2017 bonitas brochure cover - compendium insurance group bonitas brochure... · cover for major...

2017PRODUCT BROCHURE

WHY BONITAS? page 2

IMPORTANT INFORMATION page 3

OUR PLANS BONCOMPREHENSIVE page 4

BONCLASSIC page 1 0

BONCOMPLETE page 1 6

BONSAVE page 22

BONFIT page 27

STANDARD page 31

STANDARD SELECT page 37

PRIMARY page 43

BONESSENTIAL page 49

EXCLUSIONS page 52

HOW-TO GUIDEHOW TO CLAIM page 56

GET THE BONITAS BABY BAG page 56

FIND A NETWORK PROVIDER page 57

FIND A SERVICE PROVIDER page 58

INDEX

Please note: Product rules, limits, terms and conditions apply. Where there is a discrepancy between the content provided in this brochure, the website and the Scheme Rules, the Scheme Rules will prevail. The Scheme Rules are available on request. Benefits are subject to approval from the Council for Medical Schemes.

IND

EX

All claims are paid at the Bonitas Rate, unless otherwise stated. All benefits and limits are per calendar year, unless otherwise stated. Managed Care protocols apply. Benefits are subject to approval from the Council for Medical Schemes.

A�ordable, quality healthcare with *93% payout on valid claims

Largest GP network and a specialist network to give more value for money

Simple-to-use plans to meet the needs of all South Africans

Benefits for cancer, mental health, HIV/AIDS, diabetes and more

Preventative care and wellness benefits paid from risk so benefits last longer

Cover for up to 62 chronic conditions and free medicine delivery

Separate benefits for dentistry and optometry on several options

Partnerships with quality service providers and healthcare professionals

Managed Care programmes to help members manage chronic conditions

Additional benefits for maternity and children, including access to 24/7 paediatric telephonic advice, including weekends and public holidays

WHY BONITAS?

*According to Global Credit Rating (GCR) report 2015

WH

Y BON

ITAS?


IMPO

RTAN

T IN

FORM

ATIO

N

PREFERRED PROVIDERS AND DESIGNATED SERVICE PROVIDERS

We negotiate rates with preferred providers and Designated Service Providers to ensure that they do not charge you more than the agreed rate. This will ensure that your benefits last as long as possible and give you more value for money.

Please note: Where you are required to use a Designated Service Provider and you do not do so, a significant co-payment will apply. You can call us on 0860 002 108 or log in to www.bonitas.co.za to view the list of preferred providers and Designated Service Providers.

UNDERSTANDING THE BONITAS RATE

The Bonitas Rate is the rate at which we reimburse healthcare providers.

Where we pay 100% of the Bonitas Rate and your healthcare provider charges more than this, you will have to pay the outstanding amount. For example, if you visit a healthcare provider that charges 200% of the medical aid rate and you receive a bill of R1 000, we will only pay R500.

If you visit a healthcare provider that charges the Bonitas Rate, we will pay the bill in full (provided that you have benefits available).

On some options we pay more than 100% of the Bonitas Rate.

IMPORTANT INFORMATION

PROVIDERS ON THE NETWORK WILL BE PAID IN FULL

We encourage all our members to use providers on our network, as this will ensure that providers are paid in full (provided that you have benefits available).

DEPENDANTS

An adult dependant is any dependant on your medical aid who is 21 years or older.

A child dependant is any dependant on your medical aid who is under 21 years.

If your child is a student and is registered on your medical aid, child rates will apply up to and including the last day of the month in which he/she turns 24 years old. We will require valid proof of registration from a recognised tertiary institution for child rates to apply to a student.

UNDERWRITING

Late-joiner penalties and waiting periods may apply to your membership. This is a requirement of the Medical Schemes Act 131 of 1998.

A late-joiner penalty applies to members over 35 years of age or older, who have had a break in medical aid membership for more than 3 months from 1 April 2001. Late-joiner penalties will result in your premium being increased. This is based on a specific calculation considering the number of years you have not been a member of a medical aid.

A general waiting period lasts 3 months. During this period you and your dependants are not entitled to claim any benefits, except, Prescribed Minimum Benefits in some circumstances.

A condition-specific waiting period lasts 12 months. During this period you and your dependants are not entitled to claim benefits related to a specific condition.

PRORATION OF BENEFITS

If you join Bonitas during the year, benefits will automatically be prorated. This means that you will only have access to a percentage of your benefits, based on the month you join us, until the next benefit year begins. For example, if you join in June, you will have access to six months’ worth of benefits, which is 50% of the total benefits.


BONCOMPREHENSIVE

Main member

Adult dependant

Child dependant

R5 254 R4 956 R1 069

Your 4th and subsequent children will be covered free of charge.

This first-class savings plan offers ample savings, an above threshold benefit and extensive hospital cover.

Unlimited cover up to 300% in hospital Cancer benefit of R556 700 including benefit for specialised drugs

No network restrictions or co-payments on CT scans and MRIs Comprehensive preventative care benefits

Rich savings and above threshold benefits Annual wellness screening and R2 100 for Wellness Extender

Extensive cover for 62 chronic conditions Extensive maternity benefits including private ward

Specialised dentistry and refractive surgery Cover for childhood vaccines and infant paediatric and childhood illness benefits

BON

COM

PREHEN

SIVE

All claims are paid at the Bonitas Rate, unless otherwise stated. All benefi ts and limits are per calendar year, unless otherwise stated. Managed Care protocols apply. Benefi ts are subject to approval from the Council for Medical Schemes.

IN-HOSPITAL BENEFITS Cover for major medical events that result in a benefi ciary being admitted into hospital.

Pre-authorisation is required.

We negotiate extensively with hospitals to ensure the best possible value for our members. Members have access to all private hospitals. A co-payment will apply to admissions at specifi c hospitals. Please call us on 0860 002 108 or log in to www.bonitas.co.za for a list of these hospitals.

GP consultations Unlimited, covered at 300% of the Bonitas Rate

Specialist consultations Unlimited, covered at 300% of the Bonitas Rate

Blood tests and other laboratory tests Unlimited, covered at 100% of the Bonitas Rate

X-rays and ultrasounds Unlimited, covered at 100% of the Bonitas Rate

MRIs and CT scans(specialised radiology)

Unlimited

Pre-authorisation required

Paramedical/Allied medical professionals(such as physiotherapists, occupational therapists, dieticians and biokineticists)

Unlimited, covered at 100% of the Bonitas Rate

Your therapist must get a referral from the doctor treating you in hospital

Internal prosthesisR49 600 per family


External prosthesisR49 600 per family


Internal nerve stimulators R149 100 per family

Cochlear implantsR250 000 per family

You must use a preferred supplier

Mental health hospitalisation

R42 200 per family

No cover for physiotherapy for mental health admissions

You must use a Designated Service Provider

Take-home medicine R490 per benefi ciary, per hospital stay

Physical rehabilitationR44 650 per family


Alternatives to hospital(hospice, step-down facilities)

R14 900 per family


Cancer treatment

R556 700 per family


R220 900 of this can be used for specialised drugs (including biological drugs)

Non-cancer specialised drugs(including biological drugs)

R176 700 per family

Managed Care protocols apply

Organ transplantsUnlimited


Kidney dialysis

Unlimited

You must use a preferred provider


HIV/AIDS Unlimited, if you register on the HIV/AIDS programme

BON

COM

PREH

ENSI

VE


OUT-OF-HOSPITAL BENEFITSThese benefi ts provide cover for consultations with your GP or specialist, acute medicine, x-rays, blood tests and other out-of-hospital medical expenses.

Once your savings for the year are fi nished, you will need to pay for day-to-day medical expenses out of your own pocket until you have paid the full self-payment gap. You will then reach the threshold level and have access to your above threshold benefi t. Please submit all claims you have paid while in the self-payment gap to us, so that we can keep a record. Not all claims accumulate to the threshold level.

