benefits guide - mymembership

2021

BENEFITS GUIDE

SATS PENSIONERS – GUARDIAN PLAN

This guide does not replace the rules. The registered rules are legally binding, always take precedence and are available on request or on the Transmed website at www.transmed.co.za.

Welcome to Transmed

Medical Fund’s 2021

benefits guide. This guide

explains the 2021 benefits

and services available

and how you can access

it. Please read it carefully

and keep it safe for future

reference.

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2021

A. OVERVIEW OF 2021 BENEFITS

SUMMARY OF CHANGES FOR 2021• Contributions were increased by 2%.• Thegeneral,day-to-daybenefitwasincreasedby4%.

• State hospitals are the designated service providers (DSPs*3).

•MajormedicalbenefitsfortreatmentofPMB*16 and non-PMB conditions in hospitalwillbecoveredinfullifthetreatment is obtained at a State hospital.

• The Transmed private hospital network*6 is the secondary DSP*3. This network is onlyavailableforemergencyorinvoluntaryadmissionsforPMB*16 conditions where a State hospital is not accessible.

• A co-payment*9forthevoluntarilyuseofnon-DSP hospital is applicable to PMB*16 conditions.Noprivatehospitalbenefitfornon-PMBconditions.

• The Transmed pharmacy network*2 is the DSP*3forchronicandHIV/AIDSmedication.

• PreferredProviderNegotiators(PPN*10) iscontractedtomanageopticalbenefits.

• DENIS*11 is contracted to manage dental benefits.

• Improved Clinical Pathway Services (ICPS*14)networkiscontractedforselected knee and hip replacements.

• Ophthalmology Management Group Limited (OMG*12)iscontractedforcataract surgery.

• Independent Clinical Oncology Network (ICON*7) is the DSP*3forcancertreatment.

• Pre-authorisation, where necessary, can beobtained24hoursadayandonweekends and public holidays, by calling the care manager on 0800 225 151.

IMPORTANT INFORMATION

BENEFITS GUIDE

3

* Transmed rate TheTransmedrateisthefeepayableforabenefityearinrespectofaspecifictarifforservice

*1 General day- to-day limit

Theday-to-daybenefitcoversallroutineservicesreceivedoutofhospital,otherthanthosecoveredfrominsuredbenefitsintermsofanauthorisationorotherdefinedbenefitsorlimits

*2 Transmed pharmacy network

AnetworkofpharmaciesthatTransmedhasnegotiatedapreferredratewith:- Clicks pharmacy group- Dis-Chem pharmacies- MediRitepharmacygroup(pharmaciesinShoprite/Checkersstores)- Contracted independent pharmacies

*3 DSP A designated service provider is contracted by the Fund to provide certain treatment or servicestopatientsatapreferredtariff

*4 Formularies Formulariesapplicabletoaspecificmedicationbenefit:- Chronicmedication–comprehensivemedicationformulary- Acutemedication–acutemedicationformulary- Over-the-counter(OTC)medication–OTCmedicationformulary

*5 Referencepricing ThisisthemaximumpricethattheFundwillpayforaspecificclassofmedication

*6 Transmed private hospital network

AnetworkofprivatehospitalsthatTransmedhasnegotiatedapreferredratewithforadmissions approved as an emergency or an involuntary admission

*7 ICON TheIndependentClinicalOncologyNetworkisanetworkofoncologiststhatisthecontractedDSPforoncology(cancer)treatment

*8 Transmed oncology pharmacy network

ClicksDirectMedicines(CDM)isthedesignatedserviceproviderforoncology(cancer)medicine

*9 Co-payment Aco-paymentisafeethatispayablebyamemberdirectlytoaserviceproviderandiscalculatedasthedifferencebetweenthepricechargedbythemember’schosenserviceproviderandthepricenegotiatedwiththeapplicabledesignated/preferredserviceprovider

*10 PPN PreferredProviderNegotiatorsiscontractedtomanageopticalbenefits,includingtheopticalclaims processing

*11 DENIS DENISiscontractedtomanagedentalbenefits,includingdentalclaimsprocessing

*12 OMG TheOphthalmologyManagementGroupLimitedisanetworkofophthalmologiststhatiscontracted to provide cataract surgery

*13 UPFS TheuniformpatientfeescheduleisthetariffstructureapplicabletoStatehospitalfacilities

*14 ICPS ImprovedClinicalPathwayServicesisanetworkoforthopaedicsurgeonsthatiscontractedforselected knee and hip replacements

*15 Fund exclusions Services,proceduresandconsumablesthatarenotcoveredbyTransmed:- Accommodationinoldagehomes,frailcarecentresorsimilarinstitutions- Allcostsforoperations,medicines,treatmentandproceduresforcosmeticorfor

psychological purposes- Allcostsforoperations,medicines,treatmentandproceduresrelatedtoweightreduction- Operations to reverse a sterilisation- Artificialinsemination(GIFTorsimilarprocedures)- Patentfoods,includingbabyfood- Slimming preparations- Householdremediesorpreparationsandherbalandnaturalremedies- Aphrodisiacs- Cosmetic soaps, shampoos and other topical applications- Sun screening and sun tanning agents- Cosmetic preparations, medicated or otherwise- Contact lens preparations- Holidaysforrecuperativepurposes- Vitamins and mineral supplements

*16 PMBs Prescribedminimumbenefitsisasetofdefinedbenefitstoensurethatallmedicalschememembershaveaccesstocertainminimumhealthservices,regardlessofthebenefitoption

KEYTOTERMSUSEDINTHISBENEFITSGUIDE

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2021

B.EXPLANATIONOFTHE2021BENEFITS

Opticalanddentalservicesarepaidfromtherespectiveopticalanddentalbenefits.Allotherday-to-dayservices(exceptforservicescoveredonanauthorisedPMB*16 treatment plan) are paid fromthegeneralday-to-daylimit*1. Members may use any registered healthcare or service provider oftheirchoice,exceptforopticalanddentalservices,whicharemanagedbythecontractedproviders.

