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Resolution Health SUPREME 2018

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

Principal: R14 936 per annum.

Adult : R11 202 per annum.

Child: R1 562 per annum.

Co-payments: 
Various co-payments applicable.
In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
100% of Scheme Rate.
Hospitals: 

Any Hospital.

Upfront Payments to hospitals: 

CO-PAYMENTS

Arthroscopy: R3 957

Conservative back / spinal treatment: R3 957

Dental admissions: R2 642

Endometrial ablation: R3 957

Hysteroscopy: R2 971

Joint replacements: R7 550

Laparoscopic procedures: R3 957

Spinal surgery: R8 255

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 220% 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.
MRI and CT scans: 
CT, MRI, PET and Nuclear Medicine scans, R19787 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: 
Unlimited at Network Providers. Subject to Scheme Protocols. Pre-authorisation required.
Organ Transplants: 
Unlimited, subject to PMBs and Scheme Protocols.
Oncology / Cancer: 
Oncologist, Chemotherapy, Radiotherapy & Oncology-related blood tests. Unlimited (subject to ICON protocols and option specific medicine formularies), subject to Scheme Protocols and DSP Network, 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: R62 825.

Knee: R47 697.

Hip: R43 276

Shoulder / Elbow / Ankle: R55 303.

External fixator: R62 825.

SPINAL FUSION:

1 Level CERVICAL - R22 250 & LUMBAR DORSAL - R27 841.

2 Level CERVICAL - R34 499 & LUMBAR DORSAL - R42 664.

3 Level CERVICAL - R47 686 & LUMBAR DORSAL - R50 376.

4 Or more Levels CERVICAL - R62 825 & LUMBAR DORSAL - R62 825.

CORONORY STENTS: 1 Stent - R23 706. 2 Stents - R38 856. Total - R62 825.

Pelvic floor - R7 828.

Hernia mesh - R7 828.

Intraocular lens (left) - R3 629. Intraocular lens (right) - R3 629.

Medical and Surgical Appliances: 
External medical appliances, R15805 per family PA, subject to sub-limits: Back supports R4726. CPAP Machine(3y cycle) R10216. Glucometers(3y cycle) R1362. Hearing aids(annual, 3y lifespan/appliance) R15805. Nebulisers(3y cycle) R1362. Wheelchairs R7914.
Maternity Confinements: 
Normal delivery: 3 days & 2 nights. Caesarean Section (clinically indicated only): 4 days & 3 nights. Elective Caesarean Section: Included. 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. Pre-auth required for Maxillo procedures
Take home Medicine: 
Maximum of 7 days’ supply.
Rehabilitation, Hospice and Step-down facilities: 
21 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. Non PMBs limited to R31 610 per family per annum.
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 R2 million per beneficiary per incident.
Day-to-day benefits
GP consultations: 

Unlimited.

Contracted Providers up to 100% of Contracted Rate.

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

Consultations outside Provider Networks may incur a co-payment.

Chronic Disease List Prescribed Minimum Benefit 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 (up to 220% of Scheme Rate).

M 4 visits per annum

M+1 5 visits per annum

M+2+ 6 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: 

Subject to additional out-of-hospital benefit limit.

M R7 832

M+1 R13 786

M+2+ R14 972

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 R2 372

M+1 R4 086

M+2+ R4 462

Optometry benefits: 
24 month cycle, 1 consultation per beneficiary. Spectacles, Inclusive of a frame and consultation per beneficiary 1 pair of: single vision R2220, flat top bifocal R2678, multifocal R3358 or Contact lenses R2501.
Basic dentistry: 
2 Annual check-ups & 2 emergency consults per beneficiary. X-rays Intra-oral: 8 & Extra-oral: 1 per beneficiary. Fillings, Extractions, Root canal therapy covered. 1 Set of acrylic dentures per beneficiary per 4 year cycle. 2 scale and polish treatments.
Specialised Dentistry: 
Sub-limits R14 091 per family per annum. Pre-authorisation Required. Crowns, Bridges, Implants, Partial metal dentures & Periodontics Included.
Orthodontics: 

Orthodontics (Fixed braces).

Benefits for one beneficiary per cycle on pre-authorisation will be applied to cases assessed as treatment mandatory, as per orthodontic indices.

1 Per lifetime for beneficiaries younger than 38 years. 

Orthognathic surgery and repairs or replacements, including retainers, are not covered.

MRI and CT Scans (Out of Hospital): 
CT, MRI, PET and Nuclear Medicine scans, R19787 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 additional out-of-hospital benefit limit. M R7832. M+1 R13786. M+2+ R14 972. Radiology and Pathology. M: R3358. M+1: R4122. M+2+: R4979. 100% of Scheme Rate.
Pregnancy benefits: 
Antenatal care. Maternity programme (registration required). Baby care products at a DSP, R968. 9 Consultations (Midwife, GP or Specialist) included (any Provider). 2 2D Scans.
Physiotherapy and Occupational Therapy day to day: 
Subject to additional out-of-hospital benefit limit. M R7832. M+1 R13786. M+2+ R14 972. Occupational therapists, alternative healthcare services limits: M R3358, M+1 R4979, M+2+ R6587. Physiotherapy, R1 469 per family,100% of Scheme Rate.
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: • ADHD • Allergic Rhinitis • Angina Pectoris • Ankylosing Spondylitis • Arthritis • Cerebrovascular Accident (Stroke) • Cushing’s Syndrome • Delusional Disorder • Eczema • Gastro-Oesophageal Reflux Disease (GORD) • Gout • Hyperthyroidism • Idiopathic Thrombocytopenic Purpura • Interstitial Fibrosis of the Lung • Major Depression • Meniere’s Syndrome • Motor Neuron Disease • Myasthenia Gravis • Osteoporosis • Paget’s Disease • Peripheral Vascular Disease • Pituitary Adenoma • Psoriasis • Scleroderma • Urinary Incontinence

Additional Chronic Conditions: 
M R5 790, M+ R11 567. Benefits subject to stated sub-limits and thereafter to PMBs CDLs.
Preventative Care Benefits
Preventative Benefits: 

Preventative care limit: R3 957 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 35 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. Childhood immunisations as recommended by the Department of Health up to 18 months.

HPV vaccine (cervical cancer prevention), 1 course (3 doses per registered schedule) per female beneficiary per life between 9 and 46 years.

Nurse helpline (including Rape Crises Centre) Advice and 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: 
5065.00
Total Contribution Adult: 
4820.00
Total Contribution Child*: 
1255.00
SUPREME
Risk Contributions
Risk Contribution Main Member: 
5065.00
Risk Contribution Adult: 
4820.00
Risk Contribution Child: 
1255.00
How many times per annum do you and your dependants visit a doctor?: 
50
How much do you spend on Acute medication per annum?: 
More than R 5000
How much do you spend on Chronic medication per annum?: 
More than R 5000
Will you or any of your dependants require specialised Dentistry: 
Yes
Medical Aid Plan Name Term: 
Any