Brochure 2012

AD

DESIGN

INTRO

Welcome to Pro Sano

Medical Cover Made Easy

At Pro Sano Medical Scheme we don’t believe in over-complicating medical cover and we have ensured that we keep things simple and easy for our members to understand. That is why we pride ourselves as being the No nonsense. Just healthcare solution. We offer affordable, quality medical cover to suit your lifestyle and budget, ranging from hospital benefits to fully comprehensive cover.

Why Choose Pro Sano

We have been around since 1976, so we know healthcare better than most. Our strength lies in our people and the members we serve. We have a high claims paying ability ensuring our members the best service. Over the years we have forged strong relationships with our service providers so that our members have access to the very best in healthcare, at affordable rates.

Our Products

ProElite A comprehensive option, ideal for the busy corporate lifestyle, offering you extensive cover in-hospital and out-of-hospital. It has generous benefits paid from risk as well as the flexibility of a medical savings account for further peace of mind.

ProClassic

A comprehensive family option with generous limits in-hospital and out-of-hospital as well as a medical savings account for day-to-day expenses.

ProViderAn affordable option ideal for young families and individuals, offering essential in-hospital and out-of-hospital cover.

ProVision An extended hospital plan ideal for individuals catering for emergency care and hopitalisation. It also offers out-of-hospital maternity benefits.

ProCedure A low cost option ideal for groups or healthy individuals who don’t mind utilising a network of pre-selected service providers.

Pro Sano 2 Pro Sano 3

INTROINTRO

Member Information

CARD SAFETY

Please look after your Medical Scheme Card and DO NOT lend it to anyone other than your registered dependants. Fraudulent use of cards leads directly to increased costs for all members of the Scheme. You may apply to the Scheme in writing for a 2nd Membership Card.

ON-LINE QUERY FACILITY

The website online facility enables members access to extensive information such as claims submissions, payments and member updates. To gain access to the above facilities you will need to apply for a PIN number which can be easily done by filling in the details as requested on the website. We would urge you to make use of the above facility which will cut down on telephone costs and time spent making enquiries.

HOW TO REGISTER ON THE PRO SANO WEBSITE

Log on to www.prosano.co.za Click on “Register” Choose “Register now” under the heading Member Registration Follow the prompts and complete the options available to you for registration

ELECTRONIC FUND TRANSFERS

Should you wish to transfer your monthly contributions or any amount owing directly into the Scheme’s bank account, the following details apply:

Bank | Nedbank Account Name | Pro Sano Medical Scheme Account Number | 1009-459-007 Branch Code | 1009-09-00 Reference | (Your medical scheme number)

Please fax a copy of the deposit slip as proof of payment to (021) 957-8650.

Alternatively, should you wish to have your monthly contributions or any amount owing to the Scheme, deducted from your banking account, please contact the Scheme to request a DEBIT ORDER INSTRUCTION FORM. Should you wish to have any refunds due to you to also be deposited into your banking account, please contact the Scheme.

The Scheme encourages you to have your banking details loaded to avoid fraud and to facilitate payments to you. The following is required to have your details loaded:

Copy of ID document. A certified copy of your bank statement, an original cancelled cheque, or a stamped letter from

your banking institution confirming your bank details. Written notification from the principal member to change/load the bank details. If the bank account holder is not the principal member, then specific permission from the bank

account holder in addition to the member’s specific authority to use that account is also required.

THE SCHEME DOES NOT ISSUE CHEQUES FOR ANY REFUNDS TO MEMBERS.

In order to minimise risk, the Scheme only does refunds via EFT (Electronic Fund Transfers).

CLAIM STATEMENTS

Statements are generated and posted monthly, and are only generated for members who have had a claim processed during that particular month. If a member has no claims for a

particular month, no statement will be generated. However, members who have notified the Scheme of their cell phone numbers, fax number, e-mail address etc. will receive an SMS or e-mail claim notification for every claim received by the Scheme for processing.


INTRO INTRO

HOW TO SUBMIT YOUR ACCOUNTS

Please mail your first account as quickly as possible to Pro Sano Medical Scheme, Private Bag X97, BELLVILLE, 7535 so that the account can be processed promptly.

If you have already paid an account please attach your receipt and clearly mark the account“PAID”.

However, please do not submit accounts marked “FOR YOUR INFORMATION ONLY” or similar phrases. Such accounts are for your records, and should be used to check against payments onyour Member Transaction Statement.

The Medical Schemes Act requires that the supplier of service provides the following details ontheir accounts - as per the account checklist below:

The member’s and patient’s name and initials and date of birth The member’s medical aid number Date and type of service or supplier provided Amount charged for service or supplies provided Tariff code where applicable ICD10 code Verification by the member that the service was provided (Member’s signature required)

BENEFITS WILL BE PRO RATED IN THE EVENT THAT YOU CHANGE YOUR SCHEME/OPTION DURING A FINANCIAL YEAR.

Members and/or dependants who are admitted during the course of a financial year are entitled to the benefits set out in the relevant benefit option chosen, with the maximum benefits being adjusted in proportion to the period of membership.

TIPS FOR CLAIMING

Do not send in an account showing only a balance brought forward. We cannot process such amounts without the details shown on the check-list.

Please ensure that prescriptions for medicines have all the check-list details shown on them. The service provider often omits some of these details and we are therefore unable to processyour claim.

Please wait until you receive your Member Claims Statement before following up any unpaid accounts with the Scheme. Please refer to the Member Claims Statement for an explanation of these rejection codes.

VISITING A SPECIALIST

Treatment by a specialist EXCEPT a Gynaecologist or an Opthalmologist must be supported by another Doctor’s referral.

SPECIALIST REFERRAL MANAGEMENT SYSTEM

Our designated network of GP’s are dedicated to promoting quality care to our members. Your designated GP will receive an authorisation number from the Scheme for you to visit your specialist by using our innovative information system. Members should remind their GP’s to obtain an authorisation from the Scheme. This rule will apply to all specialist visits whether you make use of the network GP’s or not. Remember to contact your designated GP to create a new authorisation if one specialist refers you to another specialist.

