TABLE OF CONTENTS

Transcription

1 POLICY

2 TABLE OF CONTENTS GENERAL P 1 SECTION A Definitions P 1 SECTION B General Details P 3 SECTION C Waiting Periods P 3 SECTION D Exclusions P 4 SECTION E General Terms & Conditions P 5 SECTION F Benefit Schedule P 7 ANNEXURE A Primary Healthcare Services P 8

3 MASTER POLICY NO: A&G/FLEXICARE AND FLEXICARE PLUS / EFFECTIVE: 01 JANUARY 2017 GENERAL In contemplation of and conditional upon the payment of the Premium by or on behalf of the Insured in accordance with this Policy Document and any schedules attached thereto and the receipt of such Premium by or on behalf of the Underwriter before the Inception Date or renewal date (as the case may be) and subject to the terms, conditions, exclusions and provisions of this Policy Document and any schedules attached thereto, the Underwriter agrees to pay Benefits to the Eligible Member for an Insured Event in accordance with the sum insured, limits of indemnity and other criteria as stated in this Policy and the schedules attached thereto. A. Definitions In this document, all words and expressions signifying the singular shall include the plural and vice versa and all words and expressions signifying any one gender shall include the other gender. The following words and expressions shall have the following meanings: 1. Accidental Harm means bodily injury caused by violent, unintentional, external and physical means. 2. Administrator means Xelus (Pty) Ltd (Registration No: 2008/019335/07), 3. Benefit means the Rand amount payable by the Products to a contracted service provider for services rendered to an eligible member. 4. Benefit Plan means the Flexicare or Flexicare Plus benefit plan chosen for cover by the member in terms of this policy. 5. Benefit Year means the period from 01 January to 31 December of any year or any other period prescribed by the Underwriter. 6. Benefit Schedule means Annexure A of this document, which defines the benefits and services provided to members in terms of this policy. 7. Billing Schedule means the monthly schedule detailing membership fees due to The Underwriter and which are submitted each month where applicable by The Underwriter to participating employers. 8. Condition Specific Waiting Period means a time period, commencing on the Inception Date, during which specified benefits and services, as defined in Section C of this Policy, are excluded from cover. 9. Co-payment means an amount, either specified in Rands or as a percentage, that is payable by a member to a contracted service provider and is not covered under this policy. 10. Contracted Service Provider means any medical service provider contracted and designated by the Underwriter as a provider for the Products, to be used by members at all times. 11. Employee means a person in the employment of a participating employer. 12. ER24 means ER24 EMS (Pty) Ltd, a wholly owned subsidiary of Mediclinic SA. 13. Exclusions means the list of services, conditions or events in Section D of this policy, which are excluded at all times from cover. 14. General Practitioner or GP is a medical practitioner, as defined herein, who provides primary healthcare services and is also a contracted service provider. 15. General Waiting Period means a time period, commencing on the inception date, during which all benefits and services, except those resulting from accidental harm, are excluded from cover. 16. Hazardous Sport includes, but is not limited to, participation in or use of any of the following: All forms of motorised/jet racing or motorised/jet aerobatics, whether by land, sea or air; Mountaineering, trekking or hiking above an altitude of 4,000 (four thousand) metres; Hunting, shooting or deploying firearms in any manner other than for self-defence purposes;