Please note: You must get a GP referral for specialist consultations (excluding consultations with oncologists and ophthalmologists; maternity consultations and consultations with paediatricians for children under age 2).

GP consultations Paid from available savings and/or above threshold benefi t

Specialist consultations

Paid from available savings and/or above threshold benefi t

You must get a referral from your GP

Blood tests and other laboratory tests Paid from available savings and/or above threshold benefi t

X-rays and ultrasounds Paid from available savings and/or above threshold benefi t


R28 200 per family


Acute medicine Paid from available savings and/or above threshold benefi t

Over-the-counter medicine Paid from available savings and/or above threshold benefi t



Mental health consultations

R14 300 per family

In and out-of-hospital consultations (included in the mental health hospitalisation benefi t)

No cover for educational psychologists for benefi ciaries older than 21 years

Refractive surgeryR18 700 per family


General medical appliances(such as wheelchairs and crutches)

R7 550 per family

Stoma care and CPAP machines may exceed the general medical appliances limit by R5 550 per family

Foot orthotics paid from available savings


Hearing aids

R23 200 per family, once every 2 years (based on the date of your previous claim) 10% co-payment applies


Optometry

Limited to R2 880, once every 2 years (based on the date of your previous claim) per benefi ciary


Basic dentistry Paid from available savings and/or above threshold benefi t

Consultations Once per benefi ciary, every 6 months

X-rays: Intra-oral Managed Care protocols apply

X-rays: Extra-oral

1 per benefi ciary, every 3 years

Additional benefi ts may be considered where specialised dental treatment is required

Mainmember

Adultdependant

Childdependant

Savings R11 892 R11 220 R 2 424

Self-payment gap R 3 600 R 2 980 R 1 370

Threshold level R15 492 R14 200 R 3 794

Above threshold benefi t Unlimited Unlimited Unlimited

BON

COM

PREHEN

SIVE


Oral hygiene

Once per beneficiary, every 6 months

Fissure sealants are only covered for children under 16 years

Fluoride treatments are only covered for children from age 5 and younger than 16 years

Fillings

Benefit for fillings is granted once per tooth, in 365 days

Benefit for re-treatment of a tooth is subject to Managed Care protocols

A treatment plan and x-rays may be required for multiple fillings

Root canal therapy and extractions Managed Care protocols apply

Plastic dentures and associated laboratory costs

1 set of plastic dentures (an upper and a lower) per beneficiary, once every 4 years

Specialised dentistry Paid from available savings and/or above threshold benefit

Partial metal frame dentures and associated laboratory costs

2 partial frames (an upper and a lower) per beneficiary, once every 5 years


Crowns, bridges and associated laboratory costs

3 crowns per family, per year

Benefit for crowns will be granted once per tooth, every 5 years

A treatment plan and x-rays may be requested


Implants and associated laboratory costs

2 implants per beneficiary, once every 5 years

Cost of implant components is limited to R2 350 per implant



Orthodontics and associated laboratory costs

Orthodontic treatment is granted once per beneficiary, per lifetime

Pre-authorisation cases will be clinically assessed by using an orthodontic needs analysis

Benefit allocation is subject to the outcome of the needs analysis and funding can be granted up to 100% of the Bonitas Dental Tariff

Benefit for orthodontic treatment will be granted where function is impaired (not granted for cosmetic reasons)

Only 1 family member may begin orthodontic treatment in a calendar year

Benefit for fixed comprehensive treatment is limited to beneficiaries from age 9 and younger than 18 years



Periodontics

Benefit is limited to conservative, non-surgical therapy only and will only be applied to members who are registered on the Periodontal Programme



Maxillo-facial surgery and oral pathology

Surgery in the dental chair Managed Care protocols apply

Hospitalisation (general anaesthetic)

General anaesthetic is only available to children under the age of 5 for extensive dental treatment

General anaesthetic benefit is available for the removal of impacted teeth



Laughing gas in dental rooms Managed Care protocols apply

BON

COM

PREH

ENSI

VE


IV conscious sedation in rooms

Limited to extensive dental treatment



Scheme exclusions Please see page 52

CHRONIC BENEFITSBonComprehensive off ers extensive cover for the 62 chronic conditions listed below. This is limited to R12 450 per benefi ciary and R24 800 per family on the applicable formulary. Pre-authorisation is required. If you use medicine that is not listed on the formulary, you will have to pay a 40% co-payment.

You can get your medicine from any pharmacy.

Once the amount above is fi nished, you will still be covered for the 27 Prescribed Minimum Benefi ts, listed below.

Prescribed Minimum Benefi ts covered

1. Addison’s Disease 10. Crohn’s Disease 19. Hyperlipidaemia

2. Asthma 11. Diabetes Insipidus 20. Hypertension

3. Bipolar Mood Disorder 12. Diabetes Type 1 21. Hypothyroidism

4. Bronchiectasis 13. Diabetes Type 2 22. Multiple Sclerosis

5. Cardiac Failure 14. Dysrhythmias 23. Parkinson’s Disease

6. Cardiomyopathy 15. Epilepsy 24. Rheumatoid Arthritis

7. Chronic Obstructive Pulmonary Disease

16. Glaucoma 25. Schizophrenia

8. Chronic Renal Disease 17. Haemophilia 26. Systemic Lupus Erythematosus

9. Coronary Artery Disease

18. HIV/AIDS 27. Ulcerative Colitis

Additional conditions covered

28. Acne 40. Depression 52. Osteoporosis

29. Allergic Rhinitis 41. Eczema 53. Paget's Disease

30. Alzheimer’s Disease (early onset)

42. Gastro-Oesophageal Refl ux Disease (GORD)

54. Panic Disorder

31. Ankylosing Spondylitis 43. Generalised Anxiety Disorder

55. Pemphigus

32. Anorexia Nervosa 44. Gout 56. Polyarteritis Nodosa

33. Attention Defi cit Disorder (in children aged 5-18)

45. Huntington's Disease 57. Post-Traumatic Stress Disorder

34. Barrett's Oesophagus 46. Hyperthyroidism 58. Pulmonary Interstitial Fibrosis

35. Behcet's Disease 47. Hypoparathyroidism 59. Psoriatic Arthritis

36. Bulimia Nervosa 48. Myaesthenia Gravis 60. Systemic Sclerosis

37. Cystic Fibrosis 49. Narcolepsy 61. Tourette's Syndrome

38. Dermatitis 50. Neuropathies 62. Zollinger-Ellison Syndrome

39. Dermatomyositis 51. Obsessive Compulsive Disorder

BON

COM

PREHEN

SIVE


SUPPLEMENTARY BENEFITSWe believe in giving you more value. These additional benefi ts will not aff ect your other benefi t limits or savings.

Maternity care

Per pregnancy

Private ward after delivery

12 antenatal consultations with a gynaecologist, GP or midwife

2 2D ultrasound scans

R1 100 for antenatal classes

1 amniocentesis

4 consultations with a midwife after delivery

A Bonitas baby bag (you must register for this after obtaining pre-authorisation for the delivery)

Babyline

For children under 21⁄2 yearsAccess to telephone helpline for 24/7 medical advice, including weekends and holidays

Infant paediatric benefi t

Children under 1 year 3 consultations with a paediatrician

Children between ages 1 and 2 2 consultations with a paediatrician

Childhood illness benefi t

Children between ages 2 and 12 2 GP consultations

Preventative care

General health1 HIV test per benefi ciary

1 fl u vaccine per benefi ciary

Cardiac health 1 full lipogram every 5 years, for members aged 20 and over

Children’s health

1 thyroid stimulating hormone test for infants under 1 month old

Childhood immunisations according to Expanded Programme on Immunisation in South Africa

Women’s health

1 mammogram every 2 years, for women between ages 40 and 74

1 pap smear every 3 years, for women between ages 21 and 65

Men’s health

1 prostate screening antigen test for men between ages 55 and 69, who are considered to be at high risk for prostate cancer

Elderly health

1 pneumococcal vaccine every 5 years, for members aged 65 and over

1 stool test for colon cancer, for members between ages 50 and 75

1 bone density screening every 5 years, for women aged 65 and over

Wellness benefi ts

Wellness screening

1 wellness screening per benefi ciary at a participating pharmacy, biokineticist or a Bonitas wellness day

Wellness screening includes the following tests:• Blood pressure• Glucose• Cholesterol• Body mass index• Waist-to-hip ratio

Wellness Extender

R2 100 per family

Each benefi ciary must complete a wellness screening and register for this benefi t. You may then choose from the following additional benefi ts:• GP consultation(s)• Biokineticist consultation(s)• Dietician consultation(s)• Physiotherapy consultation(s)• A programme to stop smoking

All claims are paid at the Bonitas Rate

BON

COM

PREH

ENSI

VE


BONCLASSICThis generous savings option offers a wide range of medical benefits, in and out of hospital.