CHRONIC AUTHORISATIONS

The pharmacy or Doctor calls the Scheme. The pharmacist loads information, applies Scheme Rules and discusses with service provider. The member faxes or e-mails prescription. Documents scanned and captured in the system. The pharmacist loads and vets script, applies Scheme’s Rules and corresponds with patient/doctor. Chronic authorisation gets generated and sent to both member and doctor. The approval will only be valid for 6 months.


INTRO INTRO

CHANGE OF CONTACT DETAILS

Please inform the Scheme IMMEDIATELY of any change of:

Address E-Mail Address Tel. No. Home & Office Fax No. Cell No. Bank Details

NEW DEPENDANTS

Please register any new dependant(s) within 30 days using the prescribed form, obtainable from your employer, from our office or downloadable from our website. No benefits can be granted until a dependant is registered. Ensure that your supplier of medical service quotes the patient’s name and date of birth as it appears on your membership card.

PROBABY

ProBaby is an exciting maternity programme that is available to expectant mothers on the ProElite, ProClassic, ProVider and ProVision options. The programme provides you with valuable support and information throughout your pregnancy. On registering with ProBaby you will receive a diaper bag filled with baby goodies and a pregnancy book which covers topics crucial to you and your baby’s health. Registered ProBaby members have 24-hour access to the baby advice line, where expectant mothers can talk to a midwife regarding any concerns or queries she may have during her pregnancy.

ProElite

ProClassic

ProVider

ProVision

ProCedure

NEXT


ProElite A comprehensive option, ideal for the busy corporate lifestyle, offering you extensive cover in-hospital and out-of-hospital. It has generous benefits paid from risk as well as the flexibility of a medical savings account for further peace of mind.

Hospitalisation

Dental Specialist and Dentists

Specialised Radiology

HIV and AIDS

Oncology

Ambulance Services

Radiology

Physiotherapy & Bio Kinetics

Pathology

Medical & Surgical Appliances

Prostheses

Oxygen & Home Ventilation

Renal Dialysis

Organ Transplants

Specialists and General Practitioners

Accommodation, Theatres & Medication

Alternative to Hospitalisation

Alcoholism, Drug Dependency and Mental Health at 100% of Pro Sano tariffs

Dental Procedures Up to 100% of Pro Sano Dental Tariff

At 100% of Pro Sano tariffs for MRI, CAT, Isotopes & Angiography (In & out of hospital)

Up to 100% of Pro Sano tariffs

100% of cost

At 100% of Pro Sano tariffs for General Radiology

At 100% of Pro Sano tariffs


At 100% of cost

At 100% of cost

Internal

External

Hearing Aids

Cochlear Implants



100% of Pro Sano tariffs

Consultations & Visits Up to 200% of Pro Sano tariffs in hospital

Maternity: Delivery Up to 200% of Pro Sano tariffs in hospital

Operations and Procedures Up to 200% of Pro Sano tariffs in hospital

Unlimited subject to pre-authorisation. Medicines at SEP. Take home medicines = 7days supply.

Unlimited subject to pre-authorisation.

Accommodation at a registered facility and subject to DSP, managed care protocols and PMB requirements. Mental Health, 21 days in-patient care or 15 contacts out patient care, per beneficiary per annum. Non-PMB care limited to R7 000 per family per annum.

Unlimited subject to pre-authorisation and managed care protocols.

Subject to pre-authorisation and clinical protocols. R15 000 per family per annum and a separate limit of R10 000 per family per annum for angiograms.

Unlimited subject to pre-authorisation, PMB and managed care programme.

Subject to DSP and managed care protocols. Limited to R250 000 per family per annum.

Subject to pre-authorisation and managed care service provider protocols.

R5 000 per family per annum.

Unlimited subject to specialist motivation.

Unlimited subject to managed care protocols.

From available funds in MSA.

Subject to pre-authorisation and prosthetic benefit limits.

R50 000 per beneficiary per annum.


R10 000 per family. One hearing aid payable over a two year period.


Subject to pre-authorisation.

Subject to pre-authorisation and PMB.

Subject to pre-authorisation, PMB and case management.

Unlimited subject to pre-authorisation and managed care protocols.



Overall Annual Limit Unlimited

IN HOSPITAL BENEFITS

CATEGORY BENEFIT LIMIT PER CATEGORY

Specialists

Alcoholism, Drug Dependency and Mental Health

Radiology

Pathology

Screening Benefit

Alternative Health Care

Allied Health Practitioners (Physiotherapy, Bio Kinetics, Occupational Therapy, Speech Therapy)

Medicines At SEP plus negotiated dispensing fee.

Optical

Maternity

Dentistry

General Practitioner

Non-surgical Procedures and Tests

Consultations or visits At 100% of Pro Sano tariffs


At 100% of Pro Sano tariffs for General Radiology




Trauma and Rehabilitative services at 100% of Pro Sano tariffs

Other consultations and services

Acute

Over the Counter

Chronic: Medication plus Consultation


Eye test

Single vision lenses

Bifocal lenses

Multifocal lenses

Frames

Contact lens materials in lieu of frames and lenses

At 100% of Pro Sano tariffs for Ante-natal Consultations

At 100% of Pro Sano tariffs Post-natal Consultations

At 100% of Pro Sano tariffs Ultrasound Scans

At 100% of Pro Sano Dental tariff

Basic

Specialised

Consultations or visits At 100% of Pro Sano tariff


Specialist visits are paid for from available funds in MSA.

Refer to hospitalisation.



One blood pressure, blood glucose and cholesterol screening test per beneficiary per annum by a GP, registered nurse or pharmacist.


10 sessions per family per annum.




Unlimited for the prescribed chronic conditions. 30% co-payment for voluntary use of non-formulary medicines.

Comprehensive cover per beneficiary, every two years and subject to managed care protocols.

R330

R180

R495

R750

R1 000

R1 650

10 ante-natal consultations per pregnancy.

2 post-natal consultations with midwife per pregnancy.

2 x 2D scans per pregnancy.

Subject to managed care protocols.

From available funds in MSA subject to managed care protocols.

Subject to pre-authorisation R5 000 per family per annum.