Private hospitalisation is limited to certain conditions and procedures, where a State hospital cannot provide the service or where the Fund has contracted with a private provider. Such admissions must be pre-authorised in ordertoconfirmtheavailabilityofthebenefit.

WHEN CAN MEMBERS USE A PRIVATE HOSPITAL?Members can use a private hospital in the followingsituations:

• Incaseofamedicalemergencyorwhenimmediatemedicalorsurgicaltreatmentfora PMB*16 condition was required and could notreasonablybeobtainedfromaStatehospital (DSP *3).

AnemergencyisdefinedintermsoftheMedicalScheme’sActandtherulesasthesuddenandatthetime,unexpectedonsetofa health condition that requires immediate medicalorsurgicaltreatment,wherefailureto provide medical or surgical treatment would result in serious impairment to bodily functionsorseriousdysfunctionofa

bodily organ or part or would place a person’slifeinseriousjeopardy.

• In cases where the required service or procedure is covered by the Fund at a State hospital (DSP*3), but is not reasonably available at the time or could not be provided without an unreasonable delay. In such cases, members should use hospitalsthatformpartoftheTransmedprivate hospital network*6 or appointed specialist networks (ICON*7 and ICPS*14) to avoid co-payments*9.

• IfthePMB*16 service is not available at a State hospital (DSP*3), pre-authorisation foradmissiontoasecondaryfacilitywillbe considered by the care manager who isavailable24hoursaday.TheFundwillcover the admission costs in the alternativefacility,subjecttopre-authorisation, case management and other managed healthcare interventions.

Please call 0800 225 151 to obtain pre-authorisationorformoreinformationandguidance.

i

DAY-TO-DAY BENEFITS

HOSPITALISATION

5

TheTransmedrate*isthefeepayableforabenefityearinrespectofaspecifictarifforservice.Ifahealthcareorserviceproviderchargesfeesinexcessofthisrate,amemberwillberesponsibleforpayingthedifference,unlessitisforservicesthatqualifyforpaymentintermsofPMB*16legislation.Itisthereforeinamember’sbestinteresttonegotiatewithahealthcareorserviceprovidertochargetheTransmedrate*.

C.THETRANSMEDMEDICALFUNDRATE(TRANSMEDRATE)R

Note: The co-payment*9forusingaprivatehospital(non-DSP)couldbeveryhigh.Membersareencouraged to contact the care managers who will gladly guide them to an appropriate hospital that willassistyouinkeepingyourportionofthecostaslowaspossible.

WhentheserviceorprocedureisnotcoveredbytheFund,thememberwillbeliableforthefullaccount.WhenthememberoptstouseaprivatehospitalforaPMB*16 service or procedure that is available at a State hospital (DSP*3),thememberwillbeliableforaco-payment *9 equaltodifferencebetweenthefeescharged and the equivalent cost that would have been payable to the DSP*3 (State hospital).

CO-PAYMENT FOR THE VOLUNTARY USE OF A NON-DSP FACILITY

WHEN WILL MEMBERS BE LIABLE FOR THE COST OF USING A PRIVATE HOSPITAL?

• IfamemberusesaStatehospital,thetotaladmissioncostofR15000willbecovered by the Fund.

• Ifamembervoluntarilyusesaprivatehospitalforaserviceorprocedurethatwas available at a State hospital, cover forthistypeofadmissionislimitedto R15 000 and the member will be liable forpaymentofanyshortfallsdirectlytothe hospital and other providers.

• IfamemberusesaTransmedprivatehospital network*6facilityonavoluntarybasis,thememberwillbeliableforaco-payment*9equaltothedifferencebetween the total admission cost at a State hospital and at a Transmed private

hospital network*6facility(R40000– R15 000 = R25 000).

• Ifamemberusesanyotherprivatehospital on a voluntary basis, the memberwillbeliableforaco-payment*9 equaltothedifferencebetweenthetotaladmission cost at a State hospital and any other private hospital (R50 000 - R15 000 =R35 000).

Please note that the above is only an exampleofthecalculationofaco-payment*9 and is not based on a specificcaseoranindicationofthedifferenceincostinanactualcase.

Based on the table above, the impact on the member will be as follows:

Thefollowingisanexample oftheimpactthecostofusingaprivatefacilityvoluntarilycanhave on members.

EXAMPLE

FACILITY TOTAL ADMISSION COST

State hospitals R15 000Transmed private hospital network*6facilities R40000Other private hospitals R50 000

2021BENEFITS GUIDE

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2021

D. 2021 CONTRIBUTIONS

Thefollowingservicesmaybeobtainedinprivatefacilitiessubjecttocompliancewithcertaincriteria.

The DSP *3foroncologytreatmentistheIndependent Clinical Oncology Network (ICON *7)ofprivateoncologists.Shouldamember consult an oncologist outside this network, a 20% co-payment*9 will be applicable toallservicesreceivedfromthenon-networkoncologist.

Clicks Direct Medicines pharmacy*8 is the

contracted DSP *3foroncology(cancer)medication. A co-payment*9mayapplyfor using a non-DSP pharmacy. Pre-authorisation mustbeobtainedfortheservicesabove on 0800 225 151.

Pleasenotethatreferencepricing*5 is applicable to oncology (cancer) medication.