Main member

Adult dependant

Child dependant

R3 648 R3 132 R 900Your 4th and subsequent children will be covered free of charge.

Unlimited cover up to 100% in hospital Separate benefits for physiotherapy, blood and laboratory tests and paramedical services

Network specialists paid in full in hospital Cover for 48 chronic conditions

No co-payments for CT scans and MRIs Benefit for non-cancer specialised drugs (including biological drugs)

Generous savings and additional benefits for optometry Generous preventative care and maternity benefits

Cover for basic and specialised dentistry including orthodontics Annual wellness screening and R1 450 for Wellness Extender

BON

CLASSIC


IN-HOSPITAL BENEFITSCover for major medical events that result in a benefi ciary being admitted into hospital.





Unlimited, network specialists covered in full

Unlimited, non-network specialists paid at 100% of the Bonitas Rate




R26 100 per family, in and out of hospital


Paramedical/Allied medicalprofessionals(such as physiotherapists, occupational therapists, dieticians and biokineticists)



Internal and external prostheses

R49 150 per family

If you do not use the preferred provider for hip and knee replacements, you will have to pay a R5 300 co-payment




Spinal surgery

You will have to pay a R5 300 co-payment if you do not go for an assessment through the back and neck rehabilitation programme




R37 100 per family






Alternatives to hospital (hospice, step-down facilities)

R14 900 per family


Cancer treatment

R369 500 per family



Non-cancer specialised drugs (including biological drugs)

R110 400 per family

10% co-payment applies



Organ transplants



Kidney dialysisUnlimited, at a preferred provider



BON

CLAS

SIC


OUT-OF-HOSPITAL BENEFITS These benefi ts provide cover for consultations with your GP or specialist, acute medicine, x-rays, blood tests and other out-of-hospital medical expenses.

GP consultations Paid from available savings

Specialist consultationsPaid from available savings


Blood tests and other laboratory testsR2 800 per benefi ciary

R6 200 per family

X-rays and ultrasoundsR2 800 per benefi ciary

R4 340 per family




Acute medicine Paid from available savings

Over-the-counter medicine Paid from available savings


Main member onlyR2 670

Main member + 1 dependantR4 090

Main member + 2 dependantsR4 720

Main member + 3 dependantsR5 040

Main member + 4 or more dependantsR5 400

Physical therapyR1 380 per benefi ciary

R2 800 per family


R14 300 per family




R7 000 per family


Hearing aids

R15 200 per family, once every 3 years (based on the date of your previous claim)



Optometry


Each benefi ciary can choose glasses or contact lenses

Eye tests

1 per benefi ciary, once every 2 years at a network provider, at network rates

OR

R350 per benefi ciary, at a non-network provider

Single vision lenses (Clear) or

100% towards the cost of lenses at network rates

R150 per lens, per benefi ciary, out of network

Bifocal lenses (Clear) or



Multifocal lenses (Clear)



Frames R740 per benefi ciary, once every 2 years

Mainmember

Adultdependant

Childdependant

Savings R6 192 R5 316 R1 524

BON

CLASSIC


Contact lenses R1 790 per beneficiary, included in family limit

Basic dentistryR4 200 per family, per year

Covered at the Bonitas Dental Tariff

Consultations 2 annual check-ups per beneficiary (once every 6 months)


X-rays: Extra-oral

1 per beneficiary, every 3 years

Additional benefits may be considered if specialised dental treatment is required

Oral hygiene

2 annual scale and polish treatments per beneficiary (once every 6 months)



Fillings








Specialised dentistryR5 050 per family, per year



2 partial frames (an upper and a lower) per beneficiary, once every 5 years



1 crown per family, per year



You must use a provider on the DENIS network



No benefit










Periodontics




BON

CLAS

SIC




Hospitalisation(general anaesthetic)

A co-payment of R3 000 per hospital admission and admission protocols apply


General anaesthetic benefi t is available for the removal of impacted teeth









CHRONIC BENEFITSBonClassic off ers generous cover for 48 chronic conditions. Cover is limited to R10 200 per benefi ciary and R21 100 per family on the applicable formulary. If you choose to use medicine that is not on the formulary, you will have to pay a 40% co-payment.

Pre-authorisation is required. You can get your medicine from any pharmacy on our network.

Once the amount above is fi nished, you will still be covered for the 27 Prescribed Minimum Benefi ts, listed below, from our Designated Service Provider. If you do not use the Designated Service Provider, you will have to pay a 40% co-payment.














28. Alzheimer’s Disease (early onset)

35. Gastro-Oesophageal Refl ux Disease (GORD)

42. Panic Disorder

29. Ankylosing Spondylitis

36. Generalised Anxiety Disorder

43. Polyarteritis Nodosa

30. Attention Defi cit Disorder (in children aged 5-18)

37. Gout 44. Pulmonary Interstitial Fibrosis

31. Barrett's Oesophagus 38. Hypoparathyroidism 45. Post-Traumatic Stress Disorder

32. Benign Prostatic Hypertrophy

39. Obsessive Compulsive Disorder

46. Scleroderma

33. Depression 40. Osteoporosis 47. Tourette's Syndrome

34. Eczema 41. Paget's Disease 48. Zollinger-Ellison Syndrome

BON

CLASSIC


SUPPLEMENTARY BENEFITSWe believe in giving you more value. These additional benefi ts will not aff ect your other benefi t limits and savings.

Maternity care

Per pregnancy




1 amniocentesis



Babyline


Preventative care




Women’s health



Elderly health



1 bone density screening every 5 years, for women aged 65 and over

Wellness benefi ts

Wellness screening



Wellness Extender

R1 450 per family



BON

CLAS

SIC


BONCOMPLETE

Main member

Adult dependant

Child dependant

R2 923 R2 340 R 794

This savings option offers generous savings, an above threshold benefit and rich hospital cover.


Unlimited cover up to 100% in hospital Additional benefit for basic dentistry

Network specialists paid in full in hospital Cover for 31 chronic conditions

Additional benefit for take-home medicine after hospital stay Childhood illness, infant paediatric and maternity benefits

No co-payments for CT scans and MRIs Generous preventative care benefits

Savings and above threshold benefits Annual wellness screening and R1 450 for Wellness Extender

BON

COM

PLETE














Paramedical/Allied medicalprofessionals(such as physiotherapists, occupational therapists, dieticians and biokineticists)




R39 800 per family





Spinal surgery



R29 000 per family







R14 900 per family


Cancer treatment

R310 150 per family








BON

COM

PLET

E


OUT-OF-HOSPITAL BENEFITS

These benefi ts provide cover for consultations with your GP or specialist, acute medicine, x-rays, blood tests and other out of hospital medical expenses.

Once your savings for the year are fi nished, you will need to pay for day-to-day medical expenses out of your own pocket until you have paid the full self-payment gap. You will then reach the threshold level and have access to your above threshold benefi t. Please submit all claims you have paid while in the self-payment gap to us, so that we can keep a record. Not all claims accumulate to the threshold level.