M - 8 visits M+1 - 12 visits M2+ - 15 visits

Limited to annual benefit of:M - R4 500 M1+ - R6 500

OUT OF HOSPITAL BENEFITS


PMB = Prescribed Minimum BenefitsDSP = Designated Service Provider

GP = General PractitionerDGPs = Designated General Practitioners

Please Note: SEP = Single Exit PriceMSA = Medical Savings Account

Member

Adult

Child (max 3)

R2 256

R1 947

R597

R468

R399

R129

R2 724

R2 346

R726

R5 616

R4 788

R1 548

RISK MSA TOTAL CONTRIBUTION

ANNUAL MEDICALSAVINGS


ProElite option 2012In addition to the 26 Prescribed Minimum Benefit Chronic Conditions the following 18 conditions will also be covered.

1. Acne.2. Allergic Rhinitis.3. Attention Deficit Disorder.4. Depression.5. Dermatomyositis.6. Eczema.7. Gastro-Oesaphageal Reflux (GORD).8. Gout.9. Hepatitis (Viral and Automune).10. Menopause.11. Narcolepsy.12. Obsessive Compulsive Disorder.13. Panic Disorder.14. Post Traumatic Stress Syndrome.15. Sinusitis.16. Tourette’s Syndrome.17. Valvular Heart Disease.18. Zollinger – Ellison Syndrome.

NEXT

ProClassic

ProVider

ProVision

ProCedure


PROCLASSIC

TABLE

ProClassic A comprehensive family option with generous limits in-hospital and out-of-hospital as well as a medical savings account for day-to-day expenses.

Hospitalisation


Oncology

Pathology

Ambulance Services

Renal Dialysis

Maxillofacial & Oral Surgery

Dental Procedures



Blood & Blood Products

HIV and AIDS

Organ Transplants

Prostheses

Specialists and General Practitioners services in the hospital or clinic. Excluding services in the Emergency rooms of Private hospitals.

Radiology

Accommodation and Theatres

Medication: Acute To take out


Alcoholism, Drug Dependency and Mental Health at 100% of Pro Sano tariffs.




At 100% of cost



At 100% of Pro Sano Dental tariff

At 100% of cost

At 100% of cost

At 100% of cost


At 100% of cost

Internal (Excluding drug eluting stents)

External

Cochlear Implants and Hearing aids.

Consultations & Visits in hospital At 100% of Pro Sano tariffs

Maternity: Delivery At 100% of Pro Sano tariffs

Operations and Procedures At 100% of Pro Sano tariffs


At 100% of Pro Sano tariffs for MRI, CAT, Isotopes & Angiography

Subject to pre-authorisation and referral protocols. A co-payment of R500 per hospital admission will be payable in the event of a hospital admission following a specialist visit which was not referred by a GP. For endoscopic procedures that are normally performed in the specialist’s rooms, if performed in-hospital a R500 co-payment will apply.

Unlimited. 7 days supply.

R13 850 per family subject to pre-authorisation.

Accommodation at a registered facility and subject to DSP, managed care protocols and PMB requirements. Mental Health, 21 days in-patient care or 15 contacts out patient care, per beneficiary. Non-PMB care limited to R7 000 per family per annum.

Subject to pre-authorisation and managed care protocols. M R1 100 M+1+ R2 200 In & out of hospital.

Subject to PMB’s, pre-authorisation, case management and DSP. Non-PMB care limited to R80 000 per family per annum.

Subject to management protocols. Limited to R5 000 per family per annum.

Subject to DSP pre-authorisation and protocols.

Subject to pre-authorisation, PMB and managed care protocols.

Subject to pre-authorisation and dental management protocols.


R2 300 per family per annum in & out of hospital.






Subject to an annual limit of R40 000 per family per annum.

R4 620 per beneficiary per annum.

Subject to : Cochlear implants - R110 000 per family per annum and Hearing aids R11 000 per family per three year cycle.

Subject to authorisation and referral protocols.


Subject to pre-authorisation and GP referral protocols.

R3,300 limit per family per annum.

Subject to pre-authorisation and clinical protocols. R13 500 per family for specialised radiology and a separate limit of R9 500 per family for angiography. In & out of hospital.

Overall Annual Limit No overall annual limit



Specialists

Alcoholism, Drug Dependency and Mental Health

Pathology

Radiology

Occupational, Speech Therapy and Audiology

Medicines

Screening benefit

Alternative Healthcare Practitioners

Procedures and Tests

Remedial Therapies

Optical

Dental Procedures

Maternity


Consultations at 100% of Pro Sano tariffs



At 100% of Pro Sano tariffs for general radiology.


At SEP plus negotiated dispensing feeAcute and over the counter medicines

Chronic, including consultation fee upon first registration




At 100% of Pro Sano tariffs for Homeopaths, Dieticians, Chiropractitioners and other registered supplementary service providers


Eye test


Bifocal lenses

Multifocal lenses

Frames


At 100% of Pro Sano Dental Tariff.

At 100% of Pro Sano tariffs Ante-natal consultationsPost-natal consultations Ultrasound scans

Consultations at 100% of Pro Sano tariffs

Specialist visits must be authorised. If authorised, R120 will be paid from the risk benefit and the balance from savings.


Subject to DSP management programme. Single member R2 200 and Family R3 300.

Subject to DSP management programme. Single member R2 200 and Family R3 300.

Limited to: M R2 060, M+1 R3 150, M+2 R3 630, M+3 R3 880 and M4+ R4 120

Paid from available savings benefit.

As per PMB’s and selected list of chronic conditions and formulary: M- R7,800, M1+ R15,400 Further limited to R7,800 per beneficiary. 30% co-payment on voluntary use of all non-formulary medicines.

One blood pressure, blood glucose and cholesterol screening test per beneficiary per annum.


Single member R3 500 and Family R5 700.



R330

R180

R495

R750

R650

R1 350

Subject to Dental management programme. Basic dentistry R3 250 per family per annum. Specialised dentistry R4 050 per family per annum.

10 ante-natal consultations per pregnancy. 2 post-natal consultations with midwife per pregnancy. 2 x 2D scans per pregnancy.