E1. MAJOR MEDICAL BENEFITS AT PRIVATE FACILITIES

MONTHLYINCOME

R0 -R500

R501 -R1 000

R1 001 -R1 500

R1 501 -R2 000

R2 001 -R2 500

R2 501 -R3 000

R3 001 -R3 500

Member 70 109 146 180 219 253 291

Adult dependant** 64 101 126 165 197 227 262Child dependant* 46 64 87 109 129 154 173

MONTHLYINCOME

R3 501 -R4 000

R4 001 -R4 500

R4 501 -R5 000

R5 001 -R5 500

R5 501 -R6 000

R6 001 +

Member 327 363 401 437 472 511

Adult dependant** 295 326 361 394 425 459Child dependant* 197 218 240 262 282 306

Note the following:* Childdependantcontributionsarepayableforamaximumoffourdependants.* Childdependantsolderthan21whoarestudyingfull-orpart-timeandarefinanciallydependentonthememberwillpaychilddependantcontributionsuntiltheageof24(proofofregistrationatanaccreditedinstitutionwillberequired).

**Dependantsolderthan21(or24inthecaseofstudyingchildren)whoarefinanciallydependentonthememberwillpay adult dependant contributions.

P

ONCOLOGY (CANCER) TREATMENT

7

P

The Fund has a contract with the Ophthalmology Management Group (OMG*12) Limited to provide cataract surgery. The Fund reimbursestheproviderswithaglobalfeeforthistypeofsurgery.Theglobalfeecoversthefollowing:

• the procedure, surgeon and anaesthetist fees;equipmenthireandhospitalaccount.

• the post-operation consultation within one monthoftheprocedure.

This arrangement does not restrict doctors in termsofwheretheproceduresshouldbedone. The hospitals used depend on the arrangements that the ophthalmologists make withthehospitalsoftheirchoice.

IfacontractedOMG*12 doctor is accessible

and the member voluntarily uses a non-DSP, a 20% co-payment*9 will apply on the total hospitalandassociatedprovidercostsforthecataract surgery.

Inadditiontocataractsurgery,thefollowingservices will be covered, subject to pre-authorisation:

• the consultation during which the diagnosis ismadeandconfirmed

• therelevanttestsperformedtomakethediagnosis, as per the applicable algorithm

• medicationadministeredaspartoftheprocedure, as per the applicable algorithm

• any other indicated services, as per the applicable algorithm.

The Fund has a contract with the Improved Clinical Pathway Services (ICPS *14) to provide selected knee and hip replacements.

The Fund reimburses the providers with a globalfeeforthistypeofsurgery.Theglobalfeecoversthecostoftheadmission,ICPS*14, orthopaedic surgeon, anaesthetist, prosthesis and physiotherapist.

IfanICPS*14 provider or hospital is available, but the member elects to use a non-ICPS

provider or hospital, a co-payment*9 equal to thedifferenceincostbetweenthetotalcostincurredinrespectofthehospitalandallrelatedservices, and the cost that would have been payable to the DSP*3 (State hospital) will apply.

Pleasenotethatthisbenefitisrestrictedto selected joint replacements only. Please contact 0800 225 151formoreinformationandreferralguidancetotheICPS*14 providers.

Dialysis treatment is subject to case management and clinical protocols. Pre-authorisation is required prior to the treatment. Please contact 0800 225 151.

E1. MAJOR MEDICAL BENEFITS AT PRIVATE FACILITIES (continued)

CATARACT SURGERY

P

E2. MAJOR MEDICAL BENEFITS

WHAT IS A CHRONIC CONDITION?Achronicconditionisadiseasethatrequireslife-sustainingmedicationtobetaken continuouslyforextendedperiods–normallyforlongerthanthreemonths.Examplesofchronic conditions include diabetes, asthma, high blood pressure (hypertension), epilepsy, cardiacfailure,highcholesterol(hyperlipidaemia),Parkinson’sdisease,thyroiddysfunctionand rheumatoid arthritis.

DIALYSIS

CHRONICMEDICATION

JOINT REPLACEMENT BENEFIT

2021BENEFITS GUIDE

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1. Addison’sdisease 14.DiabetesmellitustypeII2. Asthma 15. Epilepsy 3. Bipolar mood disorder 16. Glaucoma4. Bronchiectasis 17.Haemophilia5. Cardiac(heart)dysrhythmias 18.Hyperlipidaemia(cholesterol)6. Cardiac(heart)failure 19.Hypertension7. Cardiomyopathydisease 20.Hypothyroidism8. Chronic obstructive lung disease 21. Multiple sclerosis9. Chronicrenaldisease 22. Parkinson’sdisease10. Coronary artery disease 23. Rheumatoid arthritis11.Crohn’sdisease 24. Schizophrenia12. Diabetes insipidus 25. Systemic lupus erythematosus13. Diabetes mellitus type I 26. Ulcerative colitis

WHAT IS A CHRONIC MEDICATION FORMULARY?Achronicmedicationformularyisalistofmedicationforchronicconditionsthatisapproved by the Fund. The list is compiled to ensure that you receive the most appropriate, cost-effectiveandsafesttreatmentforyourchronic condition.

HOW CAN CHRONIC MEDICATION BE OBTAINED?In order to obtain your chronic medication, youneedtodothefollowing:

• RegisterontheFund’schronicmedicinemanagementprogrammeifyouhavenotpreviously registered.

• Completethemembersectionofthechronicmedicinebenefitapplicationform,whichcanbe obtained at www.transmed.co.za or by contacting the customer service department on 0800 110 268.

• Ask your healthcare provider to complete thepractitioner’ssectionoftheform.

• Faxthecompletedapplicationform,togetherwithacopyoftheprescription,tothecaremanager at the Fund on 0800 122 236 or return it to Transmed Medical Fund, PO Box 32931,Braamfontein2017.

• Ifyourapplicationissuccessfulyouwillreceive an authorisation letter listing the approved medication.

• Once you have received this letter, take the original prescription to a network pharmacy*2 to collect the medication. A co-payment*9 mayapplyforusinganon-DSPpharmacy.

