2015 - Medical Billing Solutions

BENEFITS GUIDE
W ORKI NG M E MBERS A N D PEN SIONER S
Welcome to Transmed Medical Fund’s
2015 benefits guide. This guide explains
the different plans and benefits for 2015
and how you can access it. Please read
the guide carefully and keep it safe for
future reference.
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.
For all
our people
2015
This colour relates to all the
information on the STATE
PLUS NETWORK PLAN
To make it easier for
you to find what you
This colour relates to all the
information on the STATE
PLUS OWN CHOICE PLAN
This colour relates to all the
information on the PRIVATE
1
NETWORK
PLAN
are looking for in the
guide, please follow
our easy-to-read
colour-codes.
B E NE FITS G U ID E
For all
our people
2015
HOW TO CHANGE YOUR PLAN FOR 2015
This guide provides you with information on
each benefit plan as well as the process to
follow should you wish to change your plan
for 2015. A plan selection form has been
enclosed. The form contains a section to
update your personal and contact details,
which will enable the Fund to update our
records and communicate effectively with
you. This completed form must reach us by
no later than 31 December 2014.
carefully consider the information provided
in this guide in order to choose an
appropriate benefit plan.
Below are a few points to consider before
choosing a benefit plan for 2015:
• Look at your current and future medical
needs and those of your family.
• Compare the different benefit plans in
light of these medical needs to determine
the most suitable plan.
• Decide if you want to remain on your
current benefit plan or if you would like to
change to a new benefit plan.
• Consider the cost of the various benefit
plans to ensure that you can afford the
increased contribution for the next twelve
months.
• Complete and submit your plan selection
form if applicable.
You can also change your benefit plan
telephonically by calling 0800 450 010 and
selecting option 0 for the self-help service,
or online at www.transmed.co.za.
Remember to have your membership and
ID number handy to use this service.
Should you need to update your personal
details, you are welcome to complete the
relevant sections and return the form to
[email protected].
Please note that you do not need to submit the
plan selection form if you want to remain on your
current benefit plan or have already changed it
telephonically or electronically.
Plan changes may only be made once a year
before 1 January and take effect at the start
of each year. Members therefore need to
2
KEY TO TERMS USED IN THIS BENEFITS GUIDE
*
Transmed rate
*1
Universal
Healthcare provider
Benefit year
Lifetime benefit
*2
*3
*4
*5
Universal
Healthcare
formulary
Transmed formulary
*6
MetRef
*7
Transmed pharmacy
network
*8
*10
*11
Transmed private
hospital network
HIV and AIDS
benefit
DSP
ICON
*12
Co-payment
*13
DRC
*14
PPN
*15
OMG
*16
Fund exclusions
*9
The Transmed rate is based on the tariff payable in respect of the benefits or services for
a specific benefit year
If a particular network provider does not provide the required services on the premises,
you will be referred by the network provider to an appropriate service provider
New benefit cycle starts on 1 January 2015
This is the maximum amount that will be allowed for orthodontic treatment while the
member is a beneficiary of the Transmed Medical Fund and applies even if a beneficiary
leaves and rejoins again later
Please call the Universal Healthcare call centre on 0861 686 278 if you are unsure if
your medication is covered by this formulary
Please call the Transmed Customer Service Department on 0800 450 010 if you are
unsure if your medication is covered by this formulary
Metropolitan Heath Reference Price
This is the maximum price that the Fund will pay for generic or therapeutic medication
classes
The Transmed pharmacy network consists of:
• Clicks pharmacy group (including Clicks Direct Medicines [CDM] pharmacy)
• MediRite pharmacy group (pharmacies in Shoprite/Checkers stores)
• Chronicare, Scriptnet and Alpha Pharm pharmacy network including
Dis-Chem pharmacies
The Transmed private hospital network consists of Netcare, Mediclinic and the National
Hospital Network (NHN) groups
Paid at 100% of cost if obtained at a DSP facility
