October 2011 Dear Pioneer Foods (Pty) Ltd - Discovery Health member DISCOVERY HEALTH MEDICAL SCHEME CHANGES FOR 2012 Discovery Health Medical Scheme recently made their 2012 benefits and contributions available and you are once again given the opportunity to change your plan option with effect from 1 January 2012. You therefore need to consider your healthcare requirements for the following year and decide if you have the cover appropriate to your needs. You are under no obligation to change your plan option however if you want to change your current plan option, you would need to submit your new plan option information to Celeste Carolissen, Fund adminitrator (ccarolis@pioneerfoods.co.za) before 18 November 2011. CHANGING YOUR PLAN OPTION Discovery Health Medical Scheme will send you a brochure on behalf of Alexander Forbes Health containing a detailed summary of the 2012 benefits and rates after carefully studying the changes for 2012 you will need to decide whether you wish change your plan option. Please note that if you do not notify Celeste Carolissen of your plan option prior to the above deadline date, by completing the attached option change form (Annexure D), you will remain on your current option and only be afforded another opportunity to change your option in November 2012 for January 2013. ASSISTANCE WITH CHOOSING YOUR PLAN OPTION Members may contact the Discovery Health Medical Scheme for general plan information by: Phoning 0860 100 694; Browsing the website www.discovery.co.za Making use of the national walk-in centres DvD training dvd s will be available from your employer representative Vitality magazine (Spring edition) Alexander Forbes Health consultants will be available to assist you to make the right plan option choice and to provide advice: Alexander Forbes Health office Tel number Email address Stellenbosch 021 809 3777 clientspecialist@aforbes.co.za You may also access the healthcare website on Pioneer Foods (Pty) Ltd s intranet for all the 2012 benefit information : Pioneer Foods/Intranet/ Links/Benefits site/healthcare 2012. The 2012 benefits and contribution site will go live on 1 November 2011. Page 1
CONTRIBUTIONS We believe that the average contribution increase, effective 1 January 2012, of 8.9% reflects a positive view of the current industry scenario and the Scheme s sound operating position. The increase is applicable to all plan options, however as a result of the rounding of numbers a few variations exist. Please refer to Annexure A for the 2012 contributions as well as the increased threshold levels on the Priority, Comprehensive and Executive plan options. Medical savings as a percentage of total contributions remained unchanged for 2012. Please note that the Foundation Core Plan has been discontinued from 1 January 2012. Discovery Health will be communicating with you directly if you are currently on this plan. Please note however that if you do not select another plan choice for 2012, Discovery Health will automatically default you to the Essential Core plan if you reside inland or to the Coastal Core plan, if you reside in a coastal province. This change will however result in an additional contribution increase for members being defaulted to the Essential Core plan, however you will no longer have an overall hospital benefit limit. Discovery Health has reviewed their Adult Dependant Eligibility Criteria and as a result only the following dependants will qualify for the adult dependant contribution. spouses ex-spouses full-time students up to the age of 25 or financially dependant disabled child dependants. All other adult dependants, e.g. parents, children over the age of 25 will be charged the same contribution as a principal member. This will lead to significant contribution increases for those members affected. Discovery Health will be communicating directly with all affected existing members as part of Discovery Health s year-end member communication process. This