• Ifyouneedtochangeyourchronicmedication, ask your healthcare provider to faxthenewprescription,togetherwiththenecessary motivation and laboratory reports (where applicable), to 0800 122 236. Your healthcare provider needs to include thepatient’sname,membershipnumber,theICD-10 code pertaining to the condition and the practice number on the prescription. Your healthcare provider can also call 0800 122 263 to do the update telephonically.

WHAT IS THE CHRONIC DISEASE LIST (CDL)?(Standard condition list applies)CDLincludes26commonchronicconditionsandmedicalschemeshavetoprovidecoverforthediagnosis,treatmentandcareoftheseconditions.

E2. MAJOR MEDICAL BENEFITS (continued)P

CHRONICMEDICATION(continued)

TABLEA:PMBCDL

BENEFITS GUIDE

9

1. Acne 16. Obsessive-compulsive disorder 2. Allergic rhinitis 17. Osteo-arthritis 3. Alzheimer’sdisease 18. Osteoporosis4. Ankylosingspondylitis 19. Overactivebladdersyndrome5. Attentiondeficithyperkineticdisorders 20. Paget’sdisease6. Cysticfibrosis* 21. Panicdisorders7. Dermatopolymyositis 22. Peptic ulcer disease8. Dystonias* 23. Psoriasis9. Gastro-oesophagealrefluxdisease 24. Psoriaticarthritis10.Generalisedanxietydisorder 25. Sjogren’s/Siccasyndrome11.Huntington’sdisease 26. Systemicsclerosis/Scleroderma*12. Interstitialfibrosis* 27. Ticdisorders*13.Meniere’sdisease 28. Trigeminalnervedisorders*14.Migraine 29. Urinarytractinfection15. Myasthenia gravis

1. Aplastic anaemia 16. Pancarditis2. Benignprostatichypertrophy 17. Paraplegia/Quadriplegia3. Cardiac arrhythmias 18. Pemphigus4. Cerebrovasculardisorders(stroke) 19. Peripheralartherioscleroticdisease5. Cushing’sdisease 20. Pituitaryadenoma6. Delusional disorders 21. Polycystic ovarian disease (PCOS) 7. Depressive mood disorder 22. Polyarteritis nodosa 8. Endometriosis 23. Pulmonary hypertension9. Glomerulardisease 24. Sarcoidosis10.HIV/AIDS 25. Thromboangiitisobliterans(TAO)11.Hyperthyroidism 26. Thrombocytopeniapurpura12.Hyperparathyroidism/Hypoparathyroidism 27. Tuberculosis13. Menopausal syndrome 28. Valvular heart disease14.Motorneurondisease 29. Venousthromboembolism15. Muscular dystrophy

SUMMARY OF DESIGNATED SERVICE PROVIDERS (DSPs) AND CO-PAYMENTSFORCHRONICANDONCOLOGYMEDICATION

TABLEC:NON-PMBCONDITIONS–ADDITIONALCONDITIONSCOVEREDOUTSIDETHECDLANDDTPCRITERIA

TABLEB:PMBDIAGNOSISANDTREATMENTPAIRS(DTPs)

BENEFIT CATEGORY

DESIGNATED SERVICE PROVIDER (DSP)

CO-PAYMENT FOR VOLUNTARY USE OF A NON-

DSPPHARMACY

CHRONICMEDICATION

Transmed pharmacy network*2

• Clicks pharmacy group• Dis-Chem pharmacies• MediRite pharmacy group (pharmacies inShoprite/Checkersstores)

• Contracted independent pharmacies

Pharmacies used outside the Transmed pharmacy network*2 may result in a co-payment*9

Referencepricing*5 is applicable

ONCOLOGY (CANCER) MEDICATION

Clicks Direct Medicines (CDM) pharmacy*8

Pharmacies used outside the Transmed oncology network*8

may result in a co-payment*9

Referencepricing*5 is applicable

*These conditions may in some instances be considered as PMB*16 conditions.

BENEFITS GUIDE 2021SATS PENSIONERS – GUARDIAN PLAN

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2021

BENEFITS GUIDE

F. BREAKDOWN OF BENEFITS

General practitioner (GP)

consultations

Paid at the Transmed rate*Subjecttotheavailabilityoffundsinthegeneralday-to-daylimit*1

Specialist consultations


Acute and over- the-counter (OTC)

medication


AcuteandOTCformularies*4 applyFund exclusions*15 apply

Out-of- hospital pathology


Out-of-hospital radiology

Paid at the Transmed rate*

Basic radiology (X-rays) Subjecttotheavailabilityoffundsinthegeneralday-to-daylimit*1

iDAY-TO-DAY COVER

BENEFITS GUARDIAN PLAN

1

2

3

4

5

11

Optical benefits

BenefitprovidedthroughPPN*10 protocols

NETWORK BENEFITOpticalbenefitsaresubjecttoauthorisationbyPPN*10 and clinical protocols/prescribedrulesapply

Beneficiariescanclaimevery24months

ExaminationLimitedto1consultationtothevalueofR700,includingrefraction,glaucomaandvisualfieldscreening

Frames/Spectacles/LensesR950towardsframeand/orlensenhancements,togetherwith1pairofclear,single-visionlensestothevalueofR210orclear,bifocallensestothevalueofR445orclear,multifocallensestothevalueofR770

ORContact lenses Limited to R1 325

NON-NETWORK BENEFITMemberswillbeliableforaco-payment*9forout-of-networkservices

ExaminationLimitedto1consultationtothevalueofR350

Frames/Spectacles/LensesR760towardsframeand/orlensenhancements,togetherwith1pairofclear,single-visionlensestothevalueofR210orclear,bifocallensestothevalueofR445orclear,multifocallensestothevalueofR770