Designated service provider
The Independent Clinical Oncology Network is the contracted DSP for oncology
treatment
A co-payment is the difference between the price charged by the network service
provider and the price charged by member’s service provider of choice that is higher
than the network service provider
Dental Risk Company is contracted to provide ALL dental benefits for the State Plus
Own Choice plan
Preferred Provider Negotiators is contracted to provide ALL optical benefits including
the optical claims processing for the State Plus Own Choice plan
Ophthalmology Management Group Limited is contracted for the delivery of clinically
appropriate and cost-effective cataract surgery
Certain expenses incurred are excluded from the benefit cover:
• Accommodation in an old age home, frail care centre or similar institution
• All costs for operations, medicines, treatment and procedures for cosmetic or for
psychological purposes
• All costs for operations, medicines, treatment and procedures related to weight
reduction
• Operations to reverse a sterilization
• Artificial insemination (GIFT or similar procedures)
• Patent foods, including baby food
• Slimming preparations
• Household remedies or preparations, herbal and natural remedies
• Aphrodisiacs
• Cosmetic soaps, shampoos and other topical applications
• Sun screening and sun tanning agents
• Cosmetic preparations, medicated or otherwise
• Contact lens preparations
• Holidays for recuperative purposes
• Vitamin and mineral supplements
3
BE NE FITS G U ID E
For all
our people
2015
OVERVIEW OF 2015 BENEFITS
SUMMARY OF CHANGES FOR 2015
• The contribution payable for dependants
studying fulltime has been revised.
• Most of the benefit limits have been increased
in line with the anticipated tariff increases.
• The flu vaccination benefit has been extended
to the State Plus Own Choice plan with a
formulary applied.
• The over-the-counter (OTC) benefit for the
State Plus Own Choice and Private Network
plans has been revised to be subject to a
transaction limit as well as an annual family
limit that is payable from the general
day-to-day benefit.
• The selected additional non-PMB chronic
conditions on the State Plus Own Choice plan
will no longer be covered as part of the
chronic benefit, but from the general
day-to-day benefit.
• General practitioner and specialist networks
have been implemented on the Private
Network plan.
• The optical and dental benefits for the Private
Network plan will be integrated to form part
of the general day-to-day benefit.
• The contract with the Ophthalmology
Management Group (OMG) Limited has been
extended to include the Private Network plan
for cataract surgery.
• Vitamin and mineral supplements will be
excluded from the day-to-day benefit and will
no longer be covered, as part of an
intervention to assist with the efficient
utilisation of the general day-to-day benefit.
Note:
Members are reminded that most of the major
medical benefits (in and out of hospital) are
subject to prescribed minimum benefit (PMB)
conditions only. This means that non-PMB
admissions will not be covered by the Fund,
even if such admissions are into State facilities.
Members can call the pre-authorisation line to
confirm the availability of benefits for a
required service.
4
DAY-TO-DAY BENEFITS
STATE PLUS NETWORK PLAN
Members will receive their day-to-day services through the Universal Healthcare networks.This
includes all general practitioners (GPs), pharmacies and dental and optical services.
You can find details of your nearest network provider by calling Universal on 0861 686 278.
STATE PLUS OWN CHOICE PLAN
Day-to-day services are paid from the general day-to-day limit. Members may use any doctor or
service provider of their choice, except for optical and dental services which are being managed by
the contracted providers, Preferred Provider Negotiators (PPN) and Dental Risk Company (DRC).
PRIVATE NETWORK PLAN
Day-to-day services, including optical and dental services are paid from the general day-to-day limit.
Members are required to consult a GP within the new GP network. A referral from the respective
GP will also be required when it is necessary to consult a specialist.This specialist must also be part
of the new specialist network.