4 The above definitions apply regardless of whether these activities are performed privately, socially, during practice sessions, while participating in organised events or as an amateur or a professional. 17. Hospital means any institution in the territory of the Republic of South Africa, which provides diagnostic and therapeutic facilities for surgical and medical diagnosis, treatment and care of sick or injured persons by or under the supervision of medical practitioners on a full-time 24 hour basis 18. Hospital Network means a list of hospitals, specified by The Products as contracted service providers 19. Illness means any somatic disease or sickness which manifests in a member. 20. Inception Date means the first day of the month on which membership commences. 21. Income means the average monthly amount from all sources that has been received by, or accrued to, or deemed to have been received by or accrued to a member over the preceding 12 months. 22. Insured or insured beneficiary or beneficiary means a member covered under this policy. 23. Injury on Duty or IOD means any injury that is a valid claim under the Compensation for Occupational Diseases and Injuries Act 130 of 1993, including any amendments thereto. 24. Medical Practitioner means a qualified medical practitioner, who is registered to practice with the Health Professions Council of South Africa. 25. Medical Scheme means a medical scheme as registered under the Medical Schemes Act, No 131 of Member means a person who applied for cover and has been accepted by the Underwriter as eligible for participation in the cover provided under this policy. 27. Membership Card means the card issued by the Administrator to a member upon activation of cover and which indicates the Flexicare or Flexicare Plus benefit plan and personal details of the member. 28. Membership fees or fees means the monthly premium due to the Underwriter, payable by, or on behalf of, the member. 29. Participating Employer means an employer who pays membership premiums to The Underwriter on behalf of their employees, who are eligible members of the Products. 30. Permanent Disability means any accidental harm or physical illness that renders a person permanently unable to work in their own or other occupation for which they are suited by training, education or experience. 31. Prime Cure means Prime Cure Health (Pty) Ltd, registration number 1997/017429/ Renewal Date means 1 st January of each year or other date determined by the Underwriter upon which the benefits and membership fees will be amended. 33. Road Injury means any injury that is a valid claim under the Road Accident Fund Act 56 of 1996, including any amendments thereto. 34. Policy mean collectively this document and any relevant member schedules or annexes thereto, all of which shall apply conjunctively. 35. Products means the Flexicare and/or the Flexicare Plus benefit plans. 36. Termination Date means the effective date of termination of a member s membership under this policy. 37. Treatment means any form of medical advice, diagnosis, care or treatment provided by a medical practitioner for the purpose of treating or monitoring the medical condition of a member. 38. Trauma means accidental harm, as defined, to a member. 39. Underwriter means Auto & General Insurance Company Limited (registration number 1973/016880/06) that underwrites the cover on this Policy and is registered to do so in terms of the Short Term Insurance Act No. 53 of Waiting Periods means one or more time periods, commencing on the Inception Date, during which certain Benefits, as defined in Section C of this Policy, are excluded.

5 B. General Details 1. The benefits and services apply only to those rendered within the territory of the Republic of South Africa. Any services provided outside of the borders of South Africa are excluded from cover. 2. The Underwriter reserves the right to alter the premiums, the benefits or services provided, exclusions, or any other term or condition outlined in these rules, by giving 1 (one) calendar month s written notice of the change, to either the member, or the participating employer, whoever is relevant. 3. Any notice provided to a participating employer, is deemed to have been provided to the employees of that employer, at the same time as the notice was provided to the participating employer. 4. This policy, and any schedule or annexure thereto, form the contract between the member, the participating employer and the Underwriter. C. Waiting Periods In the event that membership of the Products is implemented on a compulsory basis by an employer for their employees, any eligible member of such defined compulsory group, will not have waiting periods imposed upon their cover In the event that membership of the Products is implemented on a voluntary basis by an employer for their employees, or in the case of an individual member joining the Products, any eligible individual member or member of such defined voluntary group, will have standard waiting periods imposed on their cover, as outlined below: 1. During the first month of membership, a general waiting period will be applied against medical advice, diagnosis, care and treatment relating to all services or conditions, except accidental harm. 2. During the first 6 (six) months of membership, a condition specific waiting period will be applied against medical advice, diagnosis, care and treatment relating to dentistry. 3. During the first 12 (twelve) months of membership, a condition specific waiting period will be applied against medical advice, diagnosis, care and treatment relating to optometry. 4. During the first 6 (six) months of membership, a condition specific waiting period will be applied against medical advice, diagnosis, care, treatment and medicines relating to all chronic conditions, as defined in Annexure A. The above waiting periods will apply, regardless of whether or not the condition, or conditions, against which the waiting period applies, existed prior to the inception date, or manifested after such date. The Underwriter reserves the right to waive some or all of the waiting periods. Any such waiver is only valid if provided in writing and confirmed on the member schedule issued to the relevant participating member.