ORContact lenses Limited to R1 325

Please call PPN*10 on 0861 103 529

Basic dentistry

Provided through DENIS*11

Subject to protocols and limitationsNo annual limit and only stated codes covered


Root canalLimitedto1perfamilyperyear

Please call DENIS*11 on 0860 104 941

DAY-TO-DAY COVER


6

7

12 13

Specialised dentistry


Subject to protocols and limitationsLimitedtoR4110perfamilyperyear


CrownsLimitedto1perfamilyevery2yearsforbeneficiaries16yearsandolder

DenturesLimitedto1setperjawevery4yearsforbeneficiariesolderthan21Limitedto1setofchromecobalt-framedenturesevery5yearsforbeneficiaries21yearsandolder Pre-authorisation required Please call DENIS*11 on 0860 104 941

Dentures

R1040stand-alonebenefitperfamilyforbeneficiariesolderthan21

AmountsinexcessofthislimitispayablefromthespecialiseddentistrylimitofR4110perfamilyperyear


Pre-authorisation required Please call DENIS*11 on 0860 104 941

General day-to-day limit*1


Includes:• GP and specialist consultations• Acute and over-the-counter (OTC) medication• Routine pathology and radiology

Allotherday-to-daybenefitsnotspecificallymentionedaboveM0 R4270M+ R7 500

DAY-TO-DAY COVER


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9

10

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2021BENEFITS GUIDE

CHRONICMEDICATION

Benefits

The Transmed pharmacy network*2 is the DSP*3

Comprehensiveformulary*4 appliesReferencepricing*5 applies

Pharmacies

The Transmed pharmacy network*2consistsof:• Clicks pharmacy group• Dis-Chem pharmacies• MediRitepharmacygroup(pharmaciesinShoprite/Checkers

stores) • Contracted independent pharmacies

Membersmaybeliableforaco-payment*9ifapharmacyoutsidethe Transmed pharmacy network*2 is used

State hospital admissions

The DSP*3 is State hospitals


100% cover at a State hospital, subject to the UPFS*13forPMB*16 and non-PMB admissions

Private hospital admissions

Only PMB*16conditionsformajormedicaleventsandselectedknee and hip replacements through ICPS*14

Nobenefitfornon-PMBconditions

IfaStatehospitalisnotaccessibleintermsofthesetcriteriaforPMB*16treatment,authorisationwillbeconsideredforadmissionto a hospital on the Transmed private hospital network*6 as the secondary DSP*3 and payable at the Transmed rate*

The co-payment*9forthevoluntaryuseofanon-DSPwillbetheamountequaltothedifferencebetweenthetotalcostincurredinrespectofthehospitalservices,includingallrelatedmedicalservices, and the cost that would have been payable to the DSP*3 (State hospital) or secondary DSP*3 – whichever is applicable

Pre-authorisation requiredPlease call 0800 225 151

P

MAJOR MEDICAL COVER


11

12

13

14

14 15

In-hospital services

(including GP and specialist services,

pathology and radiology)

100%coverforPMB*16 and non-PMB admissions at a State hospital Subject to the UPFS*13


Advanced radiology (MRI and CT scans)Subject to case management and clinical protocols


In-hospital dentistry


Subject to protocols and limitationsOnly PMB*16conditionsandcertainsurgicalprocedures(fistulaclosure) Paid at the Transmed rate* Thefeeforthehospitalisationandanaesthetistarepaidfromthemajormedicalbenefit

Dentaltreatment/proceduresaresubjecttotheavailabilityoffundsinthespecialiseddentistrylimitofR4110perfamilyperyear


Internal prostheses

Only PMB*16 conditions and selected knee and hip replacements – refertopage7

Subjecttoindividualprosthesislimits–refertoAnnexureAon page 18

Medical motivation may be required


Orthopaedic, surgical and medical

appliances

Subjecttoindividualappliancelimits–refertoAnnexureBon page 19

Medical motivation may be required


MAJOR MEDICAL COVER


16

17

18

15

YOUR BENEFITS

15

Organ transplants

Subject to case management and clinical protocols

Harvestingcostoforgans(bothliveandcadavers)issubjecttoPMB*16 legislation

International donorsThecostofaninternationaldonorsearchandharvestingshallbelimitedtoR225000(irrespectiveoftherand/dollar/euroexchangerate)

Inallcases,specialapprovalisrequiredfromthePrincipalOfficerorhisdelegatebeforeaninternationaldonorsearchcanbefundedandaconfirmationofthenon-availabilityofasuitablelocaldonorisrequired

The recipient must be a Transmed member


Ambulance services

Transferprotocalsapply



Emergency visits in hospital casualties

PaidattheTransmedrate*iflife-treatening Authorisation is required within 1 working day of the emergency treatment Ifnoauthorisationisobtained,serviceswillbepaidfromgeneralday-to-daybenefits,subjecttotheavailabilityoffunds

Please call 0800 225 151

Dialysis

The DSP*3 is State hospitals100% cover at a State hospital, subject to the UPFS*13


IfaStatehospitalisnotaccessibleintermsofthesetcriteria,authorisationcanbeobtainedforadmissiontoahospitalontheTransmed private hospital network*6 as secondary DSP*3 or approved dialysis centres


MAJOR MEDICAL COVER


22

21

20

19

2021SATS PENSIONERS – GUARDIAN PLAN

16 17

MAJOR MEDICAL COVER


Oncology(cancer) treatment

The Independent Clinical Oncology Network (ICON*7)ofprivateoncologists and State hospitals are DSPs*3

