eneficiary limited to Subject to Prime Cure
beneficiary. 20% co-payment will apply for the use of non DSP R2200 or 5 visits per family and soft tissue ultrasounds. Subject to Contracted Provider subject to GP referral. Subject to Contracted Provider One pair of spectacles every 24 months, subject to One optometric examination per per beneficiary limited to Contracted Provider Frame every 24 months subject to Lenses subject to Contracted Provider. Contact Lenses, no Unlimited subject to Pri Cure Medicine For , no benefit at a non - T sub-limit of R320 pb and R950 GP consultation in Network
Out of Network sub-limit included
in Network
Day To Day Limit
Subject to GP consultation Subject to Day to Day Benefit Subject to Day to Day Benefit Subject to Day to Day Benefit Subject to Day to Day Benefit 2-year benefit from anniversary of claiming, p .b.
Eye test - 100% of cost at PPN optometrist or to a max of R235 at non -network prescription lenses /add-ons R150 p.b.at a network single vision - R120 per lens OR Clear aquity flat -topbenefit.
bifocal - R275 per lens OR Clear Aquity Multifocal (Up to bifocal limit) - R275 per lens OR Contact lenses - R395 pb Subject to Day to Day Benefit Tradit ional
T sub-limit of R530 pb and R1600 Standard
GP consultation in Network
Out of Network sub-limit included
in Network
Day To Day Limit
Subject to GP consultation Subject to Day to Day Benefit Subject to Day to Day Benefit Subject to Day to Day Benefit Subject to Day to Day Benefit 2-year benefit from anniversary of claiming, p .b.
Eye test - 100% of cost at PPN optometrist or to a max of R235 at non -network prescription lenses /add-ons R600 p.b. at a network provider Clear single vision R120 per lens OR Clear aquity flat -top bifocal - R275 per lens OR Clear Aquity Multifocal R500 per lens OR Contact lenses - R1 220 pb Subject to Day to Day Benefit Subject to savings Subject to savings Subject to savings Subject to savings Subject to savings Subject to savings Subject to savings New Generation
Subject to savings and or threshold, 20% co-payment in Subject to savings and or threshold, 20% co-payment in Subject to savings and or threshold, 20% co-payment in Subject to savings and or threshold, 20% co-payment in Subject to savings and or threshold, limited to R5 500, 20% co-payment in threshold Subject to savings and or threshold, limited to R2250 per beneficiary. 20% co-payment in Subject to savings and or threshold, limited to: 80% of Bonitas rates accrues to threshold , 20% co-payment in Out of Hospital Benefits
Self Funding Gap
Acute Medications and PAT
eneral Appliances per family included in OAL agement programme and One consultation p.b. p .a.
One preventative treatment p.b. p .a. e.g. cleaning, polishing, fillings, extractions, pain and sepsis treatment and X-rays. 1 emergency episode p .b. p.a.
One set of plastic dentures per family over a 24-month period applicable over the age of 21, 20% co-payment Subject to Prime Cure Subject to Prime Cure HIV disease Prime Cure Protocols R8 000 per family (joint limit in and out of hospital) , subject to pre-authorisation 1 per beneficiary, per annum Included in General Appliances Included in General Appliances pre-authorisation by Prime Cure d Gen appliances by Subject to dental benef and Denis protocols.
Covered at Bonitas Dental 12 ante-natal consultations, consultations with midwife R16 000 per beneficiary subject to Aid for Aids registration R10 500 per family, sub limit consultations. Included in OAL R8 500 per family (joint limit in and out of hospital), subject to pre-authorisation R 17,500 per family included in OAL Combined Benefit with Inter 1 per beneficiary, per annum R 4 ,800 per family included in OAL Included in General Appliances R6,900 Biennial per family Subject to OAL and pre-authorisation by HBM Traditional
e-authorisation by HBM Standard
Subject to dental benefit grid Covered at Bonitas Dental Subject to dental benefit grid and Denis protocols.
Covered at Bonitas Dental 2 x 2D scans, 4 postnatal consultations with midwife R21 200 per beneficiary subje to Aid for Aids registration R26 500 per family, s R10 600 in and out of hospital R17 000 per family , subject to R29 000 per family Combined Benefit with Inter R 5 ,300 per family Included in General Applia May exceed Gen appliances by R11,000 Biennial per family Unlimited subject to Subject to dental benefit grid and Denis protocols. Covered at Bonitas Dental T Subject to dental benefit grid and Denis protocols. Covered at Bonitas Dental T 12 ante -natal consultations, 2 x 2D scans, 4 postnatal consultations with midwife , ante natal classes R800 and post confinement in a private R21 200 per beneficiary subject to Aid for Aids registration R21 200 per family, sub limit of R10 600 in and out of hospital R16 000 per family , subject to pre -authorisation 1 per beneficiary, per annum R 4 ,800 per family Included in General Appliances May exceed Gen appliances by Unlimited subject to pre-authorisation by HBM New Generation
12 ante-natal consultations, 2 x 2D scans, 4 postnatal consultations with midwife.