6 D. Exclusions The Underwriter shall not be liable for any service, claim or benefit caused by, or related to, whether such cause, or related cause, is a direct or indirect consequence of any of the following: 1. Cosmetic surgery. 2. Suicide, attempted suicide or wilful injury to oneself. 3. The consumption of any drug or narcotic, whether legal or illegal, unless legally prescribed by and taken in accordance with the instructions of a medical practitioner. 4. The failure of a member to follow any medical advice given by a medical practitioner. 5. Any incident, illness, accidental harm or event directly or indirectly caused by the continuous and excessive consumption of alcohol or where the member suffers from alcoholism. 6. Any incident, illness, accidental harm or event directly or indirectly attributable to the member having a blood alcohol content exceeding thirty milligrams per one hundred millilitres of blood. 7. Nuclear weapons, nuclear material, ionising radiations or contamination by radioactivity from any nuclear fuel, or from any nuclear waste, or from the combustion of nuclear fuel which includes any self-sustaining process of nuclear fission. Participation, or attempted participation, by any member in any of the following: 7.1. Any defence force, police force, medical rescue service, firefighting service, correctional services facility or the disarming of explosives; 7.2. Aviation activities where any medical expense incurred in relation to such activities are insured by any other party (excludes fare-paying passengers in a licensed passenger carrying aircraft); 7.3. Any hazardous sport as defined herein; 7.4. Any form of race or speed test (other than on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft). 8. Participation, or attempted participation, by any member in any of the following: 8.1. Any defence force, police force, medical rescue service, firefighting service, correctional services facility or the disarming of explosives; 8.2. Aviation activities where any medical expense incurred in relation to such activities are insured by any other party (excludes fare-paying passengers in a licensed passenger carrying aircraft); 8.3. Any hazardous sport as defined herein; 8.4. Any form of race or speed test (other than on foot or involving any non-mechanically propelled vehicle, vessel, craft or aircraft). 9. Riots, wars, political acts, public disorder, or any acts, or attempted acts, of any of the following: 9.1. Civil commotion, labour disturbances, riot, strike, lock-out or public disorder or any act or activity which is calculated, or directed, to bring about any of the above; 9.2. War, invasion, act of foreign enemy, hostilities, civil war or warlike operations (regardless of whether war is declared or not); 9.3. Mutiny, military rising or usurped power, martial law or state of siege, or any other event or cause which determines the proclamation or maintenance of martial law or state of siege, insurrection, rebellion or revolution; 9.4. Any act, whether on behalf of an organisation, body, person or group of persons, calculated or directed to overthrow or influence any state or government or any provincial, local or tribal authority with force or by means of fear, terrorism or violence; 9.5. Any act calculated or directed to bring about loss or damage to further any political aim, objective or cause, or to bring about any social or economic change, or in protest against any state or government, or any provincial, local or tribal authority, or for the purpose of inspiring fear in the public, or any section thereof; 9.6. Terrorism. An act of terrorism means the use or threat of violence for political, religious, personal or ideological reasons. This may or may not include an act that is harmful to human life. It could be committed by any person or group of persons, acting alone, on behalf of or with any organisation or government. It includes any act committed with the intention to influence any government or inspire fear in the public; 9.7. The act of any lawfully established authority in controlling, preventing, suppressing or in any other way dealing with any event referred to in any of the clauses 9.1 to 9.6 above. 10. Any claim, service or benefit that does not form part of this policy. 11. The following procedures, items, services, service providers or events: External prosthesis; Any appliances, including, but not limited to, wheelchairs, beds or convalescing equipment; All specialised dental procedures, including, but not limited to, crowns, bridges, dental implant related procedures, orthognathic surgery, temporomandibular joint ( TMJ ) surgery, labial frenectomy, bone augmentations, bone or tissue regeneration (This clause excludes basic dentistry as defined in Annexure A of these rules);