GP consultations Paid from available savings and/or above threshold benefi t




Blood tests and other laboratory tests Paid from available savings and/or above threshold benefi t

X-rays and ultrasounds Paid from available savings and/or above threshold benefi t




Acute medicine Paid from available savings and/or above threshold benefi t

Over-the-counter medicine Paid from available savings and/or above threshold benefi t



Mainmember

Adultdependant

Childdependant

Savings R5 256 R4 200 R1 428

Self-payment gap R1 568 R1 326 R 336

Threshold level R6 824 R5 526 R1 764

Above threshold benefi t R4 150 R2 450 R1 060


R14 300 per family

In and out of hospital consultations (included in the mental health hospitalisation benefi t)






Hearing aids


Available once every 2 years (based on the date of your previous claim)


OptometryPaid from available savings and/or above threshold benefi t, once every 2 years (based on the date of your previous claim)

Basic dentistry Covered at the Bonitas Dental Tariff

Consultations 2 annual check-ups per benefi ciary (once every 6 months)


X-rays: Extra-oral


Additional benefi ts may be considered if specialised dental treatment is required

Oral hygiene

2 annual scale and polish treatments per benefi ciary (once every 6 months)



BON

COM

PLETE


Fillings







Specialised dentistry Covered at the Bonitas Dental Tariff


1 partial frame (an upper or a lower) per beneficiary, once every 5 years









No benefit










Periodontics









General anaesthetic benefit is available for the removal of impacted teeth



BON

COM

PLET

E








CHRONIC BENEFITSBonComplete off ers cover for 31 chronic conditions, using the applicable formulary.Pre-authorisation is required.

You must use our Designated Service Provider to get your medicine. If you do not use the Designated Service Provider or if you use medicine that is not on the formulary, you will have to pay a 40% co-payment.













Additional conditions covered for children

28. Acne 30. Allergic Dermatitis / Eczema

31. Attention Defi cit Disorder(in children aged 5-18)

29. Allergic Rhinitis


Maternity care

Per pregnancy




1 amniocentesis



Babyline




Children between ages 1 and 2 1 consultation with a paediatrician


Children between ages 2 and 12 1 GP consultation

Preventative care




Women’s health



BON

COM

PLETE


Elderly health



Wellness benefits

Wellness screening

1 wellness screening per beneficiary at a participating pharmacy, biokineticist or a Bonitas wellness day


Wellness Extender

R1 450 per family

Each beneficiary must complete a wellness screening and register for this benefit. You may then choose from the following additional benefits:• GP consultation(s)• Biokineticist consultation(s)• Dietician consultation(s)• Physiotherapy consultation(s)• A programme to stop smoking


BON

COM

PLET

E


BONSAVEThis savings option offers sufficient savings to use as you choose for medical expenses and extensive hospital cover.

Main member

Adult dependant

Child dependant

R2 135 R1 654 R 640 Your 4th and subsequent children will be covered free of charge.

Unlimited cover up to 150% in hospital Savings plus additional benefit for basic dentistry

Specialists paid at 150% in hospital Cover for up to 6 additional GP consultations after savings are finished

No co-payments for CT scans and MRIs 27 PMB chronic conditions covered

Reasonable co-payments for certain in-hospital procedures Childhood illness, infant paediatric and maternity benefits

Additional benefit for take-home medicine after hospital stay Annual wellness screening and R1 050 for Wellness Extender

BON

SAVE






Specialist consultations Unlimited, covered at 150% of the Bonitas Rate










PMB only





R29 000 per family







R14 900 per family


Cancer treatment

R310 150 per family





Kidney dialysis

Unlimited

You must use the Designated Service Provider



BON

SAVE


A co-payment will apply to the following procedures in hospital

R1 300 co-payment R3 300 co-payment R6 500 co-payment

1. Colonoscopy 1. Arthroscopy 1. Back Surgery including Spinal Fusion

2. Conservative Back Treatment

2. Diagnostic Laparoscopy

2. Joint Replacements

3. Cystoscopy 3. Laparoscopic Hysterectomy

3. Laparoscopic Pyeloplasty

4. Facet Joint Injections 4. Laparoscopic Appendectomy

4. Laparoscopic Radical Prostatectomy

5. Flexible Sigmoidoscopy 5. Percutaneous Radiofrequency Ablations (Percutaneous Rhizotomies)

5. Nissen Fundoplication (Refl ux Surgery)

6. Functional Nasal Surgery

7. Gastroscopy

8. Hysteroscopy (not Endometrial Ablation)

9. Myringotomy

10. Tonsillectomy and Adenoidectomy

11. Umbilical Hernia Repair

12. Varicose Vein Surgery





Acute medicine and over-the-counter medicine

Paid from available savings

X-rays and ultrasounds Paid from available savings




Blood tests and other laboratory tests Paid from available savings


R14 300 per family






R6 200 per family




Optometry Paid from available savings


Consultations 2 annual check-ups per benefi ciary (once every 6 months)


Mainmember

Adultdependant

Childdependant

Savings R4 104 R3 180 R1 236

BON

SAVE


X-rays: Extra-oral


Additional benefi ts may be considered if specialised dental treatment is required

Oral hygiene

2 annual scale and polish treatments per benefi ciary (once every 6 months)



Fillings

Benefi t for fi llings is granted once per tooth, in 365 days

Benefi t for re-treatment of a tooth is subject to Managed Care protocols

A treatment plan and x-rays may be required for multiple fi llings

Root canal therapy and extractions

Benefi t for root canal includes all teeth except primary teeth and permanent molars



1 set of plastic dentures (an upper and a lower) per benefi ciary, once every 4 years

Specialised dentistry No benefi t















CHRONIC BENEFITSBonSave ensures that you are covered for the 27 Prescribed Minimum Benefi ts listed below on the applicable formulary. Pre-authorisation is required. If you do not use our Designated Service Provider or if you use medicine that is not on the formulary, you will have to pay a 40% co-payment.













BON

SAVE



Additional GP consultations

If you use all your savings for the year, your family will still get a maximum of 6 GP consultations (limited to 3 per benefi ciary) paid at the Bonitas Rate

Maternity care

Per pregnancy




1 amniocentesis



Babyline







Preventative care



Women’s health 1 pap smear every 3 years, for women between ages 21 and 65

Elderly health



Wellness benefi ts

Wellness screening



Wellness Extender

R1 050 per family



BON

SAVE


BONFITThis savings plan offers basic cover for day-to-day medical needs and essential hospital cover.

Main member

Adult dependant

Child dependant

R1 789 R1 385 R 535 Your 4th and subsequent children will be covered free of charge.

Unlimited cover up to 100% at hospitals on the BonFit network Basic savings for day-to-day medical expenses

Network specialists paid in full in hospital 27 PMB chronic conditions covered

No co-payments for CT scans and MRIs Childhood illness, infant paediatric and maternity benefits

Reasonable co-payments for certain in-hospital procedures Basic preventative care benefits

Additional benefit for take-home medicine after hospital stay Annual wellness screening and R1 050 for Wellness Extender

BON

FIT


IN-HOSPITAL BENEFITSCover for major medical events that result in a benefi ciary being admitted into hospital. You must use a hospital on the BonFit network or you will have to pay a 30% co-payment.




