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Resolution Health PROGRESSIVE FLEX 2018

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Type of Medical Aid Plan: 
Traditional
Medical Aid Year: 
2018
Day to day Benefits: 

Stated benefits as per limits indicated.

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
100% of Scheme Rate.
Hospitals: 

Unlimited, only at DSP network hospitals.

R4 110 co-payment applicable for non-DSP hospitals.

Procedure co-payments may also be applicable.

Subject to Scheme Protocols and option specific exclusion list.

Upfront Payments to hospitals: 

R4 110 co-payment applicable for non-DSP hospitals

CO-PAYMENTS

Arthroscopy: R3 957

Circumcision: R2 642

Colonoscopy, sigmoidoscopy, proctoscopy: R2 642

Conservative back / spinal treatment: R3 957

Cystoscopy: R2 642

Dental admissions: R2 642

Excision nailbed: R1 984

Gastroscopy: R2 642

Endometrial ablation: R3 957

Hernia repair: R3 957

Hysterectomy: R3 957

Hysteroscopy: R2 971

Joint replacements: R7 550

Laparoscopic procedures: R3 957

Myringotomy: R2 313

Nasal surgery (including endoscopy): R5 942

Reflux surgery: R11 343

Rotator cuff surgery: R7 550

Skin lesions: R1 984

Spinal surgery: R8 255

Tonsillectomy and adenoidectomy: R2 313

Tympanoplasty: R1 984

Urinary incontinence repair: R3 957

Varicose veins: R3 957

Casualty / Emergency Visits: 
Clinician and facility fees only, clinician paid at 100% of Scheme Rate. Limited to R1 680 for emergency visits per family per annum.
Specialists: 
Clinical medical specialist fees, including consultations and procedures. Non-Contracted Providers at 100% of Scheme Rate. Contracted Providers up to 100% of Contracted Rate.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of Scheme Rate.
Radiology and pathology: 
100% of Scheme Rate.
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
100% of Scheme Rate. R2 642 co-payment.
MRI and CT scans: 
CT, MRI, PET and Nuclear Medicine scans, R9957 per family per annum. Subject to Scheme Protocols. Co-payment of R1 996 per incident (in-and-out of hospital). Pre-authorisation required. 100% of Scheme Rate.
ICU and High Care: 
100% of Scheme Rate.
Dialysis: 
Covered at Network Providers. Subject to Scheme Protocols and PMB's. Pre-authorisation required.
Organ Transplants: 
R118 713 per family per annum. Subject to PMBs and Scheme Protocols.
Oncology / Cancer: 
Oncologist, Chemotherapy, Radiotherapy & Oncology-related blood tests. Limited to R275 941 per family per annum. Subject to ICON Network and standard protocols. Pre-authorisation required.
Neck and Back Operations: 
Conservative back / spinal treatment. Co-Payment R3 957.
Joint Replacements: 
Co-Payment R7 750.
Prosthesis: 

Prosthesis sub-limits.

Overall option limit: R56 537.

Knee: R38 919. Hip: R35 786.

Shoulder / Elbow / Ankle: R55 303.

External fixator: R56 537.

SPINAL FUSION:

1 Level CERVICAL - R22 250 & LUMBAR DORSAL - R25 109.

2 Level CERVICAL - R34 499 & LUMBAR DORSAL - R40 143.

3 Level CERVICAL - R47 686 & LUMBAR DORSAL - R50 218.

4 Or more Levels CERVICAL - R56 537 & LUMBAR DORSAL - R56 537.

CORONORY STENTS: 1 Stent - R23 706. 2 Stents - R38 856. Total - R56 537.

Pelvic floor - R7 828.

Hernia mesh - R7 828.

Intraocular lens (left) - R3 133.

Intraocular lens (right) - R3 133.

Medical and Surgical Appliances: 
External medical appliances, R4110 per family PA, subject to sub-limits: Back supports R4110. CPAP Machine(3y cycle) R4110. Glucometers(3y cycle) R775. Hearing aids(annual, 3y lifespan/appliance) R4110. Nebulisers(3y cycle) R775. Wheelchairs R4110.
Maternity Confinements: 
Normal delivery: 3 days & 2 nights. Caesarean Section (clinically indicated only): 4 days & 3 nights. Elective Caesarean Section: No benefit. Neonatal Intensive Care: Subject to Scheme Protocols.
In Hospital Dentistry: 
Surgery, dental hospitalisation, anaesthetics & associated costs. Impacted wisdom teeth & extensive procedures in children <5. Multiple hospital admissions are not covered. Co-payment will apply to all admissions. Scheme Protocols apply.
Take home Medicine: 
Maximum of 7 days’ supply.
Rehabilitation, Hospice and Step-down facilities: 
12 Days per family per annum. 100% of Scheme Rate.
Treatment for Mental Health: 
Psychiatric disorders, Limited to Network Providers and subject to PMBs and Scheme Protocols.
HIV / AIDS: 
Primary care including Voluntary Counselling, Testing & Treatment. Hospitalisation if member is registered on the HIV Management Programme, at Network hospitals. Subject to Scheme Protocols & PMBs. If not registered limited to Provincial Facility.
Ambulance Service: 
Limited to Netcare 911, 100% of Scheme Rate.
International Travel Benefit: 
Limited to emergency medical cover up to R750 000 per beneficiary per incident.
Day-to-day benefits
GP consultations: 

M 4 visits per annum.