R
TRANSMED MEDICAL FUND RATE (TRANSMED RATE)
The Transmed rate is based on the tariff payable in respect of benefits or services for a specific benefit
year as published by the Fund on an annual basis.The Fund only covers items at this rate. If a service
provider charges in excess of this rate, a member will be responsible for paying the difference, unless it
is a PMB-related service obtained on an involuntary basis. In this case it will be dealt with in terms of
the PMB provisions. It is therefore in a member’s best interest to negotiate with a practitioner to
charge the Transmed rate.
STATE PLUS NETWORK PLAN
The agreed tariff is the fee that is negotiated by Universal Healthcare with the relevant contractors
and/or Universal designated service providers (DSPs). Where no fee has been negotiated, the
benefits will be paid at the lowest of the fees claimed or at the Transmed rate.
STATE PLUS OWN CHOICE PLAN
Services are paid at the Transmed rate as published annually by the Fund.
PRIVATE NETWORK PLAN
Services are paid at the Transmed rate or another negotiated rate, as published or agreed upon with
the networks annually.
5
B E NE FIT S G U ID E
For all
our people
2015
2015 CONTRIBUTIONS
STATE PLUS NETWORK PLAN
MONTHLY
INCOME
R0 R2 000
R2 001R3 000
R3 001- R4 001- R5 001R4 000 R5 000 R6 000
R6 001- R8 001R8 000 R10 000
R10 001 +
Member
548
586
625
665
703
743
782
821
Adult dependant*
438
469
499
531
563
594
625
657
Child dependant**
164
175
187
200
211
222
234
246
STATE PLUS OWN CHOICE PLAN
MONTHLY
INCOME
R0 R2 000
Member
759
Adult dependant*
530
R2 001R3 000
R3 001- R4 001- R5 001R4 000 R5 000 R6 000
825
890 2014 BENEFITS
954
1019
OVERVIEW
OF
578
OF CHANGES
2014
ChildSUMMARY
dependant**
229 FOR246
R6 001- R8 001R8 000 R10 000
R10 001 +
1085
1150
623
668
715
759
804
851
267
286
306
326
344
365
PRIVATE NETWORK PLAN
Total monthly contributions (R)
Member
3 175
Adult dependant*
2 859
Child dependant**
952
*Dependants older than 21 years who are financially dependent on the member will pay adult contributions.
**Child contributions are payable for a maximum of four dependants.
**Child dependants older than 21 who are studying fulltime and financially dependent on the member, will pay child
contributions until the age of 24 (proof of registration at an accredited institution will be required).
6
1214
i
BENEFITS
BREAKDOWN OF BENEFITS
STATE PLUS OWN
CHOICE PLAN
STATE PLUS
NETWORK PLAN
PRIVATE
NETWORK PLAN
DAY-TO-DAY COVER
1
All other dayto-day benefits
2
General
practitioner
(GP)
consultations
Obtain from the Universal network
Paid at the Transmed rate*
Paid at the Transmed rate*
Only PMB conditions
Subject to the availability of funds
in the day-to-day limit
Subject to the availability of funds
in the day-to-day limit
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
Paid at the Transmed rate*
Paid at the Transmed rate*
Subject to the availability of funds in
the day-to-day limit
Obtain from Transmed general
practitioner (GP) network
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
Subject to the availability of funds
in the day-to-day limit
Please call 0861 686 278
Network providers
Number of consultations per year:
Member without dependants: 8
Member with 1 dependant: 12
Member with 2 dependants: 14
Member with 3 dependants: 15
Non-network providers
One consultation to a non-network
provider per beneficiary, up to a
maximum of two consultations per
family per year
Limited to R800 per event
3
Specialist
consultations
Three specialist consultations
per beneficiary per year, up to a
maximum of five consultations per
family per year up to a maximum
amount of R2 400 for one
beneficiary or R3 500 per family
Pregnant beneficiaries are entitled
to two additional specialist
consultations per year
Paid at the Transmed rate*
Subject to the availability of funds in
the day-to-day limit
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
Specialist consultations are subject
to pre-authorisation and referral by
a network GP
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
A co-payment applies for the
voluntary use of a non-network GP
Specialist referral required