Unlimited, network specialists coveredin full





Unlimited


Paramedical/Allied medical professionals (such as physiotherapists, occupational therapists, dieticians and biokineticists)




PMB only





R29 000 per family







R14 900 per family


Cancer treatment

R310 150 per family





Kidney dialysis

Unlimited














5. Flexible Sigmoidoscopy 5. Percutaneous Radiofrequency Ablations (Percutaneous Rhizotomies)



7. Gastroscopy


9. Myringotomy




BON

FIT






Blood tests and other laboratory tests Paid from available savings

X-rays and ultrasounds Paid from available savings




Acute medicine Paid from available savings

Over-the-counter medicine Paid from available savings




PMB consultations only



General medical appliances Paid from available savings

Optometry Paid from available savings

Basic dentistryPaid from available savings


Consultations Paid from available savings

X-rays: Intra-oral Paid from available savings

X-rays: Extra-oral Paid from available savings

Oral hygiene Paid from available savings

Fillings Paid from available savings

Root canal therapy and extractions Paid from available savings



Surgery in the dental chairManaged Care protocols apply




General anaesthetic is only available to children under the age of 5 years for extensive dental treatment

General anaesthetic benefi ts are available for the removal of impacted teeth

BonFit hospital network applies










Mainmember

Adultdependant

Childdependant

Savings R3 228 R2 496 R 960

BON

FIT


CHRONIC BENEFITSBonFit ensures that you are covered for the 27 Prescribed Minimum Benefi ts listed below on the applicable formulary. Pre-authorisation is required. If you do not use our Designated Service Provider or if you use medicine that is not on the formulary, you will have to pay a 40% co-payment.














Maternity care

Per pregnancy



1 amniocentesis



Babyline







Preventative care




Elderly health



Wellness benefi ts

Wellness screening



Wellness Extender

R1 050 per family



BON

FIT


This traditional option offers rich day-to-day benefits and comprehensive hospital cover.

Main member

Adult dependant

Child dependant

R2 998 R2 600 R 880

STANDARD


Unlimited cover up to 100% in hospital Rich day-to-day benefits plus optometry benefit

Network specialists paid in full in hospital Cover for basic and specialised dentistry including orthodontics

Additional benefit for take-home medicine after hospital stay Cover for 44 chronic conditions


Separate benefit for GP consultations Annual wellness screening and R1 450 for Wellness Extender

STAN

DARD


IN-HOSPITAL BENEFITS Cover for major medical events that result in a benefi ciary being admitted into hospital.







Blood and other laboratory tests Unlimited, covered at 100% of the Bonitas Rate









R39 800 per family





Spinal surgery






R36 550 per family







R14 900 per family


Cancer treatment

R310 150 per family








STANDARD


OUT-OF-HOSPITAL BENEFITSOut-of-hospital claims will be paid from available day-to-day benefi ts. There is a separate benefi t for GP consultations.

GP consultationsIf you do not use a GP on our network, your benefi t for GP consultations will be limited to the non-network GP consultation benefi t. This is shown in the table below.

Main member only R3 750 (R1 220 of this can be used for non-network GP consultations)

Main member + 1 dependant R5 500 (R1 880 of this can be used for non-network GP consultations)

Main member + 2 dependants R6 100 (R2 050 of this can be used for non-network GP consultations)

Main member + 3 dependants R6 400 (R2 150 of this can be used for non-network GP consultations)

Main member + 4 or more dependants R6 950 (R2 320 of this can be used for non-network GP consultations)

Day-to-day benefi tsThese benefi ts provide cover for consultations with your specialist, acute medicine, x-rays, blood tests and other out-of-hospital medical expenses.


Main member only R 5 232

Main member + 1 dependant R 7 970

Main member + 2 dependants R 9 214

Main member + 3 dependants R10 062

Main member + 4 or more dependants R10 966

Specialist consultationsPaid from available day-to-day benefi ts


Blood tests and other laboratory tests Paid from available day-to-day benefi ts

X-rays and ultrasounds Paid from available day-to-day benefi ts




Acute medicine Paid from available day-to-day benefi ts

Over-the-counter medicine

R700 per benefi ciary

R2 121 per family

Paid from available day-to-day benefi ts




R14 300 per family




R6 900 per family

Stoma care products and CPAP machines may exceed the general medical appliances limit by R5 900 per family

No benefi t for foot orthotics


Hearing aids




Optometry

R5 550 per family, once every 2 years (based on the date of your previous claim) Each benefi ciary can choose glasses or contact lenses

Eye tests

1 per benefi ciary, once every 2 years at a network provider, at network rates

OR

R350 per benefi ciary, once every 2 years at a non-network provider

STAN

DARD




R150 per lens, per beneficiary, out of network







Frames R850 per beneficiary, once every 2 years

Contact lenses R1 850 per beneficiary (included in the family limit)




X-rays: Extra-oral


Additional benefit may be considered if specialist dental treatment planning/follow up is required

Oral hygiene




Fillings




Root canal and extractions Managed Care protocols apply





1 partial frame (an upper or lower) per beneficiary, once every 5 years









No benefit










STANDARD


Periodontics

Benefi t is limited to conservative, non-surgical therapy only and will only be applied to members who are registered on the Periodontal Programme

















CHRONIC BENEFITSThe Standard Option off ers cover for 44 chronic conditions. Cover is limited to R8 650 per benefi ciary and R17 350 per family on the applicable formulary. Pre-authorisation is required. If you choose to use medicine that is not on the formulary, you will have to pay a 40% co-payment. You can get your medicine from any pharmacy on our network.

Once the amount above is fi nished, you will still be covered for the 27 Prescribed Minimum Benefi ts, listed below, through the Designated Service Provider. If you do not use the Designated Service Provider, you will have to pay a 40% co-payment.














28. Acne 34. Dermatitis 40. Obsessive Compulsive Disorder

29. Allergic Rhinitis 35. Depression 41. Panic Disorder


36. Eczema 42. Post-Traumatic Stress Disorder


37. Gastro-Oesophageal Refl ux Disease(GORD)

43. Tourette’s Syndrome

32. Barrett’s Oesophagus 38. Gout 44. Zollinger-Ellison Syndrome

33. Behcet’s Disease 39. Narcolepsy

STAN

DARD


SUPPLEMENTARY BENEFITS

We believe in giving you more value. These additional benefi ts will not aff ect your other benefi t limits.

Maternity care

Per pregnancy




1 amniocentesis



Babyline











Women’s health



Elderly health



Wellness benefi ts

Wellness screening



Wellness Extender

R1 450 per family



STANDARD


STANDARD SELECT

Main member

Adult dependant

Child dependant

R2 597 R2 247 R 760

This traditional option uses a quality provider network to offer rich day-to-day benefits and hospital cover.


Unlimited cover up to 100% at hospitals on the Standard Select network Rich day-to-day benefits plus optometry benefit

Network specialists paid in full in hospital Cover for basic and specialised dentistry including orthodontics

Additional benefit for take-home medicine after hospital stay Cover for 44 chronic conditions


Separate benefit for GP consultations Annual wellness screening and R1 450 for Wellness Extender

STAN

DARD

SEL

ECT


IN-HOSPITAL BENEFITS Cover for major medical events that result in a benefi ciary being admitted into hospital. Please note: You must use a hospital on the Standard Select network or you will have to pay a 30% co-payment.















R39 800 per family

You must use a Designated Service Provider for hip and knee replacements




Spinal surgery






R36 550 per family







R14 900 per family


Cancer treatment

R310 150 per family





Kidney dialysis

Unlimited




STANDARD

SELECT


OUT-OF-HOSPITAL BENEFITSOut-of-hospital claims will be paid from available day-to-day benefi ts. There is a separate benefi t for GP consultations.

GP consultationsYou must choose 1 GP on our network for each benefi ciary. This is your nominated GP for the year. If you do not use your nominated GP, your benefi t will be limited to the non-nominated GP consultation benefi t as indicated in the table below.

Main member only R3 750 (R1 220 of this can be used for non-nominated GP consultations)

Main member + 1 dependant R5 500 (R1 880 of this can be used for non-nominated GP consultations)

Main member + 2 dependants R6 100 (R2 050 of this can be used for non-nominated GP consultations)

Main member + 3 dependants R6 400 (R2 150 of this can be used for non-nominated GP consultations)

Main member + 4 or more dependants R6 950 (R2 320 of this can be used for non-nominated GP consultations)

Day-to-day benefi ts

These benefi ts provide cover for consultations with your specialist, acute medicine, x-rays, blood tests and other out-of-hospital medical expenses.