Consultations are payable from the savings accounts. By using a Pro Sano designated doctor, R120 of the consultation fee will be paid from the risk benefit and only the balance of the consultation fee will be paid from the savings benefit.



PMB = Prescribed Minimum BenefitsDSP = Designated Service Provider

GP = General PractitionerDGPs = Designated General Practitioners

Please Note: SEP = Single Exit PriceMSA = Medical Savings Account

Member

Adult

Child (max 2)

R1 857

R1 596

R456

R207

R177

R54

R2 064

R1 773

R510

R2 484

R2 124

R648

RISK MSA TOTAL CONTRIBUTION

ANNUAL MEDICALSAVINGS


ProClassic option 2012In addition to the 26 Prescribed Minimum Benefit Chronic Conditions the following 39 conditions will also be covered

1. Alzheimer disease (early onset). 2. Angina. 3. Ankylosing Spondylitis.4. Attention Deficit Disorder. 5. Barrett’s Oesophagus.6. Benigen Prostatic hypertrophy. 7. Bulima Nervosa. 8. Cancer. 9. Cardiac Arrhythmias. 10. Chronic Bronchitis. 11. Cushing Syndrome.12. Cystic Fibrosis.13. Deep Vein Trombosis. 14. Depression.15. Dermatomyositis. 16. Eczema. 17. Emphysema.18. Gastro-Oeosphageal Reflux Disease. 19. Generalised Anxiety Disorder.20. Gout21. Hormone Replacement Therapy.22. Hypoparathyroidism. 23. Infective Endocarditis. 24. Ischaemic Heart Disease.25. Motor Neuron Disease.26. Obsessive Compulsive Disorder. 27. Osteoporosis.28. Paget’s Disease.

29. Panic Disorder.30. Paraplegia/Quadriplegia. 31. Polyarteritis Nodosa.32. Post Traumatic Stress Syndrome. 33. Pulmonary Interstital Fibrosis.34. Scleroderma. 35. Thromboangitis Obliterans.36. Thrombocytopaenic Purpura.37. Tourette’s Syndrome. 38. Valvular Heart Disease. 39. Zollinger-Ellison Syndrome.

NEXT

ProVider

ProVision

ProCedure


ProVider An affordable option ideal for young families and individuals, offering essential in-hospital and out-of-hospital cover.

Hospitalisation At Pro Sano Tariffs


Pathology

Renal Dialysis

HIV and AIDS

Organ Transplants

Ambulance Services

Radiology

Operations and Procedures



Maternity: Delivery

Prostheses


Specialised Radiology

Oncology

Mental Health & Alcoholism & Drug Dependency


Consultations & Visits At Pro Sano tariffs

Medication:To take out



At 100% of Pro Sano tariffs in hospital




At 100% of cost

At 100% of Pro Sano tariffs for General Radiology in hospital


At 100% of cost

At 100% of cost


At 100% of cost

Internal

External

Hearing Aids


MRI, CAT, Isotopes & Angiography



Subject to pre-authorisation and referral protocols. R500 co-payment on non-PMB elective procedures. An additional co-payment of R500 per hospital admission will also be payable in the event of a hospital admission following a specialist visit which was not referred by a GP. For endoscopic procedures that are normally performed in the specialist’s rooms, if performed in-hospital a R500 co-payment will apply.

Subject to pre-authorisation and referral protocols.

7 days supply.

R6 000 per family subject to pre-authorisation.

Subject to pre-authorisation and dental management protocols pre-authorisation and referral protocols.

Subject to DSP management protocols R3 300 per family per annum.



Unlimited subject to pre-authorisation and PMB’s.

Subject to DSP, pre-authorisation and protocols.


Subject to pre-authorisation and referral protocol.

Refer to Supplementary Health Services.




Overall limit of R25 000, including joint replacement but excluding drug eluting stents, per family.


Included in the external prosthesis benefit.

Subject to pre-authorisation and managed care protocols M R1 000 M+1 R1 200 M+2 R1 400 M3+ R1 700 In & out of hospital.

Subject to pre-authorisation and clinical protocols. R8 500 per family for specialised radiology and a separate limit of R9 000 per family for angiography, in & out of hospital.

Subject to PBM’s, pre-authorisation, case management and DSP. Non-PMB care shall be limited to R60 000 per family per annum.

21 days in-patient care or 15 contacts out patient care per beneficiary per annum at a registered facility and subject to DSP, managed care protocols and PMB requirements. Non-PMB care limited to R5 000 per family per annum.

Overall Annual Limit Subject to overall annual limit of R750 000 per family



Procedures and Tests

Maternity

Radiology and Pathology

Optical


Supplementary Health Services: Audiologist, Chiropractor etc.

Screening Benefit

Medicines


Basic Dentistry

Specialists



Post-natal Consultations

Ultrasound Scans

Subject to DSP management protocols. At 100% of Pro Sano tariffs out of hospital.


Eye test


Bifocal lenses

Multifocal lenses

Frames




At 100% Pro Sano tariffs

At 100% of the lower of SEP or Pro Sano tariff for Acute & Over the Counter

Chronic Medication plus Consultation

At 100% of Pro Sano tariffs for Consultations, visits and SEP for medicines

At 100% of Pro Sano Dental tariffs

Specialised

At 100% of Pro Sano tariffs for Consultations, visits and SEP for medicines

M R1 600M+1+ R2 500



2 x 2D Scans per pregnancy.

M R1 100M+1 R1 600


R330

R180

R495

R750

R500

R1 050


R1 200 per family.


Refer to General/Specialist benefit.

As per PMB’s and subject to pre-authorisation & formulary.30% co-payment on all voluntary use of non-formulary medicines.

For Pro Sano DGPs: The following combined limits are available at Pro Sano tariff for GPs, specialists & medicines for Pro Sano accredited GPs. M0 - R2 900M1 - R3 800 M2+ R4 800 M3+ R5 800 For non-Pro Sano DGPs: A co-payment of R100 is payable for each consultation for non-Pro Sano DGPs - subject to above limits.