7 11.3. Rehabilitation, frail care or hospice services; Step-down facilities; TTO (to-take-out) medicines; 12. Any claim incurred as a result of a road injury, as defined in these rules. In practice, these claims can be paid for under the the Products rules, where the member agrees to cede their benefits derived under the Road Accident Fund Act, to cover the costs paid for by the Products on behalf of the member. 13. Any claim incurred as a result of an injury on duty, as defined in these rules. In practice, these claims can be paid for under the Products rules, where the member agrees to cede benefits derived under the Compensation for Occupational Diseases and Injuries Act, to cover costs paid for by the Products on behalf of the member. 14. Any fee charged by a medical practitioner, hospital or other contracted service provider that constitutes split billing or balance billing. 15. Any criminal act or attempted criminal act by a member, which shall include the submission of any fraudulent information, or the use of any fraudulent means, to obtain any benefit or service under these rules; 16. Expenses incurred for non-emergency transport charges, including services rendered whilst being transported in any vehicle, vessel or craft, whether or not such vehicle, vessel or craft is specifically designed for the purposes of medical emergency transport. 17. Any act by a member that wilfully exposed the member to danger, except where such act was necessitated in order to save human life or prevent accidental harm. E. General Terms And Conditions 1. Claim Payments Contracted Service Providers will submit accounts to the Administrator for payment of services rendered to members of the Products, under the following conditions: a. The contracted service providers will supply adequate proof, copies of medical accounts or other information as may reasonably be required for The Underwriter to process the claim or to ensure the validity of any claim. b. No amount payable shall carry interest. c. Any amount due to a contracted service providers will be paid within a maximum of 30 days from submission. 2. Membership Fees a. All premiums due and payable to the Underwriter are, where applicable, to be collected by the participating employer or paid by the individual member, as the case may be and paid in accordance with clauses 2b, 2c, 2d, 2e, 2f, 2g and 2i below. b. Membership fees are due monthly in advance, by the 3 rd working day of the month. c. In the event that the membership fee remains outstanding for more than 14 days, the Underwriter reserves the right to suspend the cover. d. In the event that payment remains outstanding for more than 30 days, The Underwriter reserves the right to cancel the cover. f. Inception of cover may only commence on the first (1 st ) day of a particular month and may not be backdated. The Underwriter shall not be obliged to accept membership fees tendered to it after the inception date but may do so upon such terms as it may determine in its sole discretion. g. The payment of all membership fees shall be made in the currency of the Republic of South Africa. h. The minimum fee payable for any participating employer group is R5,000 (five thousand rand) excl VAT per month. i. Premiums for private individuals will be collected on the 1 st working day of the month via debit order. 3. Termination of cover a. The Underwriter may cancel this cover at any time by giving 1 (one) calendar month s written notice thereof to the member, or the participating employer, as the case may be. b. The member, or the participating employer, may cancel this cover at any time, by giving 1 (one) calendar month s written notice thereof to The Underwriter c. Cover or services provided will only be valid if the treatment or service was provided prior to the termination date. d. Premiums are payable up to and including the termination date. e. In the event that any fraudulent act is committed by any member, participating employer or service provider, the Underwriter reserves the right to immediately cancel this cover and/or to institute legal proceedings against the relevant party to recover any losses. e. At the sole discretion of the Underwriter, premiums may be accepted in arrears, under the same terms and conditions as outlined in this section E2.

8 4. Medical examination Payment of any Benefit is conditional on the member supplying such medical evidence as is required for the Underwriter to adequately assess the validity of the claims or for a member to undergo any medical examination at a service provider nominated by the underwriter, if requested and paid for by the Underwriter. 5. Jurisdiction These rules shall be subject to the jurisdiction of the courts of the Republic of South Africa and South African law will apply. 6. Commencement of cover Cover shall commence on the first day of the calendar month for which the membership fees have been paid by, or on behalf of, the member, subject to all the terms and conditions of these rules. 7. Premium Amendments The Underwriter may adjust the membership fees by giving at least 1 (one) calendar month s written notice thereof to the member, or the participating employer, as the case may be. 8. Membership Eligibility a. Any participating employer making the Products membership a compulsory condition of employment, shall include such eligibility criteria within the general conditions of employment for the eligible members. A participating employer, who makes membership a compulsory condition as per 8(a) above, shall ensure that such eligible employees retain their membership and are liable for the payment of the relevant membership fees, in accordance with section E2 of this policy. b. The maximum entry age for individual members joining the Products is 60 years at the date of commencement. Individuals who are 60 or older at the date of commencement are not eligible to become members. 9. Cover, Services and Benefits a. No benefit shall be payable, or a service provided, unless such treatment occurred during the period of valid and paid up membership. b. A member is required at all times to present his/her membership card to a contracted service provider when obtaining services. c. The Underwriter may alter the benefits or services, or the basis upon which the benefits or services are calculated under this policy, by giving 1 (one) calendar month s written notice thereof. d. In the event that a member, or a participating employer, or any intermediary acting on their behalf, has misrepresented, inaccurately described or not provided all the details that may affect the risk covered under these rules, the Underwriter may declare that the cover, or any part thereof, is invalid. In such event the Underwriter shall be entitled to reject any claim or service under these rules and/or to void the cover from the inception date. e. Any member who knowingly allows another person to present themselves to a contracted service provider as a member eligible for services under these rules, or knowingly allows such other person to use their membership card in order to obtain services as if they were the eligible member under this policy, shall be committing an act of fraud and shall be prosecuted accordingly. In either such event, the Underwriter may immediately cancel the membership of such a member and recoup any losses incurred as a result of such fraudulent act.