Please call 0800 450 010
Paid at the specialist network rate
Referral from a network GP
required prior to specialist
consultation
Subject to the availability of funds
in the day-to-day limit
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
A 20% co-payment applies for the
voluntary use of a non-network
specialist
A 30% co-payment applies for
voluntary consultations at specialists
and consultations without preauthorisation according to the
agreed referral process
Please call 0800 450 010
Pre-authorisation required
Please call 0861 686 278
7
B E NE FITS G U ID E
BENEFITS
STATE PLUS OWN
CHOICE PLAN
STATE PLUS
NETWORK PLAN
PRIVATE
NETWORK PLAN
DAY-TO-DAY COVER
4
Acute and
over-thecounter
(OTC)
medication
Unlimited if according to the
Universal medicine formulary
and obtained from accredited
Universal pharmacies
Formulary reference pricing applies
Over-the-counter (OTC)
medicine benefit
R200 per family per year, with a
maximum of R80 per event
Medication must be dispensed by
a Universal network pharmacy or
accredited service provider
No benefit for medicine
dispensed or prescribed by a
specialist if the referral process
was not adhered to, unless a
specialist consultation was as
a result of an involuntary PMB
consultation
Unlimited, subject to Universal
network codes
5
Basic
pathology
(out of
hospital)
Subject to referral by Universal
network GP or accredited service
provider
No benefit for pathology
requested by specialist if the
specialist referral process was
not adhered to, unless specialist
consultation was as a result of an
involuntary PMB consultation
6
Unlimited, subject to Universal
network codes
Radiology
(out of hospital)
Subject to referral by Universal
network GP or accredited
service provider
No benefit for radiology
requested by specialist if the
specialist referral process was
not adhered to, unless specialist
visit was as a result of an
involuntary PMB consultation
Paid at the Transmed rate*
Paid at the Transmed rate*
Formularies apply
Formularies apply
Subject to the availability of funds in
the day-to-day limit
Subject to the availability of
funds in the day-to-day limit
OTC medicine benefit
Subject to a transaction limit of
R200
OTC medicine benefit
Subject to a transaction limit
of R200
Subject to an annual OTC sub-limit
of R1 000 per family per year
Subject to an annual OTC sublimit of R1 000 per family per year
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
Paid at the Transmed rate*
Paid at the Transmed rate*
Subject to the availability of funds in
the day-to-day limit
Subject to the availability of
funds in the day-to-day limit
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
Paid at the Transmed rate*
Paid at the Transmed rate*
Subject to the availability of funds in
the day-to-day limit
Subject to the availability of funds
in the day-to-day limit
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
For MRI and CT scans refer to 20
For MRI and CT scans refer to 20
8
For all
our people
2015
BENEFITS
STATE PLUS OWN
CHOICE PLAN
STATE PLUS
NETWORK PLAN
PRIVATE
NETWORK PLAN
DAY-TO-DAY COVER
Obtained from the Universal
network
7
Optical
benefits
One examination per beneficiary
per year
One pair of single vision or bifocal
lenses and specified frame or
contact lenses, every 24 months
according to Universal network
criteria
Contact lens benefit limited to
R560 per beneficiary per year
Please call 0861 686 278
Benefit provided through Preferred
Provider Negotiators (PPN*14)
protocols
Network benefit
Beneficiaries can claim every
24 months and optical benefits are
subject to authorisation by PPN*14
and clinical protocols/prescribed
rules
Paid at the Transmed rate*
Subject to the availability of funds
in the day-to-day limit
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
Limit of one consultation, including
refraction, tonometry and visual field
screening
Either spectacles or contact
lenses
Spectacles
R400 towards frame and/or lens
enhancements together with either
one pair of clear single vision
or clear bifocal lenses
or clear multifocal lenses
OR
Contact lenses
Limit of R1 110
Non-network benefit
