PLUS PLAN SUMMARY OF BENEFIT AND CONTRIBUTION S FOR 2016 Contributions on the Plus Plan for 2016 will increase by approximately 9.5 across all family sizes (Bankmed average: 7.8). Please also note that the savings allowance included in the overall contributions for the Plus Plan will increase by 5, which is lower than the total contribution increase catered for on this plan. Please refer to the enclosed 2016 Benefit and Contribution Schedule to calculate your total monthly contribution for 2016. A contribution calculator is also available on our website at www.bankmed.co.za. Rand limit and other changes are provided in a summarised format in the tables below. Please refer to the 2016 Benefit and Contribution Schedule for detailed rates of cover and any other arrangements that may apply to the benefits/services listed. The numbering in this summary corresponds to the numbering in the 2016 Benefit and Contribution Schedule. PLUS PLAN: RAND LIMIT S EFFECTIVE 1 JANUARY 2016 3.12 Wellness and preventative R240 pbpa R250 pbpa 4.16 care (insured) benefits: Cholesterol screening, blood sugar screening and blood pressure measurements 3.14 Pap smear consultation R375 pbpa R395 pbpa 5.33 3.15 Personal Health Assessment R575 pbpa R605 pbpa 5.21 (PHA) 3.16 Contraception: R1 500 per female beneficiary per annum R1 575 per female beneficiary per annum 5 Oral contraceptives, devices and injectables 14.4 Pregnancy and childbirth Birthing facilities as an alternative to hospitalisation Cost of disposables R855 per case R900 per case 5.26 /S 1
PLUS PLAN: RAND LIMIT S EFFECTIVE 1 JANUARY 2016 (CONTINUED) 16.3 Alternatives to hospitalisation: R355 pb per day R375 pb per day 5.33 Frail care facilities 16.4 Home nursing R270 pb per day R285 pb per day 5.55 17.1 Internal prosthesis: R54 580 pbpa R57 350 pbpa 5 Combined limit for all internal prosthesis items, excluding pacemakers and defibrillators 17.2 Internal prosthesis sub-limits (subject to combined limit for all internal prosthesis items): Partial hip replacement R20 555 R21 600 5.08 Total hip replacement R45 480 R47 800 5.10 Total knee replacement R49 850 R52 350 5.01 Shoulder replacement R44 040 R46 250 5.01 Spinal fusions R36 745 R38 600 5.04 Cardiac stents R54 315 R57 050 5.03 Grafts R29 400 R30 900 5.10 Cardiac valves R30 900 R32 500 5.17 Non-specified items R16 940 R17 800 5.07 19.2 Cochlear implants: R13 545 pb per lifetime Pre-operative evaluation and associated preparation costs 19.3 Cochlear implant device R311 620 pb per lifetime R284 500 pb per lifetime 5 19.4 Intra-operative audiology R715 pb per lifetime testing 19.5 Post-operative evaluation costs R28 455 pb per lifetime 20.1 Speech processors: R101 175 pb over a five-year cycle R106 250 pb over a five-year cycle 5 Upgrade or replacement of speech processors 21.1 Hearing aids: R25 400 pb every second year R26 700 pb every second year 5.11 Supply and fitment 21.2 Hearing aid repairs 100 of cost, limited to R1 130 pbpa 100 of cost, limited to R1 190 pbpa 5 21.3 Bone anchored hearing aids 90 of cost, limited to R116 300 pfpa 90 of cost, limited to R122 150 pfpa 5 /S Cost split provided for clarification 5 increase on 2015 benefit allocation 2
PLUS PLAN: RAND LIMIT S EFFECTIVE 1 JANUARY 2016 (CONTINUED) 22.1 External prosthesis: Benefit for limbs and eyes 22.2 Medical and surgical appliances Post-surgery appliances Medical and surgical appliances Chronic appliances R18 585 pfpa R19 515 pfpa 5 R5 460 pbpa R5 750 pbpa 5.31 R17 150 pbpa for oxygen/oxygen delivery systems R17 150 pbpa for stoma products R18 050 pbpa for oxygen/oxygen delivery systems R18 050 pbpa for stoma products 5.24 5.24 /S R5 460 pbpa for other chronic appliances, including wheelchairs R5 750 pbpa for other chronic appliances, including wheelchairs 5.31 Medical and surgical appliances Appliances for acute conditions (Other chronic appliances limit extended to R8 000 for beneficiaries requiring a CPAP machine) Subject to limit for other chronic appliances of R5 460 pbpa (Other chronic appliances limit extended to R8 400 for beneficiaries requiring a CPAP machine) Subject to limit for other chronic appliances of R5 750 pbpa 5 5.31 22.3 Blood pressure monitors, nebulisers and glucometers (subject to combined limit for other chronic appliances) Blood pressure monitors: R920 pbpa Nebulisers: R1 295 pbpa Glucometers: R650 pbpa Blood pressure monitors: R970 pbpa Nebulisers: R1 360 pbpa Glucometers: R685 pbpa 23.1 Psychiatry, clinical psychology and related occupational therapy: Hospitalisation and in-hospital consultations/sessions R50 910 pbpa R53 500 pbpa 5 24.1 Occupational therapy: Psychiatric consultations/sessions in hospital Combined limit Combined limit 36.5 Medicine: Chronic medication R20 500 pbpa R21 525 pbpa 5 5.31 5.43 5 3
