Version

2011.11.03.22

2011 Medical Scheme Quotation

RESOLUTION
Foundation 5501-7500

M Bernardo
2011/07/07
Quote Ref : 496317 Pay 3 children

SCHEME OPTION:
Description of Cover:
Principal Member
Adult Dependant no. 1

Discovery
Keycare Plus
3901-6250

MEDIHELP
Necesse
0 - 7500

Pay 3 Children

Pay 4 Children

TOPMED
Network 3501-7500

Pay 4 children

H1

G2

D1

B1

(Income R5 501 - R7 500)

(Income R3 901 - R6 250)

(Income 0 - 7500)

(Income R3 501 - R7 500)

Capitation

Capitation

Capitation
(Private Network)

Capitation
(CareCross)

Risk Contribution

Risk Contribution

Risk Contribution

Risk Contribution

R 670
R 512

R 533
R 533

R 684
R 540

R 763
R 763

Risk Only

Risk Only

Risk Only

Risk Only

R 45

R 45

R 45

R 45

R 1,227

R 1,111

R 1,269

R 1,571

R 60

R 53

R 62

R 77

R 1,287

R 1,164

R 1,331

R 1,648

Zurreal4Life Platinum - R145 per family

KeyFIT R33/Vitality R145 (Both R158)

N/A

Multiply - R146

Various products available

ranging from R80 - R95

Various products available

ranging from R80 - R95

Various products available

ranging from R80 - R95

Various products available

ranging from R80 - R95

Service Fee: A fee is included in the total for assisting members with: claims /
query resolution, annual personal assistance at option renewal, quartely news
letter etc.

Total Monthly Contribution

(Including R45 Service Fee)

Late Joiner Penalty

(This penalty will be added to your premium every month)

Total Monthly Contribution with Late Joiner Penalty

Optional Loyalty Club
Gap Cover:
Optional Insurance product that provides cover for specialist's fee's whilst
hospitalised, above 100% of Scheme Tariff up to 400% of Scheme Tariff.
Terms will apply.

This summary is for information purposes only and does not supersede the Rules of a Scheme. In the event of any discrepancy between the summary and the Rules of a Scheme, the Rules will prevail.
Underwriting that can be applied to your membership:
3 Month general waiting period
12 month exclusion on pre-existing condition
Late joiner penalty
Advice Provided by:
Optivest - a licensed financial services provider: FSB 13475
Optivest in an Independent healthcare consultancy organisation that strives to present
clients with the highest level of service and does not have shareholding or direct interest
in any medical scheme or medical scheme administrator.

Jackie Verster
Marketing Consultant
OPTIVEST HEALTH SERVICES
Tel: 021 970 6897
Fax: 0866 875 501
Email: jverster@optivest.co.za
FSB license: 13475
Page 1 (of 3)

SCHEME OPTION:

H1

G2

D1

B1

(Income R5 501 - R7 500)

(Income R3 901 - R6 250)

(Income 0 - 7500)

(Income R3 501 - R7 500)

100% of Scheme Tariff

100% of Scheme Tariff

100% of Scheme Tariff

100% of Scheme Tariff

Network Hospitals

Network

Any Hospital

Any Hospital

None
(co-payments apply)

None

IN HOSPITAL BENEFITS:
Rate of Cover for Specialist fees during hospitalisation
Hospitals that may be utilized
(Pre-authorisation is required before treatment starts, or in case of an emergency
within the next two business days)

Overall limits & Deductibles

Listed Procedures: Procedures normally performed in hospital, performed in
Doctor's room/Day Ward e.g.Gastroscopy, etc.

R800 000 Per Family

Unlimited - Subject to pre-authorisation. R1000

In Hospital: Unlimited at Network Hospitals. *CoCovered in Network of Day-Case facilities within
payments apply - see below
co-payment unauthorised non-emercency
50km radius, otherwise Keycare Network hospital
Out of Hospital: Unlimited at Network Provider
admission

None
Colonoscopy, Endoscopy, Gastroscopy in doctor's
rooms/as day case in hospital under concious
sedation, unless clinically appropriate for general
anaestetic - req pre-auth at 100% of Scheme Tariff

In Hospital: Normal delivery: 3 days & 2 nights.

Caesar: 4 days & 3 nights
Out of Hospital: 2 x 2D scans

In Hospital: Unlimited
Out of Hospital: 4 Antenatal visits, 1 Scan and
selected blood test - referred by KeyCare
Network doctor

In Hospital: R16 000 per confinement, subject to

OAL. Out of Hospital: Ltd to 2 Sonars & 2
Specialist consultations per pregnancy, within
Network.