Main member only R 5 232

Main member + 1 dependant R 7 970

Main member + 2 dependants R 9 2 1 4








R23 500 per family, in and out of hospital Pre-authorisation required



R700 per benefi ciary

R2 121 per family





R14 300 per family




R6 900 per family

Stoma care products and CPAP machines may exceed the general medical appliances limit by R5 900 per family

No benefi t for foot orthotics


Hearing aids


20% co-payment


Optometry


Each benefi ciary can choose glasses or contact lenses

Eye tests

1 per benefi ciary, once every 2 years at a network provider at network rates

OR

R350 per benefi ciary, once every 2 years at a non-network provider

STAN

DARD

SEL

ECT












Contact lenses R1 850 per beneficiary, included in the family limit




X-rays: Extra-oral


Additional benefits may be considered if specialised dental treatment is required

Oral hygiene




Fillings









1 partial frame (an upper or a lower) per beneficiary, once every 5 years




You must use a provider on the DENIS network and pre-authorise this procedure




No benefit










STANDARD

SELECT


Periodontics

Benefi t is limited to conservative, non-surgical therapy only and will only be applied to members who are registered on the Periodontal Programme









Standard Select hospital network applies









CHRONIC BENEFITSStandard Select off ers cover for 44 chronic conditions. Cover is limited to R8 650 per benefi ciary and R17 350 per family using the applicable formulary. Pre-authorisation is required. If you do not get your medicine from our Designated Service Provider or if you use medicine that is not listed on the formulary, you will have to pay a 40% co-payment.

Once the amount above is fi nished, you will still be covered for the 27 Prescribed Minimum Benefi ts, listed below.














28. Acne 34. Dermatitis 40. Obsessive Compulsive Disorder

29. Allergic Rhinitis 35. Depression 41. Panic Disorder


36. Eczema 42. Post-Traumatic Stress Disorder


37. Gastro-Oesophageal Refl ux Disease(GORD)

43. Tourette’s Syndrome

32. Barrett’s Oesophagus 38. Gout 44. Zollinger-Ellison Syndrome

33. Behcet’s Disease 39. Narcolepsy

STAN

DARD

SEL

ECT


SUPPLEMENTARY BENEFITSWe believe in giving you more value. These additional benefi ts will not aff ect your other benefi t limits.

Maternity care

Per pregnancy




1 amniocentesis



Babyline







Preventative care




Women’s health



Elderly health



Wellness benefi ts

Wellness screening



Wellness Extender

R1 450 per family


All claims are paid at the Bonitas Rate STANDARD

SELECT


PRIMARYThis traditional option offers simple day-to-day benefits and hospital cover.

Main member

Adult dependant

Child dependant


Unlimited cover up to 100% in hospital Separate benefit for GP consultations

Network specialists paid in full in hospital Rich day-to-day benefits plus basic dentistry and optometry benefits

Additional benefit for take-home medicine after hospital stay 27 PMB chronic conditions covered

Reasonable co-payments for certain in-hospital procedures Childhood illness, infant paediatric and maternity benefits

No co-payments for CT scans and MRIs Annual wellness screening and R1 050 for Wellness Extender

PRIM

ARY


















PMB only





R14 250 per family







R14 900 per family


Cancer treatment

R149 000 per family



Organ transplantsPMB only


Kidney dialysis

PMB only




PRIMARY












5. Flexible Sigmoidoscopy 5. Percutaneous Radiofrequency Ablations

(Percutaneous Rhizotomies)



7. Gastroscopy


9. Myringotomy




OUT-OF-HOSPITAL BENEFITS

Out-of-hospital claims will be paid from available day-to-day benefi ts. There is a separate benefi t for GP consultations.

GP consultationsIf you do not use a GP on our network, your benefi t for GP consultations will be limited to the non-network GP consultation benefi t. This is shown in the table below.

Main member only R1 800 (R580 of this may be used for non-network GP consultations)

Main member + 1 dependant R3 300 (R1 100 of this may be used fornon-network GP consultations)

Main member + 2 dependants R3 900 (R1 250 of this may be used fornon-network GP consultations)

Main member + 3 dependants R4 200 (R1 400 of this may be used for non-network GP consultations)

Main member + 4 or more dependants R4 750 (R1 650 of this may be used for non-network GP consultations)

Day-to-day benefi ts

These benefi ts provide cover for consultations with your specialist, acute medicine, x-rays, blood tests and other out-of-hospital medical expenses.


Main member only R1 900

Main member + 1 dependant R3 400












PRIM

ARY



R1 290 per family

R440 per beneficiary

Paid from available day-to-day benefits


Paid from available day-to-day benefits


R8 600 per family

In and out-of-hospital consultations (included in the mental health hospitalisation benefit)

No cover for educational psychologists for beneficiaries older than 21 years


R6 200 per family


No benefit for foot orthotics


Optometry


Each beneficiary can choose glasses or contact lenses

Eye tests

1 per beneficiary, once every 2 years at a network provider at network rates

OR

R350 per beneficiary, once every 2 years at a non-network provider











Contact lenses R1 225 per beneficiary, included in the family limit

Basic dentistry





X-rays: Extra-oral 1 per beneficiary, every 3 years

Oral hygiene




Fillings




Root canal therapy and extractions


Benefit for root canal includes all teeth except primary teeth and permanent molars



PRIMARY

















CHRONIC BENEFITSThe Primary Option ensures that you are covered for the 27 Prescribed Minimum Benefi ts listed below on the applicable formulary. Pre-authorisation is required. If you do not use our Designated Service Provider or if you use medicine that is not on the formulary, you will have to pay a 40% co-payment.













PRIM

ARY


PRIMARY


Maternity care

Per pregnancy



1 amniocentesis



Babyline



Children under 1 year 1 consultation with a paediatrician




Preventative care




Elderly health



Wellness benefi ts

Wellness screening



Wellness Extender

R1 050 per family




BONESSENTIALThis hospital plan offers rich hospital benefits with some value-added benefits.

Main member

Adult dependant

Child dependant


Unlimited cover up to 100% in hospital 27 PMB chronic conditions covered

Network specialists paid in full in hospital Childhood illness and maternity benefits

Additional benefit for take-home medicine after hospital stay Basic preventative care benefits

Reasonable co-payments for certain in-hospital procedures Annual wellness screening and R750 for Wellness Extender

BON

ESSE

NTI

AL


IN-HOSPITAL BENEFITSCover for major medical events that result in a benefi ciary being admitted into hospital. Pre-authorisation is required.









Unlimited






PMB only





R29 000 per family

Physiotherapy will be excluded for all mental health admissions






R14 900 per family


Cancer treatment

R310 150 per family,



Organ transplants Unlimited, pre-authorisation required

Kidney dialysis

Unlimited, at a Designated Service Provider














5. Flexible Sigmoidoscopy 5. Percutaneous Radiofrequency Ablations

(Percutaneous Rhizotomies)



7. Gastroscopy


9. Myringotomy




BON

ESSENTIAL


CHRONIC BENEFITSBonEssential ensures that you are covered for the 27 Prescribed Minimum Benefi ts listed below on the applicable formulary. Pre-authorisation is required. If you do not use our Designated Service Provider or if you use medicine that is not on the formulary, you will have to pay a 40% co-payment.