ANNUAL THRESHOLD AND ABOVE THRESHOLD BENEFIT 37.2 Annual threshold (accumulation) Above Threshold Benefit (ATB) PLUS PLAN: S TO THE ANNUAL THRESHOLD AND ABOVE THRESHOLD BENEFITS FROM 1 JANUARY 2016 2015 2016 Combined annual threshold of R12 700 for the principal member R9 500 per adult dependant R3 100 per child dependant (limited to three children) Combined ATB of Combined annual threshold of R13 900 for the principal member R10 400 per adult dependant R3 400 per child dependant (limited to three children) Combined ATB of 9.44 9.47 9.67 /S R12 700 for the principal member R9 500 per adult dependant R3 100 per child dependant (but limited to three children) R13 300 for the principal member R10 000 per adult dependant R3 300 per child dependant (but limited to three children) 4.72 5.26 6.45 4
PLUS PLAN: S TO LIMITS ON ACCUMULATION TOWARDS ANNUAL THRESHOLD AND/OR PAYMENT OF INSURED ATBs EFFECTIVE 1 JANUARY 2016 Benefits listed in this section are payable from savings, with accumulation towards the annual threshold at 100 of the Scheme rate (or Bankmed Network rate) Payment from insured ATBs only applies once the annual threshold has been reached BENEFIT/SERVICE 15.4 Radiology and pathology 23.2 Psychiatry, clinical psychology and related occupational therapy: Consultations/sessions out of 2015 LIMIT ON ACCUMULATION TOWARDS THRESHOLD AND/OR PAYMENT OF ATB 2016 LIMIT ON ACCUMULATION TOWARDS THRESHOLD AND/OR PAYMENT OF ATB /S R4 795 pfpa R5 035 pfpa 5 hospital R11 290 pfpa R11 855 pfpa 5 24.2 Occupational therapy: Psychiatric consultations/sessions 24.4 Non-psychiatric consultations/sessions 25.1 Speech therapy, audio therapy and audiology (in and out of hospital) 26.2 Physiotherapy: Posthospitalisation physiotherapy within six weeks of discharge from hospital following an R5 645 pfpa R5 950 pfpa 5.4 R1 695 pfpa R1 780 pfpa 5 authorised hospital admission R2 260 pbpa R2 375 pbpa 5 26.3 Physiotherapy 5
PLUS PLAN: S TO LIMITS ON ACCUMULATION TOWARDS ANNUAL THRESHOLD AND/OR PAYMENT OF INSURED ATBs EFFECTOVE 1 JANUARY 2016 (CONTINUED) 2015 2016 BENEFIT/SERVICE LIMIT ON ACCUMULATION TOWARDS LIMIT ON ACCUMULATION TOWARDS THRESHOLD AND/OR PAYMENT OF ATB THRESHOLD AND/OR PAYMENT OF ATB /S 28.1 Other auxiliary services (in and out of hospital): Chiropody, podiatry, dietetics (nutritional assessments), orthotics, massage, chiropractors, herbalists, naturopaths, family planning clinics, homeopaths and biokineticists (fitness assessments) 30.1 Dentistry and orthodontics: Preventative and basic dentistry 30.2 Advanced dentistry (caps, crowns, bridges and cost of endosteal and osseaintegrated implants) 30.3 Orthodontics (subject to orthodontic quotation and prior approval from Scheme) 30.4 All other dental services 34.1 Optometry: Consultations 34.3 Prescription lenses and readymade readers 34.4 Contact lenses 34.5 Fitting of contact lenses 35.1 Refractive surgery and associated costs: Other optometric services (refractive surgery/excimer laser treatment, hospitalisation and associated costs) 36.2 Medicine: Prescribed acute medication R2 400 pfpa R2 520 pfpa 5 R13 580 for a single member R20 470 for a family R14 260 for a single member R21 500 for a family R3 420 pbpa R3 600 pbpa 5.26 R13 580 for a single member R20 500 for a family R14 260 for a single member R21 525 for a family 5 5 5 5 6
PLUS PLAN: FURTHER BENEFIT S EFFECTIVE FROM 1 JANUARY 2016 3.5 Wellness and preventative care (insured) benefits: Pneumococcal vaccine for beneficiaries younger than 60 years 3.11 Bankmed Stress Assessment (online stress assessment) 14.8 Pregnancy and childbirth: Additional insured pathology benefits subject to registration on the Baby and Me programme Benefits subject to registration on the Bankmed Special Care Programmes for asthma, chronic obstructive pulmonary disease, diabetes, cardiovascular disease or HIV/AIDS Benefits for beneficiaries younger than 60 years who have been diagnosed with asthma, chronic obstructive pulmonary disease, diabetes, cardiovascular disease or HIV/AIDS 100 of cost, limited to one assessment pbpa Visit www.bankmed.co.za to do your free online Bankmed Stress Assessment There is no limit on the number of assessments pbpa - Additional pathology at 100 of Scheme rate, subject to Baby and Me care plan /S Registration will no longer be a requirement for benefit allocation Wellness Aware Assessment renamed to Bankmed Stress Assessment Free service as of January 2016 (unlimited) Enhancement: Additional insured pathology benefits subject to registration on the Baby and Me programme PLUS PLAN: DESIGNATED SERVICE PROVIDER (DSP), PREFERRED PROVIDER AND FORMULARY S EFFECTIVE 1 JANUARY 2016 6.1 Ambulance services Preferred provider: Netcare 911 (Call 082 911) 7.1 Hospitalisation: All Netcare, National Hospital Network (NHN), Life Hospital Network DSPs Healthcare and Mediclinic hospitals, any other independent private hospitals contracted to the Scheme, and all State facilities Preferred provider: Discovery 911 (Call 0860 999 911) All Netcare, National Hospital Network (NHN), Life Healthcare, Mediclinic and Clinix hospitals, any other independent private hospitals contracted to the Scheme, and all State facilities /S Discovery 911 replaces Netcare 911 Please note the inclusion of the Clinix hospital network as a DSP Disclaimer: Although every effort was made to ensure complete accuracy of this summary, errors may occur. In the event of a dispute, the registered rules will apply. 7