In Hospital: Unlimited (limited to 1 birth per family

per year). Out of Hospital: Pre & postnatal care
provided by Carecross provider,up to 20 weeks,
2 Ultrasound Scans

Covered at Network Provider. Subject to PMB

21 Days per beneficiary

Prescribed Minimum Benefits

Prescribed Mininum Benefits only

Covered at Network Provider. Subject to PMB

In Hospital: Unlimited if related to approved

hospital event (back & neck not covered)
Out of Hospital: Ltd to R2100 per beneficiary
(paid from Specialist benefit)

In and out of Hospital: R10 000 per family per

year

In Hospital: Unlimited - subject to preauthorisation

Out of Hospital: No Benefit

Unlimited through ICON Network. Protocols apply

Cover PMB at cancer specialist in the ICON

network. Register on the Oncology Programme

Subject to ICON Oncology management program Limited to R200 000 pbpa.

protocols - PMB Only
Treatment limited to Tier 1 protocols.

HIV Programme (Network Hospitals). Subject to

Scheme Protocols and PMB. Covered at
provincial facility if not registered

Unlimited if registered on HIVCare Programme R12 000 if not registered

Unlimited, subject to Disease Mangement

Programme and protocols

Subject to registration on the CareWorks

program

ER24

Discovery 911

Netcare 911

ER 24 - Unlimited.
Non-Prefered Provider: Ltd to R1600 per family

7 Days supply

R100 per beneficiary per admission

R240 per beneficiary per admission

No Benefit

Emergency Ward Treatment which does not result in

Hospitalisation

R1 115 per family

Preferred Casualty units in Keycare Network of

hospitals, only pay R110 of consultation. Other
casualty units will pay R250 for consultation

Covered only if indicated as Emergency (PMB)

by treating doctor

No Benefit

International Medical Travel Assistance

No Benefit

No Benefit

No Benefit

No Benefit

No Benefit

No Benefit

R13 500 per family for sub-acute & private

nursing facilities. Subject to pre-authorisation &
case management.

Limited to PMB treatment only

Prescribed Minimum Benefits

Subject to PMB treatment

Prescribed Minimum Benefits

Unlimited to PMB

Prescribed Minimum Benefits

Prescribed Minimum Benefits and 8 additional

conditions covered

Maternity Benefits
(In & Out of Hospital)

Psychiatric & Psychological Treatment

MRI & CAT Scans
(In & Out of Hospital)

Oncology/Cancer (In & Out of Hospital)

(Comprehensive Oncology benefits per scheme available on request)

HIV/Aids - Sub limits on Medicine might apply

Ambulances Services/Administrators used by the Scheme (In case
of an Emergency any service can be used)

Discharge Medicine (Take Home Medicine)

Post Hospitalisation Benefit (Treatment after discharge pertaining to

hospitalisation paid from Risk benefits)

Internally Implanted Prostheses

(Limits apply only on Prostheses)

Dialysis

Joint replacements, including but not limited to

R30 600 per family, subject to Prosthesis specific hips, knees, shoulders and elbows will be
limit
excluded.
No cover for elective hip & knee replacements

Cover for PMB Emergencies only

Covered at Network hospitals and subject to

PMB. Protocols apply

Covered up to maximum of 100% of Scheme

Tariff at a network provider only

Chronic Benefits:
All Schemes provide unlimited Prescribed Minimum Benefits (PMB) for the
Prescribed Minimum Benefits
treatment of Conditions (Chronic Disease List) e.g. Diabetes, Asthma, Cholesterol,
Hypertension, etc. Benefits are Subject to a Scheme treatment plan, formulary, Subject to Network formulary
registration, pre-authorisation and a Designated Service Provider (DSP) to avoid a
co-payment. Benefits will be paid first from stipulated (if any) available Chronic
Designated Service Provider: Network Provider
Benefits, thereafter unlimited at DSP. Non-PMB conditions will be paid from
Acute/Savings benefits if Chronic Benefits are not available/depleted.
Page 2 (of 3)

Prescribed Minimum Benefits

Designated Service Provider: Chosen primary
dispensing GP, Optipharm, DisChem or Clicks
If the designated service provider is not used, a
40% co-payment will apply

Designated Service Provider: Medihelp

Pharmacy Network

Designated Service Provider: CareCross

SCHEME OPTION:

OUT OF HOSPITAL BENEFITS:

*Day-to-Day Benefits, or **Savings, which is included
in the Total Monthly Premium to make provision for
medical expenses that does not require hospitalisation
e.g. GP visits & Dentistry is displayed on this page.