R22 000 per beneficiary subject to Aid for Aids registration R21 200 per family subject to 1 per beneficiary, per annum HIV only. No benefit for Flu V Subject to dental benefit grid and Denis protocols. Covered at Subject to dental benefit grid and and Denis protocols. Covered at Bonitas Dental T 12 ante-natal consultations, 2 x 2D scans, 4 postnatal consultations with midwife, antenatal classes R800 and post confinement in a R11 000 per family Unlimited subject to Aid for Aids R32 000 per family, sub limit of R10 600 in and out of hospital R22 000 per family, subject to pre R 38,000 per family R 38,000 per family 1 per beneficiary, per annum R 6 ,500 per family Included in General Appliances May exceed Gen appliances by R20,000 Biennial per family Unlimited subject to pre-authorisation by HBM Principal Member Refractive Surgery Specialised Radiology Ambulance - Emergency Endoscopies in Dr's Rooms* General Appliances Wheelchairs & Large Orthapaedic Stoma Products and CP Subject to pre-authorisation Contributions - Member BonComprehensive * Subject to pre-authorisation Contact Us
0860 002 108
Hospital and Specialised Radiology Authorisations:
08h00-16h00
Bonitas Customer Service: Mon-Fri 08h30-16h00
Fax: 0860 002 145 (authorisations only)
E-mail: [email protected]
(This 0860 number is charged at local rates wherever
0860 002 144
you are in South Africa)
Chronic Medicine Authorisations:
E-mail Members: [email protected]
E-mail Doctors & Pharmacists: [email protected]
Bonitas Medical Fund, PO Box 1101 Florida Glen, 1708
0860 100 608
37 Conrad Drive, Florida North, 1709
Aid for Aids Patient Care Line:
0800 112 811
SMS (call me):
08h30-17h00
Doctor & Pharmacist Line: 0800 227 700
Cape Town Office Line: +27 21 466 1700
Visit us at any of the following walk-in branches Monday to Friday,
Fax: 0800 600 773
08h30 to 16h00
Suite 13, Westdene Office Park, President Reitz 0860 100 646 / 083 410 9078
Avenue, Westdene, Bloemfontein Oncology Management:
08h00-16h00
Atterbury House, 15th Floor, 9 Reibeek Street, Fax: 021 514 2303
3rd Floor, 67 Old Fort Road, Durban 0860 100 572
Medscheme House, 39 Balfour Road, Vincent, Fax: 086 611 4000/1/2/3 or 012 643 3040
E-mail: [email protected]
Onverwacht Business, Mienie Building, Block C, Walter Sisulu Avenue, Ellisras 0860 027 800
Office No.1, Vusa House, Mezzanine Floor, Ghandi Square, Johannesburg 6 Rietbok Street, Kathu, Northern Cape 0860 103 529
Ground Floor, Trust Bank Building, George Street, (Open till 31/12/2010) The Upper Ground Floor, Colfin House, 11 Ferreira Fax: 0866 770 336
(Open till 28/02/2011) Street, Nelspruit Web: www.denis.co.za
0860 336 346
Block 6, Greenacres Office Park, 2nd Avenue, Prime Cure:
Newton Park, Port Elizabeth Ground Floor, Bonitas House, Fax: 012 665 8601
22 Hans van Rensburg Street, Polokwane Web: www.primecure.co.za
0861 665 665/012 665 8690
Ground Floor, Benstra Building, Netcare 911:
473B Church Street, Arcadia, Pretoria Medical Advice Line: 082 911
International Travel: 010 209 8387
37 Conrad Road, Florida North, Roodepoort International Travel Fax: 010 209 8405
E-mail: [email protected]
1st Floor Femina Street, 148 Kerk Street, Rustenburg 0866 372 506
(From 01/11/2010) Centre for Diabetes and Endocrinology (CDE):
08h30-17h00
Shop 1, Sanlam Plaza, Horwood Street, Secunda Tel: 011 712 6000
Fax: 011 728 6661
2nd Floor, 36 Merriman Avenue, Vereeniging First Floor, Hidas Centre, 21 Nelson Mandela Avenue, Windhoek, Namibia

Source: http://propratt.co.za/Documents/2011/Bonitas_Sales_Brochure.pdf