communication will request that proof of eligibility should be returned by 9 December 2011 which may include proof that main member is responsible for medical aid (ex spouse/partner); registration documents recognised by law/custom (additional spouses); medical proof of disability (financially dependant disabled children) etc. Discovery Health will only amend the contributions on the first of the month following the month in which proof has been received, i.e. no backdating or refunds will be granted. BENEFIT CHANGES The majority of benefits will increase in line with the contribution increase of 8.9%, however the benefit limits for prescribed medication, internal prosthesis and oncology remain unchanged. The limits for external medical appliances and devices will increase with surgical inflation. HOSPITALISATION BENEFITS Networks Refer to Annexure C for the list of hospitals applicable to the KeyCare and Delta plan options. Please note that no changes were announced on the Delta Network however the Moot Hospital () has been removed and the Clinix Phalaborwa Private Hospital has been added to the KeyCare Hospital Network. The keycare 2012 Day Surgery Network has also been extended. Deductibles Members participating on Priority plans should note that the defined deductibles for in-hospital procedures will range from R1 750 to R8 600 in 2012. Please refer to Annexure B for more details. Members participating on Delta plans should note that the deductible has increased to R4 550 per planned hospital admission if you do not make use of the Delta network of hospitals (Refer to Annexure C). You should take note of the below increases in the deductibles if you consider having in-hospital dentistry treatment during 2012: Hospital % change Day Clinic % increase 2011 2012 2011 2012 Member younger than 13 R1 200 R1 300 8.3% R600 R650 8.3% Member older than 13 R3 000 R3 300 10% R2 000 R2 200 10% Page 2
DAY-TO-DAY BENEFITS Members participating on Core plans do not have access to Day-to-day benefits. Except for the KeyCare Plus plan option which offers limited benefits through network providers, all other plan options provide day to day cover through the Medical Savings Account and Above Threshold Benefit (where applicable). INSURED BENEFIT This benefit extends Day-to-day cover once funds in the Medical Savings Account are depleted. Discovery Health will cover consultations, as follows, provided you visit a general practitioner (GP) in the Discovery Health GP Network. Plan Single member Family Saver Plans Classic and Coastal 3 consultations 6 consultations Essential 2 Consultations 4 consultations Priority, Comprehensive and Executive Plans THE ALLIED AND THERAPEUTIC BENEFIT This GP benefit is unlimited on the above mentioned plans as long as the member goes to a GP in Discovery Health s network. This benefit also covers pathology at specific network providers however your GP or specialist must request the tests by completing the Discovery Health pathology form (available on www.discovery.co.za). Discovery Health has redesigned the allied health benefits on the Executive, Comprehensive and Priority plans. The following limits will apply for allied and therapeutic services from 2012, subject to available funds in the Medical Savings Account and Above Threshold benefit: Health Professional 2011 Benefit 2012 Benefit Psychiatrists Registered counselors Psychometrists Education Psychologists Clinic Psychologists Stoma sister Wound care sister Registered nursing sister Chiropractors Homeopaths Podiatrists Speech Therapists Occupational Therapists Physiotherapists Mental Health Benefit: R12 000 to R16 000 Home nursing benefit: R6 650 per family Covered through the Above Threshold Benefit with no sub-limits Covered as a specialist out-patient consultation, with no sub-limit Cover provided through the Allied and Therapeutic Benefit: Executive Comprehensive Priority Classic Essential Classic Essential M R12 500 R10 000 R6 000 R6 