M+1 7 visits per annum.

M+2+ 9 visits per annum.

Non-Contracted Providers up to 100% of Scheme Rate.

Contracted Providers up to 100% of Contracted Rate.

CDL PMB consultations covered separately.

Subject to Disease Management Protocols. Pre-authorisation required.

Specialist consultations: 

Non-Contracted Providers up to 100% of Scheme Rate. Contracted Providers at 100% of Contracted Rate.

M 2 visits per annum

M+1 3 visits per annum

M+2+ 3 visits per annum

Additional visits subject to Prescribed Minimum Benefits and pre-authorisation.

Consultations outside Networks may incur a co-payment.

Room procedures (require pre-authorisation, limited to Scheme Protocols).

Acute medicine: 

Limited to:

M R2 372

M+ R3 065

Acute medication subject to relevant plan formulary.

Reference and Generic Reference Pricing may apply.

Benefit protocols apply.

Use preferred provider pharmacies.

Over-the-counter (OTC) Medicine: 

A sub-limit on Schedule 0-2 drugs of: M R657 M+ R921

Optometry benefits: 
24 month cycle, 1 consultation per beneficiary. Spectacles, Inclusive of a frame and consultation per beneficiary 1 pair of: single vision R1210, flat top bifocal R1844, multifocal R2137 or Contact lenses R1210.
Basic dentistry: 
Annual limits: M R3287 M+ R5284. 2 Annual checkups & 2 emergency consults, Oral Xrays Intra: 8 & Extra: 1 per beneficiary. Fillings, Extractions, Root canal therapy covered. 1 Set of acrylic dentures per beneficiary per 4 years. 2 scale & polish treatment
Specialised Dentistry: 
R5 602 per family per annum. Pre-authorisation required. Crowns included.
Orthodontics: 

No benefit.

MRI and CT Scans (Out of Hospital): 
CT, MRI, PET and Nuclear Medicine scans, R9957 per family per annum. Subject to Scheme Protocols. Co-payment of R1 996 per incident (in-and-out of hospital). Pre-authorisation required. 100% of Scheme Rate.
Radiology and Pathology: 
Subject to Flexi Benefit, M R2 393, M+ R3 036.
Pregnancy benefits: 
Antenatal care. Maternity programme (registration required). Baby care products at a DSP, R634. 9 Consultations (Midwife, GP or Max 3 Specialist) included (any Provider). 3 2D Scans.
Physiotherapy and Occupational Therapy day to day: 
Subject to Flexi Benefit, M R2 393, M+ R3 036.
Chronic Conditions
Provider: 
Should be obtained from a Designated Service Provider.
Chronic Conditions: 

25 CDL conditions + HIV, BPH and HRT. • Addison’s Disease • Asthma • Benign Prostatic Hypertrophy • Bipolar Affective Mood Disorders • Bronchiectasis • Cardiac Dysrhythmia (Arrhythmia) • Cardiac Failure • Cardiomyopathy • Chronic Obstructive Pulmonary Disorders (COPD) • Chronic Renal Failure / Disease • Crohn’s Disease • Diabetes Insipidus • Diabetes Mellitus Type 1 & 2 • Epilepsy • Glaucoma • Haemophilia • HIV • Hormone Replacement Therapy • Hyperlipidaemia • Hypertension • Hypothyroidism • Ischaemic Heart Disease (Coronary Artery Disease) • Multiple Sclerosis • Parkinson’s Disease • Rheumatoid Arthritis • Schizophrenia • Systemic Lupus Erythematosis • Ulcerative Colitis

Additional Chronic Conditions: 
No benefit.
Preventative Care Benefits
Preventative Benefits: 

Preventative care limit: R2 630 per family per annum. Scheme Rate applies.

Blood pressure, Blood sugar, Cholesterol, Body Mass Index, R124 per beneficiary over the age of 18 years. Only at pharmacy.

HIV test, 1 Test per beneficiary per annum. Mammogram (screening), 1 Examination per female beneficiary per annum over the age of 40 years.

Pap smears, 1 Test per beneficiary per annum.

PSA testing, 1 Test per beneficiary per annum over the age of 45 years.

Vaccinations, Flu, 1 Dose flu vaccination per beneficiary per annum. R1 978 benefit for childhood immunisations as recommended by the Department of Health up to 18 months.

Nurse helpline (including Rape Crises Centre) Advice anad information regarding any emergency medical condition. Call 086 111 2162.

Oral contraception R1 584 per female beneficiary per annum (R132 per month).

Total Contributions
Total Contribution Main Member: 
2365.00
Total Contribution Adult: 
2190.00
Total Contribution Child*: 
725.00
PROGRESSIVE FLEX
Risk Contributions
Risk Contribution Main Member: 
2365.00
Risk Contribution Adult: 
2190.00
Risk Contribution Child: 
725.00
How many times per annum do you and your dependants visit a doctor?: 
20
How much do you spend on Acute medication per annum?: 
R1000 - R4999
How much do you spend on Chronic medication per annum?: 
R1000 - R4999
Will you or any of your dependants require specialised Dentistry: 
Yes
Medical Aid Plan Name Term: 
Any