Subject to pre-authorisation and managed care protocols. M R1 200M+1 R1 400M+2 R1 600M3+ R2 000

Included in Basic Dentistry.

Designated General Practitioner referrals: The above combined limits are available at Pro Sano tariff for specialists & medicines where a member is referred by aPro Sano DGP. Unauthorised referrals: A co-payment of R100 is payable for each consultation where there is no referral by the GP - subject to above limits.

OUT OF HOSPITAL BENEFITS Subject to overall annual limit of R18 000 per familyCATEGORY BENEFIT LIMIT PER CATEGORY

Please Note: PMB = Prescribed Minimum BenefitsDSP = Designated Service Provider

GP = General PractitionerDGPs = Designated General Practitioners R1 329 R894 R321

MEMBER ADULT CHILD


ProVider option 2012Below is the list of Prescribed Minimum Benefits as per the Chronic Conditions List

1. Addison’s Disease. 2. Asthma.3. Bipolar Mood Disorder. 4. Bronchiectasis.5. Cardiac Failure. 6. Cariomyopathy. 7. Chrohn’s Disease.8. Chronic Obstructive Pulmonary Disorder. 9. Chronic Renal Disease. 10. Coronary Artery Disease.11. Diabetes Insipidus. 12. Diabetes Mellitus Type 1&2.13. Dysrhytmias.

14. Epilepsy.15. Glaucoma. 16. Haemophilia.17. HIV & AIDS. 18. Hyperlipidemia.19. Hypertension. 20. Hypothyroidism.21. Multiple Sclerosis. 22. Parkinson’s Disease.23. Rheumatoid Arthritis. 24. Schizophrenia. 25. Systemic Lupus. Erythematosus. 26. Ulcerative Colitis.

NEXT

ProVision

ProCedure


ProVision An extended hospital plan ideal for individuals catering for emergency care and hopitalisation. It also offers out-of-hospital maternity benefits.

Below is the list of Prescribed Minimum Benefits as per the Chronic Conditions List

1. Addison’s Disease. 2. Asthma.3. Bipolar Mood Disorder. 4. Bronchiectasis.5. Cardiac Failure. 6. Cariomyopathy. 7. Chrohn’s Disease.8. Chronic Obstructive Pulmonary

Disorder. 9. Chronic Renal Disease. 10. Coronary Artery Disease.11. Diabetes Insipidus. 12. Diabetes Mellitus Type 1&2.13. Dysrhytmias.14. Epilepsy.15. Glaucoma. 16. Haemophilia.17. HIV & AIDS. 18. Hyperlipidemia.19. Hypertension. 20. Hypothyroidism.21. Multiple Sclerosis. 22. Parkinson’s Disease.23. Rheumatoid Arthritis. 24. Schizophrenia. 25. Systemic Lupus Erythematosus. 26. Ulcerative Colitis.

Hospitalisation

Pathology

Renal Dialysis

HIV and AIDS

Organ Transplants

Ambulance Services

Radiology

Operations and Procedures




Maternity

Prostheses


Oncology



Consultations & Visits 150% of Pro Sano tariffs

Medication:To take out





At 100% of the lower of Pro Sano tariffs


At 100% Pro Sano tariffs for General Radiology

At 100% of Pro Sano tariffs for MRI, CAT, Isotopes & Angiography

At 150% of Pro Sano tariffs for Surgical Procedures

Non-surgical Procedures and Tests

At 100% of cost

Up to 150% of Pro Sano tariffs


At 150% of Pro Sano tariffs for Delivery

At 100% of cost Internal (Excluding drug eluting stents)

External

At 100% of cost

At 100% of the lower of cost or Pro Sano tariffs


Unlimited subject to pre-authorisation. For endoscopic procedures that are normally performed in the specialist’s rooms, if performed in-hospital a R500 co-payment will apply.

Unlimited subject to pre-authorisation within 24hrs of event and managed care protocols. R2 000 per annum - for after hours crisis consultations at an out-patient facility (benefit applicable to dependants under the age of 14 years old only).

7 days supply.

R12 600 per family: Subject to pre-authorisation.




Unlimited subject to pre-authorisation and PMB’s.



Subject to pre-authorisation and clinical protocols. R12 000 per family for specialised radiology and a separate limit of R8 400 per family for angiography (in & out of hospital).


M R2 900 M+1+ R4 750 In & out of hospital.



Unlimited subject to specialist motivation.


Subject to pre-authorisation and limited to R40 000 per family per annum. Cochlear implants limited to R110 000 per family per annum. Hearing aids limited to R11 000 per family per three year cycle.

R4 200 per beneficiary.

R2 100 per family in & out of hospital.

Subject to PMB’s, pre-authorisation, case management and DSP. Limit of R80 000 for non-PMB care per family per annum.

21 days at a registered facility and subject to DSP, managed care protocols and PMB requirements or 15 contacts for out patient treatment per beneficiary per annum by a registered mental health professional. Non PMB services limited to R7 000 per family per annum.

Overall Annual Limit No overall annual limit



Maternity

Screening Benefit

Medicines


Post-natal Consultations

Ultrasound Scans

At 100% of the lower of cost or Pro Sano tariffs

At 100% of SEP for Chronic Medication plus Consultation



2 x 2D Scans per pregnancy.


As per PMB’s and subject to pre-authorisation & formulary. 30% co-payment on voluntary use of non formulary medicine.



R1 002 R870 R261

MEMBER ADULT CHILD (Max 2)

DSP = Designated Service ProviderGP = General Practitioner

DGPs = Designated General PractitionersPlease Note: SEP = Single Exit PricePMB = Prescribed Minimum Benefits


ProCedure A low cost option ideal for groups or healthy individuals who don’t mind utilising a network of pre-selected service providers.

R500 000 overall annual limit per family

Prescribed Minimum Benefits

General Ward Fees and Theatre Time

ICU and High Care Ward Fees

General Practitioner Consultations and Procedures In-hospital

Specialist Consultations and Procedures In-hospital

Oncology, Radiation and Chemotherapy

Visits and Procedures Performed by Dental Practitioners In-hospital

Diagnostic Procedures (Excluding Radiology & Pathology)

Prescribed Medication

Hospital Equipment and Consumables In-hospital

100% of Cost

100% of Agreed Tariff









Subject to contracted network facilities.