000 R4 000 M+1 R15 000 R13 500 R8 500 R8 500 R6 000 M+2 R17 500 R16 500 R11 000 R11 000 R7 500 M+3 R21 000 R19 000 R13 000 R13 000 R9 000 Please note that these changes are not applicable to the Saver, Core and KeyCare plans. THE ALLIED AND THERAPEUTIC EXTENDER BENEFIT This has been introduced to cater for members who meet specific clinical entry criteria and exceed the above limits. The benefit will provide additional cover for serious conditions e.g. Autism, Cerebral Palsy, Parkinsons Disease, Multiple Sclerosis, Muscular Dystrophy etc. for a list of allied healthcare services, including physiotherapy, psychologist, occupational therapists, speech and hearing therapists and biokineticists. CHRONIC MEDICATION (PREFERRED PROVIDERS) You have cover for a list of chronic conditions as per your plan choice as well as cover for approved medicine on Discovery Health s medicine list. If you take medicine that falls outside of Discovery Health s medicine list there is a set monthly amount available to cover medicine costs. Discovery Health will pay medicine up to the Discovery Health Medicine Rate. Chronic conditions need to be approved by Discovery Health in order for the condition to be covered from the Chronic Illness Benefit. When you utlilize MedXpress, Discovery s medicine delivery service, you will not be required to fund any delivery or administration fees. Discovery s qualified service agents can also advise you on the most costeffective alternatives and you will be charged at the Discovery Health Medicine Rate or less minimising copayments. All major pharmacy chains, including Clicks, Dis-Chem and MediRite, as well as over 1 200 community pharmacies are contracted to charge Discovery Health members at this rate. Page 3
DISCOVERY HEALTH MEDSAVER BENEFIT From January 2012, you will qualify for up to 25% cash back on all schedule 1 and 2 medicines purchased from any Clicks store countrywide. You must activate the benefit on www.discovery.co.za and complete a Vitality Check (screening tests) in the Vitality Pharmacy Network or at a Wellness Day. All spouses and/or adult dependants on the membership will need to complete a Vitality Check to earn 25% cash back at Clicks. The MedSaver cash back will be paid back into your DiscoveryCard or a nominated bank account on a monthly basis. The minimum amount that will be paid as a cashback benefit to you is R50. If the accumulated cashback is less than R50 the payment will be held until such time that it exceeds R50. KEYCARE PLANS The KeyCare income bands remain unchanged for 2012. The casualty fee for ALL KeyCare casualty units for 2012 is R185, therefore the preferred casualty network falls away and the flat rate will apply at all KeyCare hospitals with a casualty unit. Discovery Health has added additional day case procedures which will be covered through the enhanced KeyCare Day Surgery network. The details will be included in your Discovery plan information which will be distributed early in 2012. New exclusions applicable to KeyCare plans include arthroscopies, removal of varicose veins and bunions. VITALITY AND KEYFIT BENEFIT Refining the key Vitality benefits From 1 April 2012, the number of compulsory gym visits will increase from 24 to 36 visits in a rolling 12 month period, which equates to 3 times a month. The penalty for not meeting the minimum requirement will reduce the monthly discount from 80% to 50% for members who joined the gym after 1 January 2011. You will earn booster Vitality points, if the results of your Vitality Check and fitness assessment are within the healthy range. If the results are not within a healthy range, you will earn fewer points in 2012. The Pick n Pay DiscoveryCard benefit has been integrated with the Pick n Pay Smart Shopper card. You will continue to receive up to a maximum of 25% cash back on your HealthyFood purchases, and will therefore no longer have the option to increase their savings to 75% by opting to have the cash back