Rules

Annexure B

NOTES TO THE BENEFITS AND LIMITATIONS

MEMBERs and their registered DEPENDANTs shall be entitled to the following benefits subject to the SOCIETY’s limitations.
Pre-authorisation shall be required before non-emergency hospitalisation, surgical procedures and other specified items. In the case of an emergency the SOCIETY must be notified thereof within 24 hours or on the first working day after such an admission or treatment having been initiated. No benefit if not pre-authorised.
Pre-authorisation shall be required for chronic medication through the SOCIETY’s contracted provider.
All benefits will be calculated according to the National Health Reference Price List (NHRPL) except where preferred provider arrangements have been concluded at the scheme rate.
Benefits are not transferable from one financial year to another or from one category to another.
Unless otherwise provided for, maximum benefits shall be calculated from 1 January to 31 December each year, based on the services rendered during that year.
Where the SOCIETY has entered into a preferred provider arrangement with a provider, or a group of providers, to supply a service, the SOCIETY shall not be liable for the COST of services provided from other providers without the prior APPROVAL of the SOCIETY.
Subject to rule 15.5 and paragraph 29 of Annexure C, claims not submitted within four months after the month in which the service was rendered shall not be paid for by the SOCIETY.
Where the maximum as provided in these rules has been exceeded, the MEMBER will be liable for the payment of any subsequent accounts directly to the supplier of service.
Notwithstanding any other provisions in the rules, the SOCIETY will cover in full the diagnosis, medical management and medication for the prescribed chronic conditions to the extent that this is provided for by way of a therapeutic algorithm for a specified condition, as published by the Minister of Health by notice in the Government Gazette.
MEMBERs and their registered DEPENDANTs will also be entitled to medication for other (non-prescribed) chronic conditions as indicated in the benefits schedule. The co-payments and annual limits applicable to the diagnosis and medical management of these conditions are indicated in the benefits schedule.
Cover for chronic conditions (prescribed and non-prescribed) will only be provided subject to pre-authorisation, diagnostic and treatment protocols, formularies and/or reference prices and the use of designated services providers.
Prescribed Chronic Condition List

Addison’s Disease
Asthma
Bipolar Mood Disorder (will be covered when an algorithm has been developed)
Bronchiectasis
Cardiac Failure
Cardiomyopathy
Chronic Obstructive
Chronic Renal Disease
Coronary Artery Disease
Crohn’s Disease
Diabetes Insipidus*
Diabetes Mellitus Type 1 & 2
Dysrhythmias
Epilepsy
Glaucoma
Haemophilia*
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple Sclerosis*
Parkinson’s Disease
Rheumatoid Arthritis
Schizophrenia
Systemic Lupus Erythromatosis
Ulcerative Colitis
HIV/AIDS

Non-prescribed Condition List: (Conditions marked § may have prescribed minimum benefit entitlement in terms of the diagnosis and treatment pairs as per Annexure A to the Regulations of the Medical Schemes Act.)

Acne*
Allergic Rhinitis*
Alzheimers Disease*
Ankylosing Spondylitis
Benign Prostatic Hypertrophy
Cushing’s Disease §
Cystic Fibrosis*
Deep Vein Thrombosis §
Gastro-oesophageal Reflux Disorder*
Gout*
Hyperparathyroidism §
Hypoparathyroidism §
Hyperthyroidism §
Major Depression §
Meniere’s Disease*
Menopausal and Perimenopausal Disorders §
Motor Neuron Disease
Myasthenia Gravis
Osteoarthritis
Osteoporosis*
Paget’s Disease
Paraplegia, Quadriplegia* §
Peripheral Vascular Disease §
Pituitary Adenomas
Psoriasis
Pulmonary Interstitial Fibrosis
Stroke / Cerebrovascular Accident §
Systemic Connective Tissue Disorders ( incl. Scleroderma and Dermatomyositis)
* under certain conditions only.
BENEFITS