Tiger Brands Medical Scheme 2017 - · PDF file3 Day-to-day benefits All out-of-hospital...
Transcript of Tiger Brands Medical Scheme 2017 - · PDF file3 Day-to-day benefits All out-of-hospital...
Tiger Brands Medical Scheme Benefit and member guide
2018
1
Chronic Medicine Benefit
Unlimited PMB CDL-ChronicMedication
Annual Routine Care Benefit (ARCB) for day-to-day
expenses
GP and Specialist consultationsAcute medication, Radiology & pathology, Basic & specialised
dentistry & optometry
Hospitalisation (major medical expenses)
Unlimited cover in private hospital of choice
Unlimited cover for Prescribed
Minimum Benefits
Tiger Brands Medical SchemeTiger Brands Medical Scheme is an affordable scheme which offers four options. Three options with traditional benefits, Level A, B and C and Mzansi which offers medical cover through a Network environment
1
Why Tiger Brands Medical Scheme? Members choice to select an option cover that suits their pocket and their medical needs Generous day-to-day benefits (Annual Routine Care Benefit) Separate chronic medicine benefit Freedom of choice in service provider selection Unlimited overall annual benefit A wellness benefit - including flu vaccines and mammograms
AbbreviationsPMB Prescribed Minimum Benefit
ARCB Annual Routine Care BenefitMRP Medicine Reference Price
MMAP Maximum Medical Aid PriceCDL Chronic Disease List
*Scheme Rate Scheme rate 2017 + 5.7% or **Agreed TariffSAOA South African Opthalmology Association
Auxiliary services Associated Medical Services e.g. speech therapyTBMS Tiger Brands Medical Scheme
* Scheme rate: the rules of the Scheme make provision for benefits to be paid at a specific tariff, or rate, known as the Scheme rate. This Scheme rate is in line with the industry benchmark tariff.
** Agreed tariff: this is a rate negotiated between the Scheme and certain health care providers.
2
3
Day-to-day benefitsAll out-of-hospital day-to-day claims, except for authorised chronic medicine, are paid at 100% of the Scheme Rate from the Annual Routine Care Benefit (ARCB). The ARCB limit is based on the level selected. All annual limits specified in this section, are pro-rated if membership commences during the year.
Annual Routine Care Benefit (ARCB)Level A Level B Level C
Member R 14 200 R 10 800 R 7 200Member + 1 R 22 600 R 16 900 R 11 600Member + 2 R 25 300 R 18 600 R 12 600Member + 3 R 27 600 R 20 400 R 13 500
Thereafter add* R 2 400 R 1 800 R 900
* Add this amount to the Member + 3 amount for each additional dependant
The following benefits are payable from the ARCB; subject to specified sub-limits for:
Optical Acute medicine Appliances Radiology Pathology Physiotherapy
Day-to-day services payable from the ARCB, unless otherwise specified
BENEFITS LIMITSConsultations
GP consultations 100% of Scheme rateSpecialist consultations* 100% of Scheme rate
* Subject to specialist authorisation (Pg 7)
Specialist referral and authorisation processMembers and their beneficiaries are required to obtain a referral from a GP before going to a specialist for a consultation and treatment. This is only for out-of-hospital consultations.The benefits of this initiative are as follows: It ensures that your GP is in control of your healthcare, co-ordinates your health care and has a
holistic view of your health. It ensures that only appropriate, complex cases are referred to specialists for treatment. It ensures that referral to the correct type of specialist takes place.
The authorisation process will support the process that is used by your GP. When you obtain the referral letter from your GP, the referral letter should be submitted to Universal Health. Based on the referral letter, an authorisation will be created in the administration system. If a referral has been obtained the claim will be paid, subject to limits and the scheme rate.
The referral letter can be submitted via: E-mail to [email protected]; Fax to 086 503 8038; The call centre on 0800 002 636.
4
The authorisation will be:
Granted for a period of three months in order to give the member a chance to obtain an appointment with a specialist.
Limited to one consultation. For the speciality and not a particular specialist.