paid into the Medical Savings Booster. The additional discount you receive for paying with their DiscoveryCard at Pick n Pay will be replaced with Smart Shopper points, depending on your Vitality status. Building on the HealthyFood Benefit Discovery Vitality has introduced the Clicks HealthyCare and the Adidas HealthyGear Benefits. HealthyCare Benefit HealthyGear Benefit You can save up to 25% on all products in the HealthyCare Product range available from Clicks after activating the benefit and completing a Vitality Check (screening tests). The saving is in addition to the existing 5% to 15% Clicks Cashback rewards you already receive depending on your Vitality status. You can save up to 25% on Adidas active gear and sports equipment available at all Adidas Stores and Totalsport Stores after activating the benefit and completing a fitness assessment. The discount is also in addition to the existing Vitality partner discount at Totalsports of up to 20% depending on your Vitality status. You also have access to the social networks, Facebook and twitter for the information on the Vitality benefit. The process to register is as follows: Log onto www.discovery.co.za/click on the Vitality drop down menu/scroll to the bottom of the page and click on the interact with us link with facebook or twitter. If on facebook click the like button to join the page and if on twitter, once the page opens click on follow. You will then be subscribed and receive notifications from Discovery Vitality. Page 4
ONLINE TOOLS Discovery Health has developed a range of tools to guide you through the system and to identify when you can expect benefits to be reimbursed in full i.e. Hospital Advisor (Going to hospital); MaPS Advisor (Visiting the doctor); Med Advisor (Buying medicine); Benefit Advisor (Day-to-day medical expenses). GAP COVER INSURANCE PULSE The AdmedPulse contribution will increase with 6.9% with effect from 1 January 2012. Please refer to Annexure A for the Contributions AdmedPulse is a short term insurance policy that covers the difference between the doctors private costs (e.g. anaesthetists, surgeons, other specialists and GP s) and the Admed-tariff for procedures done in hospital, subject to a maximum of four times the Admed Tariff. It is important to note that most medical schemes such as Discovery Health have adopted their own internal rates of reimbursement (internal tariffs) and that these may not necessarily agree with the Admed tariff rate. The AdmedGap benefits will continue to be linked to the Cost of the Practitioner as it is not possible to set benefits that are linked to all the various internal tariffs adopted by the many medical schemes registered in South Africa. No changes have been made to the policy benefits, exclusions and waiting periods for 2012. The policy limits have however been increased to R200 000 per insured person and R2 000 000 per family per calendar (policy) year. Details of the general exclusions and waiting periods can be obtained from Alexander Forbes Health or the Admed website on www.admed.co.za. An excess will be applicable to all claims in respect of claiming members who are 60 years of age or older. This excess will amount to 5% of the benefit payable, subject to a minimum of R250.00. All principal members of Admed automatically qualify for Personal Accident cover amounting to R25 000.00. Existing employees who have not yet joined Admed may join on 1 January. An application form needs to be completed and can be obtained from your company intranet or Alexander Forbes. This form must be submitted by 18 November 2011. Finally, we wish you good health in 2012! Alexander Forbes Health Consultants and Actuaries Live without regret. Annexures A Standard 2011 Discovery Health rates B Priority Series - Deductibles C Delta and KeyCare Network of hospitals D Plan Option Change Form Alexander Forbes Health - Stellenbosch Tel: 021 809 3777 Email: clientspecialist@aforbes.co.za Discovery Health Tel: 0860 100 694 Email: healthinfo@discovery.co.za AdmedPulse Tel: 0860 102 936 Email: Admed@guardrisk.co.za Website: www.admed.co.za Disclaimer: While all reasonable care has been taken by Alexander Forbes Health in compiling this communication, we have relied upon the accuracy and completeness of the information made available to us and subsequently cannot accept any liability or any errors or omissions that may arise as a result of the reliance of such information. Page 5