9 F. Benefit Schedule The events listed in the clauses below are deemed as separate events and may qualify for coinciding yet distinct benefits or services, as the case may be. The headings below are for reference purposes only and will not form part of any benefit definition. 1. Primary Healthcare Medical Services Annexure A outlines the primary healthcare medical services delivered under this policy by Prime Cure. 2. In-Patient Accidental Casualty This service is only applicable to Flexicare Plus benefit option members. Benefits relating to this clause will only be paid in respect of emergency in-patient services that are a direct result of accidental harm to a member and are provided within a casualty ward or inpatient ward of a contracted hospital and where the member is transported to the relevant hospital by ER24. The benefit payable is equal to the actual cost of the services provided, subject to an overall maximum of R200,000 (two hundred thousand rand) per event. The authorisation of benefit amounts to the relevant hospital are provided by ER24, using managed care protocols with consideration of cost effective and appropriate treatment. No benefit is payable under this clause F.2 for services that are related to an illness. 3. Out-Patient Accidental Casualty This service is applicable to Flexicare and Flexicare Plus members. Benefits relating to this clause will only be paid in respect of emergency out-patient services that are a direct result of accidental harm to a member and are provided within an outpatient casualty ward or trauma ward of a contracted hospital and where the member is transported to the relevant hospital by ER24. The benefit payable is equal to the actual cost of the services provided, subject to an overall maximum of R10,000 (ten thousand rand) per event. The authorisation of benefit amounts to the relevant hospital are provided by ER24, using managed care protocols with consideration of cost effective and appropriate treatment. 4. Ambulance Services Ground ambulance services are provided to all the Products members by ER24. Members are required to access these services via the ER24 toll-free line on (24/7/365) or by direct referral from the The Underwriter call centre (office hours only). These services are only provided in the event of an emergency. 5. RAF & IOD Claims This service is provided to all the Product members. An end-to-end legal service is provided by the nominated service provider of the Underwriter to assist members with legitimate claims against the Road Accident Fund or the Compensation for Occupational Injuries and Diseases Act. This service is only available for events that occurred after the date of inception of cover 6. MyDoctor This service is provided to all the Product members. Members and dependants will have access to a health line on symptoms, advice and information, nutrition etc. The line is managed by clinical call centre nurses who are qualified to provide the clinical advice. In addition to the health line, members and their dependants will have access to the Doctors, Dieticians, Biokineticists and Counsellors via the website to submit anonymous questions and request assistance and information. 7. Death Cover This service is provided to all the Product members. The benefit payable is R15000 for accidental causes. In the event of death claim, proof of death must be submitted to KaeloXelus. Notification of a claim must be made within six months of death No benefit is payable under this clause F.2 for services that are related to an illness.

10 ANNEXURE A SERVICE General Practitioner Consultations with a Prime Cure contracted GP Pathology Services Radiology Services Unlimited visits at network GP Office hours only Any contracted GP in the Prime Cure network can be used. 100% of Prime Cure agreed tariff All out-of-hospital General Practitioner consultations, including small in-rooms procedures at Prime Cure approved Network Providers, provided such consultations are medically indicated. Consultations with a non-network GP will result in the account and associated accounts being rejected for payment. The account will be for the member s responsibility. Prime Cure agreed tariff Limited to Prime Cure list of Approved Pathology List of Codes Prime Cure contracted general practitioner must request the pathology test; Benefit is subject to case management No cover if referred by a non-contracted Provider Prime Cure agreed tariff Limited to the list of codes for Radiology. Soft Tissue Ultrasounds and Black & White x-rays according to a list of Prime Cure approved codes 2 sonar scans per pregnancy Prime Cure Network GP must request the radiology test; This benefit is subject to case management. No cover if referred by a non-contracted GP Acute Medication Prime Cure agreed tariff Must be prescribed by a contracted GP Only medication on Prime Cure acute medicine formulary will be covered. The medication will be provided as part of the acute consultation (when dispensed by a dispensing practitioner) or by an accredited Prime Cure/pharmacy if prescribed by a non-dispensing practitioner Standard formulary medication is available without co-payment, subject to case management No cover if referred by a non-contracted GP

