Co-payments | POLMED

Overview of Plans

BENEFITS	MARINE	AQUARIUM	CO-PAYMENTS AND COMMENTS
IN-HOSPITAL BENEFITS
PMB hospital cover	Unlimited	Unlimited	Subject to POLMED network on the Aquarium option R15 000 co-payment for admission in a non-network hospital on the Aquarium option Negotiated network tariff Subject to pre-authorisation Subject to R5 000 penalty where pre-authorisation was not obtained Subject to managed care protocols and guidelines
Non-PMB hospital cover	Unlimited	R200 000	R15 000 co-payment for admission in a non-network hospital on the Aquarium option Negotiated network tariff Subject to pre-authorisation Subject to R5 000 penalty where pre-authorisation was not obtained Subject to managed care protocols and guidelines
Allied health services and alternative healthcare providers: Biokineticists Chiropractors Chiropodists Dieticians Homeopaths Naturopaths Orthoptists Osteopaths Podiatrists Reflexologists Therapeutic massage therapists	Yes Yes	Yes Yes	Referral required for services rendered by all allied and auxilliary service providers in-hospital A referral by the treating healthcare professional is required for services rendered. Number of consultations limited to 4 sessions in a benefit cycle
Anaesthetist’s rate	150%	150%
Caesarean sections	Yes	Yes	Subject to PMB Subject to pre-authorisations Considered in line with managed care and funding protocols A co-payment of R10 000 will apply for voluntary Caesarean sections
Chronic renal dialysis	Yes	Yes	100% agreed tariff Subject to pre-authorisation Subject to network Subject to 30% co-payment when using a non-network provider
Dentistry (conservative and restorative)	Yes	Yes	100% POLMED rate Subject to out-of-hospital (OOH) Subject to dentistry sublimit Hospital and anaesthetist costs will be reimbursed from in-hospital benefits
Emergency medical services	Yes	Yes	Subject to authorisation within 72 hours following the incident or next day post-emergency Authorisation required for inter-hospital transfers before the event Subject to 40% co-payment when using a non-network provider
General practitioners	Yes	Yes	100% of agreed tariff at network provider 100% of POLMED rate at non-network provider
Medication (specialised drug limit) e.g. biologicals	Yes	Yes	100% of POLMED rate Subject to pre-authorisation Subject to listed sublimit
Mental health	Yes	Yes	100% of POLMED rate Annual limit of 21 days in-hospital or 15 out-of-hospital sessions per beneficiary Limited to a maximum of three day’s hospitalisation if admitted by a GP or a specialist physician Additional hospitalisation subject to motivation by the medical practitioner
Oncology (chemotherapy and radiotherapy)	Yes	Yes	100% if agreed tariff at network provider Subject to set limit and includes MRI/CT or PET scans Subject to oncology formulary Subject to medicines from the preferred provider network
Organ and tissue transplants	Yes	Yes	100% of agreed tariff at network provider Subject to clinical guidelines
Pathology	Yes	Yes	Service linked to hospital pre-authorisation
Prosthesis (internal and external)	Yes	Yes	100% POLMED rate Subject to pre-authorisation Subject to approved product list Subject to overall prosthesis benefit limit Subject to specific prosthesis sublimit
Radiographers	Yes	Yes	Referral by the treating healthcare professional is required for services rendered
Refractive surgery	Yes	No benefit	100% POLMED rate Subject to pre-authorisation Procedure performed out-of-hospital and in day clinics
Specialists	Yes	Yes	100% agreed tariff at network provider 100% POLMED rate at non-network provider

OVERALL OUT-OF-HOSPITAL (OOH) BENEFITS
Annual OOH benefits	Yes	Yes	Subject to OOH limit, protocols and guidelines
Audiology	Yes	Yes	Subject to OOH limit and referral Audiology network must be used
Conservative and restorative dentistry	Yes	Yes	Subject to OOH limit and includes dentist costs for in-hospital, non-PMB procedures Routine consultation, scaling and polishing limited to two annual check-ups per beneficiary Oral hygiene instructions are limited to once in 12 months per beneficiary Dental network applies to Aquarium option – 30% co-payment for use of a non-network provider
General practitioners	Yes	Yes	100% agreed tariff at Network Subject to OOH limit Subject to listed number of consultations per family per annum Subject to network and/or nominated general practitioner (GP)
Medication (acute)	Yes	Yes	100% POLMED rate at Network Subject to the OOH limit Subject to POLMED Formulary reference price Subject to 20% co-payment for non-network utilisation
Medication (over-the-counter (OTC))	Yes	Yes	100% of POLMED rate at Network Subject to annual sublimit Subject to OOH limit Subject to POLMED Formulary Subject to 20% co-payment for non-network utilisation
Occupational and speech therapy	Yes	PMB only	100% POLMED rate Subject to OOH limit Subject to annual sublimit
Pathology	Yes	Yes	Subject to OOH Subject to annual pathology sublimit
Physiotherapy	Yes	Yes	100% of POLMED rate Subject to OOH limit Subject to annual physiotherapy sublimit
Psychology plus social worker	Yes	Yes	100% of POLMED rate Subject to OOH limit Subject to psychology plus social worker sublimit
Specialists	Yes	Yes	100% of POLMED rate at network provider Subject to OOH limit Subject to maximum listed number of visits/consultations per beneficiary and per family per annum Subject to GP referral to network listed specialists Subject to R1 000 co-payment on Marine plan if no referral is obtained

STAND-ALONE BENEFITS
Allied health services and alternative healthcare providers: Biokinetics, chiropractors, chiropodists, dieticians, homeopath, naturopaths, orthoptists, osteopaths, podiatrists, reflexologists and therapeutic massage therapists	Yes	No benefit	100% POLMED rate Subject to annual limit Subject to clinical appropriateness
Appliances (medical and surgical)	Yes	Yes	100% POLMED rate Subject to listed limit Subject to referral Subject to pre-authorisation Subject to applicable clinical protocols and guidelines Subject to quotations
Chronic medications	Yes	PMB only	100% of POLMED rate at network provider 20% co-payment at non-network provider Subject to formulary reference price Subject to prior application and registration of chronic condition PMB-CDL conditions are not subjected to limit Extended list of chronic conditions (non-PMB) subject to listed chronic medications limit
Maternity benefits (including home birth)	Yes	Yes	Subject to pre-authorisation Subject to treatment and clinical protocols and guidelines
Ultrasound scans	Yes	Yes	Subject to listed limit Pre-authorisation applies for extra ultrasound after 32 weeks of pregnancy
Maxillofacial	Yes	No benefit	Subject to pre-authorisations Shared limit with specialised dentistry
Optical	Yes	Yes	Subject to listed limit Each beneficiary is entitled to either spectacles or contact lenses Subject to 24-month benefit cycle No prorating, benefits will be calculated from benefit service date
Basic radiology	Yes	Yes	100% of agreed tariff Subject to basic radiology family limit Includes basic radiology in- and out-of-hospital Claims for PMB first accrue towards the limit
Specialised dentistry	Yes	PMB only	100% POLMED rate Subject to pre-authorisation Subject to annual family limit Subject to dental protocols Subject to 5-year cycle for crown and bridges Includes specialised dental procedures done in- and out-of-hospital Includes metal-based dentures subject to a 5-year cycle Aquarium plan only PMB benefits
Specialised radiology	Yes	Yes	100% of agreed tariff Subject to pre-authorisation Includes specialised radiology in- and out-of-hospital Claims for PMB first accrue towards the limit PMB rules apply