ANNEXURE A - CONTRIBUTION TABLES DISCOVERY HEALTH 2012 Total monthly contributions Series Plan Principal Member Adult Dependant** Child Dependant * Executive Executive 3 365 3 365 638 Comprehensive Classic Comprehensive 2 760 2 609 552 Classic Delta Comprehensive 2 485 2 350 494 Essential Comprehensive 2 320 2 191 463 Essential Delta Comprehensive 2 088 1 972 417 Priority Classic Priority 1 850 1 457 740 Essential Priority 1 590 1 249 635 Saver Classic Saver 1 652 1 300 660 Classic Delta Saver 1 320 1 038 529 Essential Saver 1 312 982 524 Essential Delta Saver 1 049 787 418 Coastal Saver 1 277 957 513 Core Classic Core 1 229 967 491 Classic Delta Core 984 773 393 Essential Core 1 056 791 422 Essential Delta Core 844 633 339 Coastal Core 892 669 356 KeyCare KeyCare Plus (R8 301+) 1 211 1 211 324 KeyCare Plus (R6 251 to R8 300) 813 813 228 KeyCare Plus (R3 901 to R6 250) 581 581 168 KeyCare Plus (R0 to R3 900) 485 485 129 KeyCare Core (R8 301+) 894 894 202 KeyCare Core (R6 251 to R8 300) 579 579 144 KeyCare Core (R0 to R6 250) 465 465 117 *Contributions are charged up to a maximum of 3 children **Eligible adult dependants are spouses, common-law spouses, ex-spouses, full-time students up to the age of 25 or disabled. If an adult dependant does not meet the required eligibility criteria, they will be charged the same contribution as the principal member s contribution. Medical Savings Account (included in the above monthly contribution) Series Plan Principal Member Adult Dependant Child Dependant Annual Monthly Annual Monthly Annual Monthly Executive Executive 10 092 841 10 092 841 1 908 159 Classic 8 280 690 7 824 652 1 656 138 Comprehensive Classic Delta 7 452 621 7 044 587 1 476 123 Essential 4 176 348 3 936 328 828 69 Essential Delta 3 756 313 3 540 295 744 62 Priority Classic 5 544 462 4 368 364 2 220 185 Essential 2 856 238 2 244 187 1 140 95 Classic 4 956 413 3 900 325 1 980 165 Saver Classic Delta 3 960 330 3 108 259 1 584 132 Essential 2 352 196 1 764 147 936 78 Essential Delta 1 884 157 1 416 118 744 62 Coastal 3 828 319 2 868 239 1 536 128 Page 6
ANNEXURE A - CONTRIBUTION TABLES ANNUAL THRESHOLD LEVELS Executive & Comprehensive plans Executive Plan Comprehensive Plans Principal member 10 090 9 300 Per adult 10 090 9 300 Per child* 1 900 1 750 * A maximum of 3 children are counted when calculating the Annual Threshold Priority plans Annual Threshold Above Threshold Limit Principal member 8 200 7 000 Per adult 6 150 4 950 Per child* 2 690 2 400 * A maximum of 3 children are counted when calculating the Annual Threshold and Above Threshold Limit VITALITY & KEYFIT CONTRIBUTIONS Single Member Member with one dependant Vitality 136 158 167 KeyFIT 29 36 45 Vitality & KeyFIT 145 172 193 Member with two or more dependants ADMEDPULSE 2012 Age / Plan 00-30 31-40 41-45 46-50 51-55 56-60 61-65 66-70 70+ Plan 1 44 56 70 87 111 143 176 250 497 Plan 2 61 67 87 112 145 187 239 335 677 Plan 3 63 77 99 129 166 210 268 378 768 Plan 4 72 91 121 153 191 252 322 457 905 Plan 1: Single member Plan 2: Member & children Plan 3: Member & Spouse Plan 4: Member, spouse and children Page 7