Paid at the Transmed rate* Benefitsarerestrictedtotier1oftheSouthAfricanOncologyConsortium (SAOC) guidelinesLimitedto1PETscanperbeneficiaryperyearA 20% co-payment*9appliesforusingaproviderotherthananICON*7 service provider or the StateOncology (cancer) medication to be obtained through the Transmed oncology pharmacy network*8 and is subject to evidence-based clinical protocolsA co-payment*9mayapplyforobtainingoncology(cancer)medicationfromanon-oncologymedicinenetworkReferencepricing*5 applies to oncology (cancer) medicationPre-authorisation required Please call 0800 225 151

HIV and AIDS benefit

MembersareencouragedtoregisterontheHIVYourLifeprogrammeObtainmedicinefromaTransmedpharmacynetwork*2 or courier pharmacy, as selected during enrolmentMembersmaybeliableforaco-payment*9ifapharmacyoutsidethe Transmed pharmacy network*2 is usedReferencepricing*5 appliesPre-authorisation required Please call 0860 109 793(allcallsarehandledconfidentially)

Cataract surgery

The Ophthalmology Management Group (OMG*12) network and State hospitals are DSPs*3

Paid at the Transmed rate*A 20% co-payment*9 on the total hospital and associated provider costs appliesforusingaproviderotherthananOMG*12 provider or the State Inadditiontocataractsurgery,thefollowingserviceswillbecovered,subjecttopre-authorisation:• theconsultationduringwhichthediagnosisismadeandconfirmed• therelevanttestsperformedtomakethediagnosis,asperthe

applicable algorithm• medicationadministeredaspartoftheprocedure,asperthe

applicable algorithm• any other indicated services, as per the applicable algorithmPre-authorisation required Please call 0800 225 151

Terminal care benefit

Subjecttopre-authorisation(homeassessmentifindicated)Once-offlimitofR15000perbeneficiary(thisisanadditionalbenefitandthefinanciallimitisnotapplicabletoanyservicesrenderedwhichqualifyforpaymentintermsofthePMB*16 legislation)Onlyapplicablefortreatmentprovidedinanaccreditedfacility(hospice/sub-acute/homecarebyregisterednurse)Pre-authorisation required Please call 0800 225 151

YOUR BENEFITS

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24

25

26

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2021SATS PENSIONERS – GUARDIAN PLAN

PRESCRIBED MINIMUM BENEFITS


Prescribed minimum

benefits (PMBs)

Hospitalisation100% cover at a State hospital, subject to the UPFS*13 IfaStatehospitalisnotaccessibleintermsofthesetcriteria,authorisationcanbeobtainedforadmissiontoahospitalontheTransmed private hospital network*6 as the secondary DSP*3 and payable at the Transmed rate*The co-payment*9forthevoluntaryuseofanon-DSPwillbetheamountequaltothedifferencebetweenthetotalcostincurredinrespectofthehospitalservices,includingallrelatedmedicalservices,and the cost that would have been payable to the DSP*3 (State hospital)IfthePMB*16 service was not accessible in a State hospital, but available at a Transmed private hospital network*6 hospital, and the member voluntarily uses a non-network private hospital, the co-payment*9 will betheamountequaltothedifferencebetweenthetotalcostincurredinrespectofthehospitalservices,includingallrelatedmedicalservices,and the cost that would have been payable to the DSP*3 (State hospital)

Treatment plan servicesPaid at costSubject to the approved treatment plan servicesSupplierofownchoicemaybeusedforPMB*16 CDL conditions

Chronic medication – the Transmed pharmacy network*2 consists of:• Clicks pharmacy group• Dis-Chem pharmacies• MediRitepharmacygroup(pharmaciesinShoprite/Checkersstores)• Contracted independent pharmaciesMembersmaybeliableforaco-payment*9ifapharmacyoutsidetheTransmed pharmacy network*2 is used

Health advisor

FreeaccesstoHelloDoctor,amobilephone-basedservicethatgivesyouaccesstodoctors24hoursaday,7daysaweek.YoucangetexperthealthadvicefromqualifiedSouthAfricanmedicaldoctorsthrough your phone, tablet or computer, at absolutely no cost to you! Just download the app, request a call, and the doctor will phone you back within an hour. Refertopage21formoreinformation

Flu vaccinations

AvailabletoallbeneficiariesThe Transmed pharmacy network*2 is the DSP*3

Paid at the Transmed rate*Subjecttothefluvaccinationformulary*4Onevaccinationperbeneficiaryperyear

Pneumococcal vaccination

Availabletohigh-riskbeneficiarieswithrespiratorycomplicationsSubject to an approved treatment plan The Transmed pharmacy network*2 is the DSP*3

Paid at the Transmed rate*Subjecttotheapplicableformulary*4

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PREVENTATIVE BENEFITS

ADDITIONAL BENEFIT

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2021

ANNEXURE A:INTERNALPROSTHESES

Please note: These prostheses are only reimbursed for PMB*16 conditions or unless otherwise specified in the guide.

G.HOWTOCLAIMPROSTHESES SUB-LIMITS

COMBINED ANNUAL SUBLIMIT

1. Pacemaker and leads R40000

R74200perbeneficiaryperyear

1.1 Pacemaker (double chamber) R450002. Cervical and lumber disc replacement R16 0003. Partial hip replacement R19 0004. Total hip replacement R540005. Hiprevision R430006. Total knee replacement R46500

7. Total shoulder replacement R490008. Total knee revision R450009. Spinalfusion(perprocedure) R4600010. Cardiacstents(perstent)uptoamaximumof3 R21 200

11. Grafts(pergraft) R22 500

12. Cardiac valves (per valve) R30 00013. Herniamesh(umbilicalrepair) R11 000

13.1 Herniamesh(other) R5 500

14. Non-specifieditems R21 00015. Endovascular aneurysm repair (EVAR),

Anaconda and equivalentsR70 000 Perbeneficiaryperyear

16. Pacemakerplusdefibrillator R100 000 Perbeneficiaryperyear17. Brain stimulator R150 000 Perbeneficiaryperyear

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Please note: These prostheses are only reimbursed for PMB*16 conditions or unless otherwise specified in the guide.