Maternity care

Per pregnancy



1 amniocentesis



Babyline




Preventative care



Elderly health



Wellness benefi ts

Wellness screening



Wellness Extender

R750 per family



BON

ESSE

NTI

AL


EXCLUSIONSAlternative health practitioners• Acupuncture on BonCap• Aromatherapy• Ayurvedics• Herbalists• Homoeopathy on BonCap• Iridology• Naturopathy on BonCap• Osteopathy on BonCap • Phytotherapy on BonCap• Reflexology• Therapeutic massage therapy (masseurs)

Ambulance services• Services not authorised by ER24

Appliances, external accessories and orthotics • Appliances, devices and procedures not scientifically proven or appropriate• Back rests and chair seats• Bandages and dressings (except medicated dressings)• Beds and mattresses, pillows and overlays • Long-term implantable ventricular assist devices and total artificial hearts e.g. Heart

Ware® and Berlin heart• Diagnostic kits, agents and appliances, unless otherwise stated, except for diabetic

accessories• Electric toothbrushes• Humidifiers• Ionisers and air purifiers• Orthopaedic shoes and inserts• Pain relieving machines, e.g. TENS and APS• Stethoscopes and sphygmomanometers (blood pressure monitors) • Portable oxygen cylinders are excluded on all options. Portable oxygen concentrators

will be excluded on all options except BonComprehensive and BonClassic, subject to pre-authorisation and available appliance benefit.

Blood, blood equivalents and blood products• Hemopure (bovine blood)

Dentistry • Appointments not kept• Orthodontic treatment for individuals 18 years and older

• Dental procedures or devices which are not regarded by the relevant managed healthcare programme as clinically essential or clinically desirable

• Orthognathic (jaw correction) surgery, other orthodontic related surgery and the associated laboratory costs

• Instruction for oral hygiene• Nutrition and tobacco counselling• Caries susceptibility and microbiological tests• Oral hygiene evaluation• Crown and bridge procedures where there is no extensive tooth structure loss and

associated laboratory costs, electrognathographic recordings, pantographic recordings and other such electronic analyses

• Fissure sealants on patients 16 years and older • Pulp tests and pulp capping (direct and indirect)• Polishing of restorations• Ozone therapy• Metal base to full dentures, including the laboratory costs• The clinical fee of dental repairs, denture tooth replacements and the addition of a soft

base to new dentures (the laboratory fee will be covered at the Bonitas Dental Tariff where Managed Care protocols apply)

• Diagnostic dentures and associated laboratory costs• Provisional crowns, including laboratory costs• Resin bonding for restorations charged as a separate procedure to the restoration• Dental bleaching • Porcelain veneers and inlays/onlays and associated laboratory costs• Pontics on second molars • Laboratory fabricated crowns on primary teeth• Fixed prosthodontics used to repair occlusal wear• Gold foil restorations• Surgical periodontics, which includes gingivectomies, periodontal flap surgery, tissue

grafting and hemisection of a tooth • PerioChip®• Emergency crowns that are not placed for immediate protection in tooth injury and the

associated laboratory costs• Orthodontic re-treatment and the associated laboratory costs• Lingual orthodontics• Implants on wisdom teeth (3rd molars)• Orthodontic treatment for cosmetic reasons and associated laboratory costs• Sinus lifts• Bone augmentations• Bone and other tissue regeneration procedures• Older bars and associated abutments on implants including the laboratory costs• Laboratory costs where the associated dental treatment is not covered • Laboratory costs associated with mouth guards• Snoring appliances• High-impact acrylic• Cost of mineral trioxide• Cost of gold, precious metal, semi-precious metal and platinum foil• Cost of invisible retainer material• Cost of bone regeneration material• Cost of prescribed toothpastes, mouthwashes (e.g Corsodyl) and ointments• Topical application of fluoride in patients 16 years and older

EXCLUSIO

NS


• Cost of dental materials in hospital• Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and

fluorosis• Crowns or crown retainers on wisdom teeth (3rd molars)• Crown and bridge procedures for cosmetic reasons and associated laboratory costs• Occlusal rehabilitation and associated laboratory costs• Provisional dentures and associated laboratory costs• Root canal therapy on wisdom teeth and primary (milk) teeth• Enamel microabrasion• Behaviour management• Intramuscular or subcutaneous injection• Special reports and dental testimony including dento-legal fees• Autotransplantation of teeth• Closure of an oral-antral opening (item code 8909) when claimed during the same visit

with impacted teeth (item code 8941, 8943 and 8945)• Hospitalisation (general anaesthetic): where the reason for admission to hospital is

dental fear or anxiety; multiple hospital admissions; where the only reason for admission to hospital is to acquire a sterile facility

• Hospital and anaesthetist claims will not be covered for the following procedures when performed under general anaesthesia: apicectomies, dentectomies, frenectomies, conservative dental treatment (fillings, extractions and root canal therapy) in hospital for adults, professional oral hygiene procedures, implantology and associated surgical procedures and surgical tooth exposure for orthodontic reasons

• Treatment plan completed (currently code 8120)• Procedures that are defined as unusual circumstances and procedures that are defined

as unlisted procedures• Laboratory delivery fees.

Hospitalisation• If application for a pre-authorisation reference (PAR) number for a clinical procedure,

treatment or specialised radiology is not made or is refused, no benefits are payable• Accommodation and services provided in a geriatric hospital, old age home, frail care

facility or similar institution.

InfertilityMedical and surgical treatment, including:• Assisted reproductive technology (ART)• In-vitro fertilisation (IVF)• Gamete Intrafallopian tube transfer (GIFT)• Zygote Intrafallopian tube transfer (ZIFT) • Intracytoplasmic sperm injection (ICS)• Vasovasostomy (reversal of vasectomy).

Maternity• 3D and 4D scans• 2D scans in excess of 2, unless motivated for an appropriate medical condition

• Antenatal classes/exercises except on BonComprehensive, BonClassic, BonSave, Standard, Standard Select and BonComplete.

Medicine and injection material• Anabolic steroids and immunostimulants• Contraceptives - oral, parenteral, foams, IUCDs• Cosmetic preparations, emollients, moisturisers (medicated or otherwise), soaps, scrubs

and other cleansers, sunscreen and suntanning preparations, medicated shampoos and conditioners (except for the treatment of lice, scabies and other microbial infections and coal tar products for the treatment of psoriasis)

• Erectile dysfunction and loss of libido medical treatment• Nutritional supplements, including baby food and special milk preparations, are

authorised by the relevant managed healthcare programme• Maintenance Rituximab (or other monoclonal antibodies) in the first-line setting for

haematological malignancies• Liposomal amphotericin B for fungal infections• Any specialised or new chemotherapeutic drugs that have not convincingly

demonstrated a survival advantage of more than 3 months in advanced or metastatic malignancies, unless pre-authorised

• Trastuzumab (Herceptin) for the treatment of HER2-positive early breast cancer and metastatic cancer on all options except for BonComprehensive

• Carmustine wafers for the treatment of malignant gliomas• Medicines not included in a prescription from a medical practitioner or other healthcare

professional who is legally entitled to prescribe such medicines (except for schedule 0, 1 and 2 medicines supplied by a registered pharmacist)

• Medicines for intestinal flora• Medicines defined as exclusions by the relevant managed healthcare programme• Medicines not approved by the Medicines Control Council, unless Section 21 approval

is obtained and pre-authorised by the relevant managed healthcare programme• Medicines not authorised by the relevant managed healthcare programme• Patent medicines, household remedies and proprietary preparations, and preparations

not otherwise classified• Slimming preparations for obesity• Smoking cessation and anti-smoking preparations, unless authorised as part of the

Wellness Extender benefit, excluded on BonCap• Tonics, evening primrose oil, fish liver oils, multivitamin preparations and/or trace

elements and/or mineral combinations (except for registered products that include haemotonics and those for use by infants and pregnant mothers)

• Biological drugs, except on BonComprehensive and BonClassic, and Beta-Interferon for the treatment of Multiple Sclerosis as per the PMB algorithm

• All benefits for clinical trials and all treatment/admission costs relating to complications of trial drugs, unless pre-authorised by the relevant managed healthcare programme

• Diagnostic agents, unless authorised • Growth hormones, unless pre-authorised• Immunoglobulins and immune stimulants, oral and parenteral, unless pre-authorised • Medicines used specifically to treat alcohol and drug addiction, unless PMB.

EXCL

USI

ON

S


Mental health• Sleep therapy• Educational psychology visits for adult beneficiaries ( over 21 years of age).