11 SERVICE Chronic Medication 1. Addison s disease 2. Asthma 3. Bipolar mood disorder 4. Bronchiectasis 5. Cardiac failure 6. Cardiomyopathy 7. Chronic renal disease 8. COPD (chronic obstructivepulmonary disease) 9. Coronary artery disease 10. Crohn's disease 11. Diabetes insipidus 12. Diabetes mellitus type Diabetes mellitus type Dysrhythmias 15. Epilepsy 16. Glaucoma 17. Haemophilia 18. HIV (see details below) 19. Hyperlipidaemia (high cholesterol) 20. Hypertension 21. Hypothyroidism 22. Multiple sclerosis 23. Parkinson's disease 24. Rheumatoid arthritis 25. Schizophrenia 26. Systemic lupus erythematosus 27. Ulcerative colitis Prime Cure agreed tariff Unlimited Chronic Medication for the above conditions but according to a fixed Prime Cure medication formulary only. Beneficiary must register on the program and comply with the Prime Cure protocol. Pre-Authorisation required from Prime Cure Call Centre. Network GP to complete Prime Cure Chronic Application Form and submit to Prime Cure, in accordance with Prime Cure Protocol, as amended from time to time. Only medication prescribed by a Prime Cure contracted GP will be covered. Medication will only be dispensed by a Prime Cure Medical Centres, Prime Cure GP in possession of a valid dispensing license or by a designated Prime Cure pharmacy or chronic medicine courier service. Members can choose how they receive their medication. No cover if referred by a non-contracted Provider Self-Medication Benefit ( OTC Pharmacy) Over-the-counter (OTC) pharmacy benefit. Limited to R240 per beneficiary per annum, Maximum of R80 per event (a maximum of 3 events per beneficiary per annum) Limited to the fixed Prime Cure medicine formulary for OTC medicines only. Self-medication items for the treatment of day to day ailments. Medication dispensed by accredited network Prime Cure pharmacy only.

12 SERVICE HIV Management Programme Ongoing care plan and anti-retroviral treatment subject to registration on Prime Cure HIV/AIDS programme and treatment according to an evidence based treatment protocol and medicine formulary Each eligible beneficiary to register on the Disease Management Program once diagnosed as HIV positive Consent to record data on Prime Cure Disease Management Information System required Compliance with clinical protocols developed by Prime Cure is mandatory for continued benefits. Includes: Voluntary counselling and testing Antiretroviral therapy, prophylactic antibiotics & supplements according to Prime Cure protocol Treatment support Pathology and monitoring (incl. CD4, viral load, liver enzymes, cholesterol, glucose, urine tests) according to protocols Patients are assigned to one of four programme categories depending on the stage i.e. post exposure prophylaxis (PEP), Prevention of mother-to-child transmission (PMTCT), Antiretroviral therapy (ART) or Pre-ART. Treatment of opportunistic infections, according to Prime Cure formulary. Emergency post exposure prophylaxis is provided within 72 hours of the accidental exposure. Basic Dental Services Unlimited when clinically appropriate, subject to Prime Cure protocols Prime Cure agreed tariffs Limited to a Prime Cure list of approved dental codes. One consultation for a full mouth examination per beneficiary per annum subject to list of benefit codes. Preventative treatments one treatment per Employee per annum. Includes Fluoride Treatment, Cleaning, Scaling and Polishing, 1 treatment per year according to Prime Cure treatment protocols, (authorization required for beneficiaries over the age of 12 years). Fillings (White or Amalgam according to Prime Cure protocols). Pre-authorisation required for 4/more restorations or 5/more Composite fillings (only anterior covered). Pain and sepsis Infection Control Oral Hygiene Instruction Extractions (Only if clinically necessary). Pre-authorisation required for 5/more extractions Local Anaesthetic Intra Oral Radiograph (X-Rays as per Prime Cure approved dental list of codes). Pre-authorisation for 3/more x-rays (maximum 4) Prime Cure designated providers only Emergency Root Canal only Subject to case management.

13 SERVICE Optometry Services Eye Examination One optometric examination per beneficiary per annum. Includes a visual evaluation, tonometry screening and a diagnosis Spectacles Pair of spectacles per beneficiary per 24 month period Includes standard CR39 lenses (High quality clear plastic lenses) Single Vision or Bi-focal lenses (Please refer to Qualifying norms) Members are not entitled to any monetary value regarding the benefit. Frames 1 Frame for spectacles allowed per beneficiary every 24 months The choice of frame is specified to be from a quality range of Prime Cure approved range of frames. An excess is payable by the member for any frame not from the specified Prime Cure range. Members are not entitled to any monetary value regarding the frame.