ANNEXURE B:ORTHOPAEDIC,SURGICALANDMEDICALAPPLIANCES

G.HOWTOCLAIM

AllaccountsmustreachtheFundnotlaterthanthelastdayofthefourthmonthfollowingthemonthinwhichtheserviceswererendered.Claimsreceivedafterthisdatewillnotbepaid.

ENSURE THAT ALL ACCOUNTS CONTAIN THE FOLLOWING DETAILS• your membership number• your initials and surname • thepatient’snameanddependantcodeasitappearsontheprincipalmember’smembershipcard• the date on which the service was rendered• thenameandpracticenumberofthehealthcareprovider• thereferringhealthcareprovider’spracticenumber(onspecialistaccounts)• thetariffcode(s)• the required ICD-10 code(s)• thepatient’sIDnumberordateofbirth.

HOW TO SUBMIT YOUR CLAIMEmail: [email protected]: 0113812041/42Post:Transmed claims departmentPO Box 32931Braamfontein2017

PROSTHESES SUB-LIMITS

COMBINED ANNUAL SUBLIMIT

1. Pacemaker and leads R40000

R74200perbeneficiaryperyear

1.1 Pacemaker (double chamber) R450002. Cervical and lumber disc replacement R16 0003. Partial hip replacement R19 0004. Total hip replacement R540005. Hiprevision R430006. Total knee replacement R46500

7. Total shoulder replacement R490008. Total knee revision R450009. Spinalfusion(perprocedure) R4600010. Cardiacstents(perstent)uptoamaximumof3 R21 200

11. Grafts(pergraft) R22 500

12. Cardiac valves (per valve) R30 00013. Herniamesh(umbilicalrepair) R11 000

13.1 Herniamesh(other) R5 500

14. Non-specifieditems R21 00015. Endovascular aneurysm repair (EVAR),

Anaconda and equivalentsR70 000 Perbeneficiaryperyear

16. Pacemakerplusdefibrillator R100 000 Perbeneficiaryperyear17. Brain stimulator R150 000 Perbeneficiaryperyear

APPLIANCES LIMITS

1. Wheelchairs (subject to clinical criteria)Non-motorised wheelchair OR Motorised wheelchair

R8000(onceeveryfiveyears)

2. Handprosthesis R10 000 (once every two years)3. Arm prosthesis R26 000 (once every two years)4. Abovekneeprosthesis R75 000 (once every two years)5. Below knee prosthesis R68 000 (once every two years)6. Siliconesleevereplacementsforallartificial

limbsR9 500 (once every year)

7. Backbracefollowingsurgicalprocedures R7 7008. Walking aids R2 0009. Hearingaids One hearing aid Setofhearingaids Hearingaidrepairs

Once every three yearsR8 800R18 300Partofthehearingaidlimit

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2021

H.EXGRATIA

Exgratiaisanadditionalfinancialbenefitthatmemberscanapplyforwhentheyexperiencefinancialhardshiprelatedtounforeseenmedicalexpenses.

WHAT YOU NEED TO KNOW ABOUT THE APPLICATION PROCESS• Thesubmissionofanexgratiaapplicationisnotaguaranteethatassistancewillbegranted.• Thecommitteewon’tconsideranyadvancepaymentofmedicaltreatment.• Membersarerequestedtoprovidefulldetailsofthefinancialassistancerequired.Detailssuchasduration,costinvolvedandmotivationforthenecessityofexpensesareessentialforthecommittee to consider an application.

• The ex gratia committee meets once a month.• A reply to your application could take up to 30 days and the decision will be issued in writing.• Thedecisionofthecommitteeisfinalandnofurthercorrespondenceregardingtheapplication

will be considered once the decision has been announced.

Anapplicationformcanbeobtainedatwww.transmed.co.zaorfromthecustomerservicedepartment on 0800 110 268.

HOW TO SUBMIT YOUR APPLICATIONEmail:[email protected]:Ex gratia CommitteePrivate Bag X50Braamfontein2017

21

I.HEALTHADVISOR–HELLODOCTOR

Talktoadoctoronyourphone,anytime,anywhere–forfree.

J.MEMBERSHIP

TheTransmedMedicalFundisamedicalschemethatisopentoemployeesandpensionersoftheTransnetGroup,itssubsidiariesandformersubsidiaries.

DEPENDANTSIntermsoftheFund’srules,thefollowingpersonsmayberegisteredasdependants,providedthattheyarenotamemberoraregistereddependantofamemberofanyothermedicalscheme.

AsaTransmedmember,yougetfreeaccesstoHelloDoctor,amobilephone-basedservicethatgivesyouaccesstoadoctor24hoursaday, seven days a week. You can get expert healthadvicefromqualifiedSouthAfricanmedical doctors through your phone, tablet or computer, at absolutely no cost to you! Just download the app, request a call and the doctor will phone you back within an hour.

ThefollowingHelloDoctorplatformsareavailabletoaccessthisservice:

THE WEBSITE: WWW.HELLODOCTOR.CO.ZA

YoucanlogintoyourpersonalprofileontheHelloDoctorwebsiteusingyouraccessdetails

and request a call back or simply send a text message to a doctor.

THE APP:DownloadtheHelloDoctorappbyvisitingthe Apple App or Google Play stores. You can sign in using your access details and request a call back or send a text message to a doctor.

USSD (UNSTRUCTURED SUPPLEMENTARY SERVICE DATA):Youcandial*120*1019#fromyourmobilephoneandfollowthemenupromptstorequestacallbackfromadoctororsendatext message to the number that they provide.