H1

G2

D1

B1

(Income R5 501 - R7 500)

(Income R3 901 - R6 250)

(Income 0 - 7500)

(Income R3 501 - R7 500)

Limited Primary Health Care available through

Network Providers
No Benefit for Wisdom teeth removal

Unlimited Primary Health Care Benefits available

through chosen KeyCare Network Doctor
(No Benefits for Wisdom teeth removal)

Screening Benefit
Guardian Benefit covers certain preventative
screening tests at Network Providers.
Trauma Recovery Extended Benefit
Includes Pharmacist Benefit of R283 per family
for over the counter medication
Mobility Devices Benefit

Unlimited Primary Health Care Benefits available Unlimited Primary Health Care available through
through the Medihelp Preferred Provider Network your chosen CareCross Provider
Dental covered at 100% of Scheme dental tariff - (Impacted Wisdom teeth - no cover, except in
Subject to DENIS limits, protocols & pre-auth
trauma cases)

TOTAL *In-Scheme Day-to-Day Benefits(if applicable) & or **Savings:

Annual Threshold/Safety Net limit to be reached:

N/A

N/A

N/A

N/A

Estimated Self Payment Gap:

N/A

N/A

N/A

N/A

General Practitioner Visits

Unlimited at Network Provider

Unlimited at chosen KeyCare Network doctor

Second GP can be nominated

Unlimited at Medihelp Network provider. Out of

network visits ltd to R700 single member,
R1 400 per family with 20% co-payment

Unlimited-at Primary CareCross GP. Non-Primary

ltd to 3 visits per family to max of R1000 per
family per year

Specialist Visits

4 network visits per family to a max of R1 000.

Subject to pre-authorisation.

R2100 per beneficiary-must be referred by GPonly at doctor working at a network hospital.

Subject to pre-authorisation.

R2000 per beneficiary, to maximum of R2 800

per family. Subject to pre-authorisation.

Limited to R2 100 per family per year. Subject to

referral by Carecross GP and pre-authorisation.

Prescribed/ Acute Medicine

Subject to Network accute formulary.

Pharmacist Benefit R283 per family

Unlimited Subject to the KeyCare Acute Medicine Subject to overall annual limit. Must be
Formulary prescribed by network General
prescribed by network GP and obtained from
Practioner
dispensing GP or network pharmacy

(Consultations, Oral hygiene, Extractions & Fillings)

2 annual check ups per beneficiary covered at

Network Providers

Unlimited at chosen KeyCare Dentist Network

Subject to DENIS protocols, e.g. 1 routine

checkup, 1 oral hygiene visit, 4 fillings pbpa

Unlimited - Subject to CareCross Dentist.

Dentures ltd to 1 set per 24-month cycle per
family. 20% co-pay

Specialised/Advanced Dentistry

No Benefit

No Benefit

No Benefit

No Benefit

No Benefit

No Benefit

Occupational Therapists & Physiotherapy

R1 300 per beneficiary to a maximum of
R2 000 per family

No Benefit

Mental Health

No Benefit

No Benefit

Prescribed Minimum Benefits

Psychiatry limited to PMB

Optical

1 Consultation per beneficiary per 24-month

cycle covered at Network Provider, including
single mono or bifocal prescription.

One eye test, 1 pair of clear single-vision, bifocal

or multi-focal lenses with basic frame or basic set
of contact lenses every 2 years per beneficiary from Keycare Optometry Network

PPN Network. 1 eye test, 1 pair clear single

vision or bifocal glasses per beneficiary in 24month cycle. R150 towards frames. R395
towards contact lenses (PPN only).

Subject to CareCross Optometrist. Benefits per

beneficiary per 24 month cycle: 1 consultation, 1
pair of white single and/or bifocal lenses and
choice of selected frames or contact lenses limit
R350 per beneficiary

Radiology & Pathology

Limited to Network Provider

Pathology: Unlimited - only if required by KeyCare

Network doctor
Radiology: Selected basic x-rays at a radiology
facility in the Network, if required by Network GP

Subject to overall annual limit. Subject to referral

Basic radiology and pathology unlimited - Subject
by network GP, preferred providers Lancet and
to CareCross Doctor/Facility
Pathcare and clinical protocols

Copyright reserved by Optivest Health Services

*Co-payments apply:
*Funeral Benefit: R5 000 benefit to Principal
R1 000 on Circumcision, Colonoscopy, Sigmoidoscopy, member for R1. Maximum age 65 next birthday.
Proctoscopy, Excision nailbed, Myringotomy (grommets);
R1 250 on Gastroscopy, Skin lesions; R2 000 on
Arthroscopy; R2 250 on Hysteroscopy; R2 500 on
Conservative Back treatment, Joint replacements; R3
000 on Functional nasal surgery,
HysterectomyLaparoscopic procedure, Reflux surgery;
R4 000 on Spinal Surgery

Basic Dentistry

Auxiliary Services (Homeopaths, Dieticians, Clinical psychologists, Speech

therapists, Physiotherapy, Chiropractors & Occupational therapists)

*In Scheme Day-to-Day Benefits:

Benefits that are part of Risk Cover, unused benefits will not carry over to next year.
**Savings:
Fixed Rand Amount for Day-to-Day Benefits upfronted annually. Savings that are not used for be
carried over to next year.
All Day-to-Day Benefits and Savings is calculated pro-rata per annum .

Co-payments will not apply for procedures performed out of

hospital or for PMB.
Optional Co-Pay Cover

Page 3 (of 3)

Children regarded as child dependants up to 21st Birthday

Unlimited - Subject to CareCross Formulary