Members may be transferred to a public facility when the annual hospital limit is reached at any private facility.

At contracted network private facilities subject to hospital limit.Subject to pre-authorisation & case management.

At contracted network private facilities subject to hospital limit. Subject to pre-authorisation & case management.

At contracted network facilities subject to hospital limit. Subject to pre-authorisation, protocols & case management.

At contracted network facilities subject to hospital limit. Subject to pre-authorisation per admission, protocols & case management. Referral from primary care designated service provider required.

Subject to DSP and pre-authorisation. PMB rules apply.

Mental Health, Alcoholism and Drug dependency

100% of Agreed Tariff At contracted network facilities, subject to hospital limit, PMB rules apply.

Organ Transplantation

Dialysis (Acute & Chronic)



Neonatal Care 100% of Agreed Tariff




Hospitalisation only for trauma, children under 7 years & impacted wisdom teeth. Subject to pre-authorisation.

Hospitalisation 100% of Agreed tariff

For endoscopic procedures that are normally performed in the specialist rooms, if performed in-hospital, a R500 co-payment will apply.

An additional co-payment of R500 per hospital admission will be payable in the event of a hospital admission following an unauthorised specialist visit.

At contracted network private or state facilities subject to hospital limit.

Subject to pre-authorisation & case management. Overall limit of R500 000 per family per annum with a sub-limit of R100 000 per beneficiary per annum in private facilities, after which state-facility will apply. Subject to PMBs.

Cover for non-emergency PMB’s in contracted network facility.Subject to PMB rules. No cover for experimental procedures and clinical trials. All authorisations for non-emergency admissions require referrals from a primary designated service provider. Penalty of R1 000 will apply if non-emergencies are not pre-authorised.

At contracted network private facilities subject to pre-authorisation. Experimental diagnostic procedures excluded.

Subject to hospital limit. In a contracted network facility, in accordance with pre-authorisation per admission, including medication given in Theatre, ICU, High Care, General Wards, Day Theatre & Wards. To take out medicine for a maximum of 7 days.

At contracted network facilities subject to hospital limit.

Overall Annual Limit


IN HOSPITAL BENEFITS (continued)


Radiology (Including Specialised Radiology, MRI and CT Scans)

Pathology

Alternatives to Hospitalisation

Physiotherapy

Blood Transfusions

Emergency Ambulance Services





At contracted network facilities subject to hospital limit. Case managed and subject to sub-limit of R10 000 per family per annum. Includes ultrasound scanning at an approved network provider medical centre. 2 Ultrasounds per pregnancy according to the network provider list of approved ultrasound codes.

At contracted network private facilities subject to hospital limit. Limited to R3 000 per family per annum.

Pre-authorisation required. Limited to R5 000 per family per annum.

Subject to PMB only.

Limited to R12 000 per family per annum. Subject to hospital limit.


Burns

Internal Prosthesis

Clinical Technologists




At contracted network facilities subject to hospital limit. PMB rules apply.

Limited to R19 000 per family per annum.

Limit of R10 500 per family per annum at contracted network facilities subject to hospital limit.

Specialists

Self Medication Benefit

Chronic Medication

Acute Medication


General Practitioner Emergency Consultations outside Designated Services




100% of Single Exit Price



5 Consultations per family or R2 800 to a maximum of 3 per beneficiary or R2 000 per annum for all out-of-hospital consultations and procedures in specialists’ rooms. Authorisations only on referral from network General Practitioner. 2 Additional Gynaecologist consultations per pregnancy per family per annum.

Limited to R180 per year, maximum R60 per beneficiary per event. Subject to medication formulary at network provider only.

Subject to registration by a network provider. Approval as per medication formulary and subject to PMB.

According to a fixed network provider medicines formulary. Only medication prescribed by an approved network provider general practitioner or contracted service provider according to the network provider formulary.

Unlimited at network providers only. All visits after 8th consultation per beneficiary per year must be pre-authorised by the member/provider.

Subject to a 20% co-payment and limited to a maximum of R700 per event (including all general practitioner consultations, procedures, medication, pathology). 1 visit per beneficiary or 2 per family per annum. No benefit for facility fees. Only emergencies and after hours services. Authorisation is required from Designated Service Provider call centre within 72 hours after the visit.



Basic Dentistry 100% of Agreed Tariff Consultation examination 1 per beneficiary per annum (code 8101). Preventative treatment 1 per beneficiary per year, includes Fluoride for children under 12 years. Treatment, cleaning, scaling and polishing. Subject to case management and pre-authorisation. According to the network provider list of approved codes. Treatment follow up consultations (unlimited and managed). Fillings (white or amalgam). Pain and Sepsis. Infection Control. Oral Hygiene Instruction. Extractions. Local Anaesthetic. Intra Oral Radiograph (X-rays as per the network provider approved dental list of codes).Emergency Root Canal.

Dentures 100% of Agreed Tariff Limited to 1 set of dentures per family per 24 months cycle. Only members over the age of 21 years.Co-payment 20% of total fee. At network provider dental contracted provider and accredited dental laboratories only.


Below is the list of Prescribed Minimum Benefits as per the Chronic Conditions List

1. Addison’s Disease. 2. Asthma.3. Bipolar Mood Disorder. 4. Bronchiectasis.5. Cardiac Failure. 6. Cariomyopathy. 7. Chrohn’s Disease.

Chronic Obstructive 8. Pulmonary Disorder. 9. Chronic Renal Disease.

10. Coronary Artery Disease.11. Diabetes Insipidus. 12. Diabetes Mellitus

Type 1&2.13. Dysrhytmias.14. Epilepsy.15. Glaucoma. 16. Haemophilia.17. HIV & AIDS. 18. Hyperlipidemia.

19. Hypertension. 20. Hypothyroidism.21. Multiple Sclerosis. 22. Parkinson’s Disease.23. Rheumatoid Arthritis. 24. Schizophrenia. 25. Systemic Lupus

Erythematosus. 26. Ulcerative Colitis.