Your spouse Thisreferstoamember’swife,husband or partner. Ifyouaredivorced,yourformerspousecannot be registered as a dependant.

Your immediate family/spouse’s immediate familyThisreferstoaparent,brother or sister in respect ofwhomthemember/spouseisliableforfamilycare and support.

Your childrenThisreferstoamember’snaturalchild, stepchild, a legally adopted child, an illegitimate child, a child in theprocessofbeinglegallyadoptedorplacedinfostercare,achildforwhomthememberhasadutyofsupportorachildplacedinthecustodyofthememberorhis/herspouseorpartner.

Note the following:* Childdependantcontributionsarepayableforamaximumoffourdependants.* Childdependantsolderthan21whoarestudyingfull-orpart-timeandarefinanciallydependentonthememberwillpaychilddependantcontributionsuntiltheageof24(proofofregistrationatanaccreditedinstitutionwillberequired).

**Dependantsolderthan21(or24inthecaseofstudyingchildren)whoarefinanciallydependentonthememberwillpay adult dependant contributions.

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2021BENEFITS GUIDE

J.MEMBERSHIP (continued)

DEPENDANTS OF DECEASED MEMBERSThedependantsofadeceasedmember,whoareregisteredwiththeFundasdependantsatthetimeofthemember’sdeath,willbeentitledtomembershipoftheFundwithoutanynewrestrictions, limitations or waiting periods.

MEMBERSHIP AMENDMENTSAmembermustcompleteamembershipamendmentformandsubmitittotheFundwithin 30daysofthechange,inthefollowinginstances:• whenyouregister/cancelthemembershipofdependants• whenamemberdivorceshis/herspouse• when registered dependants no longer quality as dependants• whenthereareanychangestoamember’sresidentialand/orpostaladdress,e-mailaddress,fax

number, cell phone number or other telephone numbers and banking details.

TERMINATION OF MEMBERSHIPRESIGNATIONMembersmayterminatetheirmembershipbygivingonecalendarmonth’swrittennotice. Thiswillalsoterminatethemembershipoftheirregistereddependants.Allrightstobenefits willceaseexceptforclaimsinrespectofservicesrenderedpriortoresignation.

WAITING PERIODSTheFundappliesawaitingperiod,whichisoftenreferredtoasunderwriting.

TherulesoftheFundstipulatetwotypesofwaitingperiodstobeimposedwhenamember/dependantjoinstheFund:

1.ageneralwaitingperiodofthreemonths2.acondition-specificwaitingperiodof12monthsforcertainpre-existingconditions (i.e.ninemonthsforanexistingpregnancy).

LATE-JOINER PENALTIESMedicalschemescanimposelate-joinerpenaltiesonindividualswhojoinaftertheageof35andwhohaveneverbeenmembersoforhaven’tbelongedtoamedicalschemeforaspecifiedperiodoftime.Dependingonthenumberofyearsthattheyhavenotbelongedtoamedicalscheme,late-joinerpenaltieswillbeaddedtomembers’monthlycontributions.Itiscalculatedasapercentageofthecontributionandcanrangefrom5%to75%.Late-joinerpenaltiesareappliedtodiscouragemembersfromonlyjoiningmedicalschemeswhentheyareolderorill,asthiswillmakemedicalschemesunaffordable.

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2021

K. IMPORTANT CONTACT DETAILS

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UPDATE YOUR BANKING DETAILSFraudriskhasforcedTransmedtostopanyrefundstomembersbycheque.ItisthereforeoftheutmostimportancethatyouensureyourbankingdetailsareupdatedwiththeFund.Ifyouhavenotreceivedarefundinthepastyearorifyourbankingdetailshavechangedrecently,youmustensurethattheupdateddetailsreachTransmedwithin30daysofthechange,asstipulatedintheTransmedRules.TheFundwillnotbeliableifthememberhasneglectedtofollowthisruleandmoney is deposited into an incorrect bank account.

Toupdateyourbankingdetails,thefollowinginformationisrequired:• acopyofyourID;and• abankaccountstatement,crossedchequeorletterfromthebankwithabankstampas

confirmation(notolderthanthreemonths). Please remember to include your membership number in the communication.

COMPLAINT AND DISPUTE RESOLUTION PROCESSTransmed takes pride in delivering excellent service and strives to have open communication with its members.

PleasenotethatthereisaformalcomplaintanddisputeresolutionprocessthatcanbefollowedwhenyouaredissatisfiedwithservicesrenderedbytheFund.

AnyenquirymustfirstbedirectedtotheAdministratoroftheFund.Thiscanbedonebycallingthecustomerservicesdepartmentorbysendinganemailto:

• Tollfree:0800110268• Email:enquiries@transmed.co.zaShouldyounotbesatisfiedwiththeresponsetoyourenquiry,youcanemailcomplaints@transmed.co.za.Shouldyoustillnotbesatisfiedwiththeresponsetoyourenquiry,youcandirectyourcomplaint to the Fund at [email protected],youcancontacttheRegulator,whowillevaluateyour complaint as an independent entity.

COMPLAINTS DEPARTMENT AT THE COUNCIL FOR MEDICAL SCHEMESCustomerCare:[email protected]

SERVICE CONTACT NUMBER

Customer service department (general queries) 0800 110 268Chronic medication application 0800 122 263Hospitalandmajormedicalpre-authorisation 0800225151Ambulance authorisation 0800 115 750Opticalservices(PPN) 0860304060/0861103529Dentalservices(DENIS) 0860104941Fraudhotline 0800000436HIVYourLifeprogramme 0860109793WhatsApp 0860 005 037

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Postal address: Transmed Medical FundPO Box 32931Braamfontein,2017

w w w . t r a n s m e d . c o . z a

2021

benefits guide - mymembership

Documents