ANNEXURE B PRIORITY SERIES (DEDUCTIBLES) Members need to pay an amount upfront to the hospital when the member is admitted for one of the following procedures: DEDUCTIBLE AMOUNT R1 750 PROCEDURE Adenoidectomy Conservative back and neck treatment Myringotomy (grommets) Tonsillectomy R2 350 Colonoscopy Cystoscopy Gastroscopy Proctoscopy Sigmoidoscopy R4 250 Arthroscopy Endometrial ablation Functional Nasal Procedures Hysterectomy (except for pre-operatively diagnosed cancer) Hysteroscopy Laparoscopy R8 600 Joint replacements Nissan fundoplication (reflux surgery) Spinal (back and neck) surgery If the procedure can be done out of hospital, for example in the doctor s rooms, and the member doesn t go to hospital, the member won t have to pay a deductible. It is recommended that members contact Discovery Health directly on 0860 100 694 prior to the procedure in order to confirm their benefits. Page 8
ANNEXURE C HOSPITAL NETWORKS (DELTA RANGE) GAUTENG Arwyp Medical Centre Life Bedford Gardens Hospital Netcare Bougainville Private hospital Life Brenthurst Clinic Life Carstenhof Clinic Clinix Private hospital Lesedi Clinix Private hospital Sebokeng Clinton Clinic Emfuleni Medi-Clinic Life Fourways hospital Legae Private hospital Lenmed Clinic Limited Little Company of Mary Louis Pasteur hospital Midvaal Private hospital Morningside MediClinic Life Robinson Private hospital Life Roseacres Clinic Suikerbosrand Clinic The Donald Gordon Medical Centre Life Wilgeheuwel Hospital Please note that the list of hospitals is subject to change. You can go to www.discovery.co.za for the latest list of hospitals. The list does not include the day clinics where members can get treatment without paying an amount upfront. EASTERN CAPE Life New Mercantile Hospital FREE STATE Life Rosepark Hospital Universitas Private Hospital KWA-ZULU NATAL Life Chatsmed Gardens Hospital Life Entabeni Hospital Ethekwini Hospital Life Westville Hospital Midlands Medical Centre (Pietermaritzburg) WESTERN-CAPE Cape Town MediClinic Life Claremont Hospital Life Kingsbury Hospital Mitchell s Plain Medical Centre Panorama MediClinic Vergelegen MediClinic Page 9
ANNEXURE C HOSPITAL NETWORKS (KEYCARE RANGE) EASTERN CAPE GAUTENG cont. East London East London East London East London Humansdorp Port Elizabeth Queenstown Uitenhage Umtata Life Beacon Bay Hospital St James Operation theatres East London Private hospital St Dominic s Private hospital Isivivana Private hospital Life New Mercantile Hospital Life Queenstown Private hospital Netcare Cuyler clinic Life St Mary's Private hospital Soweto Springs Springs Thembisa Vanderbijlpark Vanderbijlpark Vanderbijlpark Vereeniging Vereeniging Westgate Lesedi Clinic Life Springs Parkland Clinic Life St Mary s Women s Clinic Zamokuhle Private hospital Emfuleni MediClinic Ocumed Netcare Vaalpark hospital Clinix-Private, Sebokeng Midvaal Private Hospital Medgate Day Clinic FREE STATE KWA-ZULU NATAL Bethlehem Bloemfontein Bloemfontein Bloemfontein Bloemfontein Bloemfontein Welkom Welkom Welkom GAUTENG Benoni Boksburg Boksburg Brakpan Germiston Heidelberg Johannesburg Johannesburg Johannesburg Johannesburg Kempton park Lakefield Lenasia Midrand Randfontein Randfontein Soweto Hoogland MediClinic Bloemfontein Eye Centre Netcare Pelonomi Private hospital Life Rosepark Clinic Life Pasteur Hospital Netcare Universitas Private hospital Ernest Oppenheimer Hospital Hydromed MediClinic St Helena Hospital Life The Glynwood-Hospital Botshelong Empilweni-clinic (Clinix Vosloorus) Sunshine Centre Life Dalview Clinic Life Roseacres Clinic Life Suikerbosrand Clinic Netcare Rand Clinic Johannesburg Eye Clinic Netcare Garden City Clinic Life Brenthurst Clinic Arwyp Medical Centre Netcare Optiklin Eye Hospital Lenmed Clinic Life Carstenhof Clinic Netcare Bougainville Private Hospital Centurion Eye Hospital Life Eugene Marais Hospital Netcare Jacaranda Hospital Legae MediClinic Louis Pasteur Hospital Medforum MediClinic Muellmed Hospital -Eye Institute Zuid Afrikaans Hospital Life Robinson Hospital Sir Albert Medical Centre Clinix Soweto (Tshepo Themba) Amanzimtoti Chatsworth Durban Durban Durban Empangeni Isipingo Kokstad Ladysmith Newcastle Phoenix Pietermaritzburg Pietermaritzburg Pinetown Port Shepstone Richards Bay Sydenham Tongaat LESOTHO Lesotho LIMPOPO Bela Bela Phalaborwa Polokwane Thabazimbi Tzaneen MPUMALANGA