OUT OF HOSPITAL BENEFITS (continued)

Specialised Dentistry

Physiotherapy

Optical

Dieticians, Occupational Therapy, Speech Therapy, Social Workers and Allied Workers

Basic Radiology

Pathology

Maternity

HIV and AIDS








No benefit.

Pre-authorisation required. Limited to PMB’s only.

Limited to one pair of spectacles per beneficiary per every 24 months. Includes frames, lenses and eye examination.Single vision or bi-focal spectacles only. Qualifying norms for near and distance vision. Network provider only.

At contracted network private facilities subject to overall limit.Pre-authorisation required. PMB’s only.

According to the network provider list of codes listed in formulary. Black & white X-rays and soft tissue ultrasound only. Requested by a network provider general practitioner, or a specialist (subject to a prior referral by a DSPN general practitioner to the specialist only).

According to the network provider list of codes listed in formulary. Requested by a network provider general practitioner, or a specialist (subject to a prior referral by a contracted network general practitioner to the specialist only).

Ante-natal and follow up post-natal care at general practitioners. Referral to specialists subject to referral by contracted network provider and subject to pre-authorisation. 2 Specialist gynaecologists consultations per pregnancy. Referral to specialists subject to referral by contracted network provider and subject to pre-authorisation.

Unlimited. Contracted network provider only. No cover in respect of lost or destroyed medication. Treatment subject to registration on the HIV and AIDS Programme and treatment according to an evidence based treatment protocol and medicine formulary.

Pro Sano Dental Benefits 2012Dental benefits are paid at the Pro Sano Dental Tariff (PDT) subject to the available financial limit. Hospitalisation and certain specialised dentistry procedures must be pre-authorised. 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.

Please Note: PMB = Prescribed Minimum BenefitsDSPB = Designated Service Provider Benefits

R0 – R5 000

R5 001 – R8 000

R8 000 +

R570

R642

R903

R456

R555

R789

R255

R309

R396

INCOME MEMBER ADULT CHILD

ProElite Benefit for Conservative Dentistry Limit Dentistry is only available for the treatment according to specified Dental codes. Specialised Dentistry limit of R5 000 per family per annum.

ProClassic

Conservative Dentistry Limit of R3 250 per family per annum. Specialised Dentistry Limit of R4 050 per family per annum.

ProViderCombined Conservative and Specialised Dental LimitM R1 200 M+1 R1 400M+2 R1 600 M+3 R2 000

ProVisionNo benefit

Additional Dental exclusions:

Electrognathographic recordings, pantographic recordings and other such electronic analyses Nutritional and tobacco counselling Caries susceptibility and microbiological tests Pulp tests Cost of Mineral Trioxide Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments Appointment not kept Special report Dental testimony including Dento-legal fees Treatment plan completed (currently code 8120) Enamel microabrasion Behaviour management Intramuscular or subcutaneous injection Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures


Frequently Asked Questions

Must I disclose full details of any pre-existing conditions that I may have been treated for in the past?

Yes, it is imperative that full details of ANY pre-existing conditions, irrespective of when they occurred, are disclosed on your application for membership. It is important to note that your application for membership is deemed a contract between you and the Scheme, and therefore you must ensure that all information provided is as detailed as possible, and is true and correct at the time of signing the application form. A Scheme may, in terms of the Medical Schemes Act and the Rules of the Scheme, exclude pre-existing conditions from benefits for a period of time (up to a maximum of 12 months) or terminate the membership of a member should the Scheme be in a position to prove material misrepresentation and/or non-disclosure of factual information. The same applies to registration forms for dependant membership.

Please ensure that your membership application and/or dependant registration form is signed and dated, as the Scheme is unable to accept an application/registration which does not have a signature and/or a signed date.

Which of my dependants can be registered on the Scheme, how soon should I register them and from when will the extra contributions be charged?

A spouse or partner – the member must be able to demonstrate that they are married to the person in terms of any law or custom, or alternatively that they are in a committed and serious relationship based on mutual dependency and shared and common household, irrespective of the gender of either party. A dependent child, including a step-child, legally adopted child, or a child placed in the custody of the member or his spouse (or registered partner) by a court of law or a state institution. Children over the age of 21 will pay adult rates from the month after they turn 21, unless they are studying. Student children will pay adult rates from the month after they turn 27. The immediate family members, namely father, mother, brother or sister of the member, for whom the member is financially responsible for family care and support. (Eligibility of immediate family members is reviewed annually.)

Should the member apply to the Scheme for registration of the aforementioned beneficiaries more than 30 days after they become eligible for dependant membership, the Scheme

reserves the right to apply underwriting conditions/waiting periods in accordance with the Medical Schemes Act and the registered Rules of the Scheme.

Contributions for newborn babies, born on any day other than the 1st of the month, will be raised with effect from the month following that of the birth. This also applies to the registration of a spouse, where the date of marriage falls on any day other than the 1st of the month (kindly note that this only applies if the application for beneficiary membership is sent to the Scheme within 30 days of the date of birth/marriage). Please read this paragraph in conjunction with the previous paragraph.

General Scheme Exclusions

The following services and items are excluded from benefits with regard to Prescribed Minimum Benefits (PMBs) and will not be paid for by the Scheme.

1. All costs in respect of injuries arising from professional sport, speed contests and speed trials,except PMB’s.

2. All costs for operations, medicines, treatment and procedures for cosmetic purposes.3. All costs for operations, medicine, treatment and procedures for: Obesity. Sex change. Otoplasty. Blepharoplasty. Refractive Surgery. Any treatment associated with that of a surrogate pregnancy. Reversal of sterilisation procedures.4. Holidays for recuperative purposes.5. Purchase of: Non-prescribed medicines except as indicated in the relevant benefit schedule and

proprietary preparations; Applicators, toiletries and beauty preparations; Bandages, cotton wool and other consumable items; Patented foods, including baby foods; Tonics, slimming preparations and drugs as advertised to

the public; and Household and biochemical remedies.6. Persons not registered with a recognised

professional body constituted in terms of an Act of Parliament; or

7. Any institution, nursing home or similar institution except a state or provincial hospital not registered in terms of any law.