Non-surgical procedures and tests• Epilation – treatment for hair removal• Hyperbaric oxygen therapy except for PMBs• Facet joint injections and percutaneous radiofrequency ablations (percutaneous

rhizotomies) on BonCap.

Optometry• Coloured and other cosmetic effect contact lenses, and contact lens accessories and

solutions• Optical devices which are not regarded by the relevant managed healthcare

programme, as clinically essential or clinically desirable except on BonSave, BonFit, BonClassic and BonComprehensive

• Sunglasses and prescription sunglasses.

Organs, Haemopoietic, Stem cell (bone marrow) transplantation and immunosuppressive medication• Organs and haemopoietic stem cell (bone marrow) donations to any person other than

to a member or dependant of a member on this Fund.

Paramedical Services• Pharmacy services

Pathology and Medical Technology• HIV resistance testing, unless pre-authorised• Gene sequencing.

Physical therapy• X-rays performed by chiropractors• Chiropractor benefits in hospital• Physiotherapy for mental health admissions.

Prostheses internal and external• Cochlear implants on BonComplete, BonEssential, BonSave, BonFit, Primary and

BonCap• Osseo-integrated implants for dental purposes to replace missing teeth, unless

specifically provided for in Annexure B

• Total ankle replacement on BonEssential, BonSave, BonFit, Primary and BonCap • Implantable defibrillators on BonEssential, BonSave, BonFit, Primary and BonCap.

Radiology and radiography• MRI scans ordered by a general practitioner, unless there is no reasonable access to

a specialist• Positron Emission Tomography, except for appropriate diagnosis, staging, the

monitoring of response to treatment and investigation of residual tumour or suspected recurrence (restaging) bone densitometry performed by a general practitioner or specialist not included in the Fund credentialed list

• CT colonography (virtual colonoscopy) for screening• MDCT Coronary Angiography for screening• If application for a pre-authorisation reference number (PAR) for specialised radiology

procedures is not made or is refused, no benefits are payable• All screening that has not been pre-authorised or is not in accordance with the Fund’s

policies and protocols.

Surgical procedures• Abdominoplasties and the repair of divarication of the abdominal muscles• Balloon sinuplasty on BonCap, BonEssential, BonFit, BonSave and Primary• Bilateral gynaecomastia• Blepharoplasties unless causing demonstrated functional visual impairment and

pre-authorised• Breast augmentation• Breast reconstruction - unless mastectomy following cancer and pre-authorised• Breast reductions, (except on BonComprehensive - subject to prior

pre-authorisation and in accordance with the agreed clinical protocol)• All costs for cosmetic surgery performed over and above the codes authorised for

admission• Deep brain stimulation for Parkinson’s and intractable epilepsy on BonCap, BonClassic,

BonComplete, BonEssential, BonFit, BonSave and Primary• Erectile dysfunction surgical procedures• Gender reassignment medical or surgical treatment• Genioplasties as an isolated procedure• Custom-made hip arthroplasty for inflammatory and degenerative joint disease• Keloid surgery except for functional impairment• Laparoscopic unilateral primary inguinal hernia repair on BonCap, BonEssential,

BonSave, BonFit and Primary• Obesity - surgical treatment or bariatric surgery (except on BonComprehensive, in

accordance with the agreed clinical protocol and subject to prior pre-authorisation. Not including post-operative plastic and reconstructive surgery)

• Otoplasties• Pectus excavatum/carinatum• Percutaneous valve replacement, including transcatheter aortic valve implantation and

repairs on BonCap, BonEssential, BonSave, BonFit and Primary• Refractive surgery except on BonComprehensive• Revision of scars except for functional impairment• Rhinoplasties for cosmetic purposes

EXCLUSIO

NS


• Robotic surgery, other than for radical prostatectomy where authorised by the managed care organisation; additional costs relating to the use of the robot during such pre-authorised surgery, and including additional fees pertaining to theatre time, disposables and equipment fees remain excluded. Excluded on BonCap.

• Uvulo palatal pharyngoplasty (UPPP and LAUP).

Other• Appointments which a beneficiary fails to keep• Autopsies• Cryo-storage of foetal stem cells and sperm• Holidays for recuperative purposes• Nuclear or radio-active material or waste• Travelling expenses• Veterinary products• Delivery charges or fees.

EXCL

USI

ON

S


HOW TO CLAIMYou must send us your claim within 4 months of receiving treatment or it will not be paid. Send us your claim in one of the following ways.

Post your claim to:Bonitas Claims DepartmentPO Box 74Vereeniging, 1930

OR

Email your claim to [email protected]

OR

Drop off your claim at one of our walk-in centres

Tips to get your medical claims paid quickly

Ensure your bank details are correctClaims refunds are only paid into a bank account by electronic funds transfer (EFT). Please call us on 0860 002 108 if you need to update your banking details.

Please ensure that your claim shows the following:• Your name and initials• Your medical aid number• The treatment date• The name of the patient as shown on your membership card• The amount charged• The tariff• The ICD-10 code (diagnosis code)

Please check that prescriptions for medicine show all your details. Also check that the correct amount of medicine dispensed is shown on the claim. If the pharmacy omits any of these details, we will not be able to process your claim.

Check that your claim has been paidWe pay claims weekly. A statement showing your claims will be sent to you at the end of the month by post or email. You can also log in to www.bonitas.co.za to view the status of your claims.

GET THE BONITAS BABY BAGWe give all pregnant members a beautiful mother and baby bag to congratulate you on the arrival of your bundle of joy. You will need to register for the bag.

Who can receive the baby bag?All members who are pregnant will need to register to receive the mother and baby bag. Registration can only take place after 24 weeks of pregnancy. We require a pre-authorisation number before you can register for the Bonitas baby bag. Call us on 0860 002 108 to get pre-authorisation.

How to registerYou need the following information when you register:• Membership number• Name and surname• Contact details• Delivery address• Alternative delivery address• Date of expected delivery

Then call us on 0860 002 108 or email [email protected]

Please note: In order to ensure that you receive your baby bag, the courier company will be in contact with you to arrange a suitable date and time for delivery.

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SMS‘Find’

to 43899Receive an SMS

with a link

Click on the link andenter your membership

number

Choose the type of doctor you’re

looking for

Select your province,town and suburb

You will receive a listof doctors near you

To have the doctor’sdetails sent to you,

click on ‘SMS me’

FIND A NETWORK PROVIDERThe GP locator allows you to fi nd a doctor on our network to help stretch your benefi ts further and help you get more value for money.

Simply follow the steps below:

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HIV/AIDS programme

Aid for AIDSPlease call me: 083 410 9078Call: 0860 100 646Fax: 0800 600 773Email: [email protected]

Diabetes programme

Centre for Diabetes and EndocrinologyCall: 011 053 4400Email: [email protected]

Back and neck programme

Document Based Care (DBC)Call: 0860 105 104

Hip and knee programme

Improved Clinical Pathway ServicesCall: 011 327 2599Email: [email protected]

Chronic medicine

Pharmacy DirectCall: 0860 027 800Fax: 0866 114 000Email: [email protected]

Optical benefi ts

Iso LesoCall: 0860 10 30 50/60Fax: 011 782 5601www.isoleso.co.za

Dental benefi ts

DENISCall: 0860 336 346Fax: 0866 770 336Email: [email protected]

Emergency assistance

ER24Call: 084 124Email: [email protected]: [email protected]

FIND A SERVICE PROVIDERWe’ve partnered with several reputable service providers to ensure that our members receive excellent service and more value for money.

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Please note: Product rules, limits, terms and conditions apply. Where there is a discrepancy between the content provided in this brochure, the website and the Scheme Rules, the Scheme Rules will prevail. The Scheme Rules are available on request. Benefits are subject to approval from the Council for Medical Schemes.

Bonitas Medical Fund

@BonitasMedical

0860 002 108

www.bonitas.co.za

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