Barberton Ermelo Middelburg Nelspruit Trichardt Witbank Witbank Kingsway Hospital Life Chatsmed Garden Hospital Life City Hospital Life Entabeni Hospital McLord Hospital Life Empangeni Garden Clinic Life Isipingo Clinic Kokstad Private hospital La Verna Hospital Newcastle Private hospital Life Mount Edgecombe Midlands Medical Centre St Anne s Life Crompton Hospital Hibiscus Hospital Netcare The Bay Hospital Nu Shifa Hospital Victoria Private hospital Willies Hospital St Vincent's Hospital Clinix Phalaborwa Private Limpopo MediClinic Thabazimbi MediClinic Tzaneen MediClinicl Barberton MediClinic Ermelo Private hospital Life Middelburg Private hospital Nelspruit Private hospital Highveld MediClinic Life Cosmos Hospital Emalahleni Day hospital Page 10
ANNEXURE C HOSPITAL NETWORKS (KEYCARE RANGE) NORTH-WEST Carletonville Carletonville Klerksdorp Mafikeng Orkney Potchefstroom Rustenburg Leslie Williams Private Hospital Western Deep Clinic Life Anncron Clinic Victoria Private hospital West Vaal Clinic Potchefstroom MediClinic Life Peglerae-Hospital NORTHERN CAPE Kathu Kimberley Upington Vryburg Kathu MediClinic Kimberley MediClinic Upington Private hospital Vryburg Private hospital WESTERN CAPE Bellville Bellville Cape Town Cape Town Ceres Gatesville George George Hermanus Kuilsriver Milnerton Mitchells Plain Mossel Bay Oudtshoorn Oudtshoorn Paarl West Coast Worcester Bellville Medical Centre Louis Leipoldt MediClinic Netcare Christiaan Barnard Memorial Hospital Netcare UCT Medical Centre Ceres Private hospital Gatesville Medical Centre Geneva Clinic George MediClinic Hermanus MediClinic Netcare Kuilsriver Private hospital Milnerton MediClinic Mitchells Plain Medical Centre Bayview Hospital Cango Day clinic Klein Karoo MediClinic Paarl MediClinic Life West Coast Private Hospital Worcester MediClinic Please note that the list of hospitals is subject to change. You can go to www.discovery.co.za for the latest list of hospitals and casualty units. E&OE Page 11
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PIONEER FOODS (PTY) LTD - 2012 DISCOVERY HEALTH PLAN CHANGE FORM CURRENT DETAILS Name and Surname Current plan Medical Aid number Personnel Area Personnel Subarea PLAN CHANGE FOR 2012 MEDICAL SCHEME - - Please the respective box of your plan choice for 2012 EXECUTIVE COMPREHENSIVE PRIORITY SAVER CORE KEYCARE Executive Classic Classic Delta ** Essential Essential Delta ** Classic Essential Classic Classic Delta ** Essential Essential Delta ** Coastal * Classic Classic Delta** Essential Essential Delta ** Coastal Core Plus *** * For members residing in coastal provinces only **The Delta plans make use of a network of hospitals *** KEYCARE PLUS members ONLY: Please complete if you want to change your service provider as from 1.1.2012 (Provider list/names available from www.discovery.co.za or 0860 100 694. Principal member Name of Dependant 1 Name of Dependant 2 Name of Dependant 3 Name of Dependant 4 Name of Doctor Name of Doctor Name of Doctor Name of Doctor Name of Doctor Practice number Practice number Practice number Practice number Practice number LOYALTY PROGRAMME - - Please the respective box if you would like to join Vitality KeyFit Vitality & KeyFit I hereby declare that full product information has been made available to me by Discovery Health and/or Alexander Forbes Health which enabled me to make an informed decision with regard to selecting / changing my benefit option. I also confirm that should I require advice or assistance I will have full access to my Alexander Forbes Health consultant. In terms of the Rules of the Medical Scheme, I hereby apply to change my medical scheme option as indicated above. I understand the rules, benefits and financial implications of this option selection. Signature Employee number Date This form must be completed and returned to CELESTE CAROLISSEN (ccarolis@pioneerfoods.co.za) by 18 November 2011. (If no changes are required, please do not complete the form) Page 13