For a comprehensive list of exclusions please refer to our website: www.prosano.co.za or contact our Customer Services on 0860 109 558

Frequently Asked Questions


FAQ’S FAQ’S

It is important to note that the Scheme’s Rules do not make provision for third generation dependants to be registered, unless they meet the criteria as set for a dependent child noted previously.

It is the member’s responsibility to inform the Scheme of any changes which result in any of their registered beneficiaries no longer satisfying the conditions in terms of which they may be a dependant within 30 days of the occurrence.

I have changed options, and my new option does not offer a savings benefit. What happens to any unused, accumulated savings on my old option?

You are entitled to claim this unused, accumulated savings benefit from the Scheme. If the member’s medical savings benefit was fully utilised at the time of the option change, then no refund will be due. It is also possible that a member may have over-utilised the savings benefit if they opt to change options or resign from the Scheme during a benefit year. This over-utilised savings benefit will then have to be re-paid to the Scheme.

The same principal applies to members who resign from the Scheme and they are not joining or planning to join another Scheme that offers a savings benefit. If the new Scheme does however offer a medical savings benefit, then members are lawfully required to have the unused, accumulated savings transferred to the new Scheme.

Members can contact Customer Services on 0860 109 558 or email us at [email protected] to enquire in this regard should they be unsure if they qualify for a savings refund once they have changed options or resigned from the Scheme.

What are the requirements should I wish to terminate my membership?

In terms of the Rules of the Scheme, membership may be voluntarily terminated upon giving the Scheme one calendar months written notice. This written notice must include the reason for termination and can be emailed/faxed/posted to the Scheme at the following contact details:Email: [email protected]: 021 957 8650Post: Private Bag X97, Bellville, 7535

What is Pre-Authorisation?

Pre-authorisation is the pre-approval of any booked admission to a hospital, including the relevant treatment and/or procedure by a registered practitioner. All treating providers (GP, Specialist, Physiotherapist, etc.) during the hospital event need to be pre-authorised. In order to ensure that the Scheme approves the appropriate number of days for the hospital event, members must be aware that the service providers must provide the Scheme with all relevant clinical updates in good time. Details of the pre-booked procedures will only be released to the member or nearest relative, as the Scheme must ensure that they are aware of the various disclaimers, Scheme exclusions/prosthesis limits.

MRI and CT scans, as well as radio isotopes studies, must also be pre-authorised – for both in and out of hospital procedures.

Pre-authorisation should be obtained by the member or the dependant only.1. The member number, dependant code and the date of birth of the person being admitted.2. Admitting and treating doctor’s name and practice number.3. The name and practice number of the hospital, clinic or radiologist.4. Date of the admission and the date of the operation or procedure.

ICD 10 code and the procedure or tariff code/s, obtained from the doctor.

Are organ transplants covered?

Yes, organ transplants are covered to a maximum of R150,000.00 in a private hospital and at 100% of cost at a state facility (subject to PMB).

What is PMB?

Prescribed Minimum Benefits (PMB) is the minimum benefits that the Scheme is obliged to pay as per legislation. PMB’s are defined by specific diagnosis and treatment categories.

What is covered from the Oncology Benefit?

The Scheme only covers Chemotherapy and Radiotherapy from the Oncology benefit. Please note that once a member is diagnosed with cancer, they must register on the Scheme’s oncology program. Pro Sano has a Designated Service Provider (DSP) for all oncology treatments, namely ICON. All Pro Sano members must make use of ICON doctors for their oncology treatment.


Pro Sano contact details

PRO SANO PARK Block BCarl Cronje DriveTyger WaterfrontTYGERVALLEY7530

SCHEME POSTAL ADDRESSPro Sano Medical SchemePrivate Bag X97BELLVILLE7535

CUSTOMER SERVICESTel: 0860 109 558Fax: 021 957 8650E-mail: [email protected]

CHRONIC MEDICATIONTel: 0861 888 102 (Doctor)Tel: 0861 888 107 (Member)Fax: 021 672 1041E-mail: [email protected]

CHRONIC MEDICATION DELIVERY CLICKS DIRECT MEDICINES Tel: 011 997 3000 Tel: 0861 444 405 (Medication Orders) Tel: 0861 444 407 (Account Queries) Fax: 0861 444 414 E-mail: [email protected]

PHARMACY DIRECT Tel: 0860 027 800 Fax: 0866 114 000/1/2/3 or 012 643-3040 E-mail: [email protected]

DENTAL BENEFITTel: 021 528 5300 (Office)Tel: 0860 104 935Fax: 0866 770 336

DISEASE MANAGEMENTE-mail: [email protected]

EMERGENCY SERVICESTel: 082 911

FRAUD LINETel: 0861 888 103

HIV and AIDS: (MANAGED HEALTH CARE)Tel: 0860 224 537Fax: 021 914 3535E-mail: [email protected]

NEW MEMBERSHIPTel: 0860 109 559Fax: 021 957 8644E-mail: [email protected]

ONCOLOGY Tel: 0861 888 103 (Option 4)E-mail: [email protected]

ONCOLOGY MEDICINE DELIVERY CLICKS DIRECT MEDICINESTel: 0861 444 410 (Option 2)Fax: 086 576 3467E-mail: [email protected]

ORGAN TRANSPLANT / DIALYSIS / MEDICATIONTel: 0861 888 102Fax: 021 657 7621E-mail: [email protected]

PRE-AUTHORISATION – HOSPITALTel: 0861 888 103Fax: 021 917 4458E-mail: [email protected]

PROBABY MATERNITYTel: 0861 111 959 or 011 704 0792Fax: 011 704 4645E-mail: [email protected] Tel: 010 209 8697(for Registered ProBaby Members)

Details contained in this brochure are for information purposes only and do not supersede the Rules of the Scheme. In the event of any discrepancy between the brochure and the Rules, the Rules will prevail. The information contained in this brochure is correct as at time of printing. Any amendments will be communicated by the Scheme.

Brochure 2012

Documents

Transcript of Brochure 2012