The following will be excluded from the specialist authorisation requirement process:
1. One gynaecologist visit per female, over the age of 16, per annum;2. One urologist visit per male beneficiary, over the age of 40, per annum;3. Paediatrician consultations for children under the age of 3;4. Pregnancies;5. Oncology (will be approved as part of the oncology management programme).6. Ophthalmologist 7. Orthodontists
5
BENEFITS LEVEL A LEVEL B LEVEL C COMMENTOptical
Eye test One per beneficiary, per annumPer beneficiary at
IsoLeso Optometrist; FramesLensXtend
R 900R 1 500
R 820R 1 270
R 740R 1 060
Lenses: Single vision OR Bi-focal OR Multi-focal OR
One set of lenses every 24 months per beneficiary
Members can either have glasses or contact
lenses, not both
Contacts R 3 200 R 2 980 R 2 770 Per annum
Radial KeratotomyARCB R 6 000 R 6 000 R 6 000 Per familyHospital benefit R 6 000 R 6 000 R 6 000 Per family
AppliancesExternal fixator R 18 040 R 18 040 R 18 040BP Monitor R 780 R 780 R 780Glucometer R 780 R 780 R 780Humidifier R 340 R 340 R 340Nebulizer R 1 240 R 1 240 R 1 240Elastic stocking R 900 R 900 R 900Foot arch support 3 810 R 3 810 R 3 810Elbow crutch R 440 R 440 R 440CPAP machine R 11 990 R 11 990 R 11 990Foam walker R 2 240 R 2 240 R 2 240Walker R 390 R 390 R 390Braces & Calliper R 780 R 780 R 780Commode R 1 240 R 1 240 R 1 240Stocking (thigh) R 900 R 900 R 900Anti-embolic stocking R900 R 900 R 900Sling clavicle brace R 220 R 220 R 220Wig R 2 360 R 2 360 R 2 360Bra R 1 560 R 1 560 R 1 560
Medicine
1. Pharmacy Advised Therapy R 180 R 170 R 160Per Script
Subject to acute medicine sub-limit
2. Acute
MRPMemberMember + 1Member + 2Member + 3
R 3 700R 5 800R 7 200R 8 900
R 2 600R 4 200R 4 700R 5 100
R 1 600R 2 600R 2 900R 3 100
3. Oral contraceptives and devices - female R 1 430 R 1 430 R 1 430Per beneficiary Subject to acute
medicine sub-limit
Dentistry
Basic dentistry 100% 100% 100% of Scheme rate
Specialised dentistry Limited to R 9 500 per beneficiary and R 20 100 per family of Scheme rate
Mental health, (including substance abuse) (Out-of-hospital consultations visits)
Clinical psychologist 100% 100% 100% of Scheme rate
Psychiatry 100% 100% 100% of Scheme rate
6
BENEFITS LEVEL A LEVEL B LEVEL C COMMENTRadiology
Basic Radiology R 3 300 R 2 500 R 1 700 Per beneficiary
Pathology
Basic Pathology R 3 300 R 2 500 R 1 700 Per beneficiary
Physiotherapy
Physiotherapy (in-and-out-of hospital Sub limit)
Combined sub-limit with in-hospital
MemberMember + 1Member + 2Member + 3
R 4 330R 6 240R 7 720R 8 980
R 3 300R 4 700R 5 700R 6 700
R 2 100R 3 200R 3 800R 4 400
Other benefits
HIV/AIDS 100% of Scheme rate, subject to registration with Universal Care HIV/AIDS Disease Management Programme
Ante-natal classes R110 per class, maximum of ten classes per member family
Hospital emergency room/casualty emergency visits (not requiring admissions, excluding facility fees)
100% of Scheme rate
Auxiliary services (e.g. speech therapists, social workers and physiotherapists) 100% of Scheme rate
Maternity Consultations Consultations 100% of Scheme rate;Scans limited to two 2D scans per pregnancy.
Chronic Medicine BenefitThe Scheme offers a separate Chronic Medicine Benefit. Once the Chronic Medicine Benefit is depleted, your chronic medication will be paid from the ARCB, subject to available benefits. Once the ARCB benefit is depleted, payment of PMB medication by the Scheme is unlimited.
Beneficiaries must apply for authorisation for chronic medication benefits by submitting a prescription to [email protected] or can contact 0860 102 312.
Please note with any changes to your chronic medicine, even if it is just the dosage, you need to update the authorisation.
The Scheme covers all the PMBs as well as other conditions, as listed below, from the Chronic Medicine Benefit.
Chronic medicineSubject to approval on the Chronic Medicine
Programme
Level A Level B Level C
R 8 500 per beneficiary
R 7 200 per beneficiary
R 5 900 per beneficiary
Biological medicine Limited to R 160 100 per family; Scheme approval required
7
Prescribed minimum benefits (PMB)Tiger Brands Medical Scheme offers extensive cover for the 27 listed PMB Chronic Disease List (CDL) conditions below. These conditions are legislated.
Chronic medication is subject to the basic formulary and reference pricing. A 20% co-payment is payable for the voluntary use of non-formulary medicines
All registered PMB CDL chronic medication is unlimited. Once the ARCB limit is reached, the Scheme will continue to pay PMB CDL medicines.
Addisons disease Crohns disease Hyperlipidaemia
Asthma Diabetes mellitus type 1 & 2 Hypothyroidism
Bipolar mood disorder Diabetes insipidus Multiple sclerosis
Bronchiectasis Dysrhythmias Parkinsons disease
Cardiac failure Epilepsy Rheumatoid arthritis
Chronic renal disease Glaucoma Schizophrenia
Chronic obstructive pulmonary disorder Haemophilia Systemic lupus erythematosus
Cardiomyopathy disease HIV Ulcerative colitis
Coronary artery disease Hypertension
Cover for non-PMB chronic conditionsTiger Brands Medical Scheme also offers cover for chronic conditions on Level A and B respectively. Chr