Services out of the network will
have a co-payment*12 for member’s
own account
Please call PPN on 0860 103 529
8
Basic dentistry
One consultation, preventative
treatment and general
examination per year through a
Universal network DSP*1
Provided through the contracted
provider, Dental Risk Company
(DRC*13) and their protocols and
limitations
Paid at the Transmed rate*
Fillings, extractions and dental
X-rays, subject to Universal
protocols and applicable
Universal dental codes
No annual limits but only stated
codes are covered
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
Please call 0861 686 278
Pre-authorisation for more than
3 restorations per consultation
required
Root canal limited to 1 per
beneficiary per year
Please call 0800 450 010
9
Subject to the availability of funds
in the day-to-day limit
For all
our people
2015
BENEFITS
STATE PLUS OWN
CHOICE PLAN
STATE PLUS
NETWORK PLAN
PRIVATE
NETWORK PLAN
DAY-TO-DAY COVER
No benefit
9
Specialised
dentistry
Subject to DRC*13 protocols and
limitations
Pre-authorisation for all specialised
procedures required
Limit of R3 500 per family per year
Crowns
Limit of 1 per family every 2 years
for beneficiaries older than 16 years
Paid at the Transmed rate*
Subject to the availability of funds
in the day-to-day limit
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
Please call 0800 450 010
10
No benefit
Subject to DRC*13 protocols and
limitations
R7 292 per beneficiary once in a
lifetime
Orthodontics
Pre-authorisation required
Please call 0800 450 010
11
Dentures
One set of acrylic dentures per
family every two years
Subject to DRC*13 protocols and
limitations
Limited to R2 800 per partial or
full set of dentures
Limited to beneficiaries older than
21 years
A 20% co-payment applies
Subject to specialised dentistry limit
of R3 500 per family per year
Only 80% of the cost will be paid
One set of dentures per beneficiary
every four years
Please call 0861 686 278
One set of metal frame dentures
per beneficiary every 5 years
Pre-authorisation required
Please call 0800 450 010
10
Paid at the Transmed rate*
Subject to the availability of funds
in the day-to-day limit
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
Paid at the Transmed rate*
Subject to the availability of funds
in the day-to-day limit
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
BE NE FITS G U ID E
BENEFITS
STATE PLUS OWN
CHOICE PLAN
STATE PLUS
NETWORK PLAN
PRIVATE
NETWORK PLAN
DAY-TO-DAY COVER
12
Physiotherapy,
occupational
and remedial
therapy and
audiology
Obtained from the Universal
network
Only PMB conditions
Please call 0861 686 278
Paid at the Transmed rate*
Paid at the Transmed rate*
Subject to the availability of funds
in the day-to-day limit
Subject to the availability of funds
in the day-to-day limit
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
General day-to-day limit
Member without dependants:
R4 980
Member with dependants:
R6 820
CHRONIC MEDICATION
13
Chronic
medication
(refer to chronic
conditions covered
on page 25)
Paid at the negotiated rate
according to the Universal
Healthcare medicine formulary*4
and protocols
Paid at the Transmed rate*
according to the prescribed
minimum benefit (PMB) core
medicine formulary
Paid at the Transmed rate*
according to the prescribed
minimum benefit (PMB) core
medicine formulary
Subject to authorisation and
registration on the Universal
Healthcare chronic programme
Metropolitan Heath Reference
Price*6 applies
Metropolitan Heath Reference
Price*6 applies
Subject to pre-authorisation
and registration on the chronic
medicine management programme
Subject to pre-authorisation
and registration on the chronic
medicine management programme
Pre-authorisation required
Please call 0800 225 151
Pre-authorisation required
Please call 0800 225 151
Transmed pharmacy network*7
Transmed pharmacy network*7
A 20% co-payment applies at
non-network pharmacies
A 20% co-payment*12 applies at
non-network pharmacies
Pre-authorisation required
Please call 0861 686 278
14
Pharmacies
Universal network pharmacies
Please call 0861 686 278
*12
MAJOR MEDICAL COVER
15
State hospital
admissions
The DSPs are State hospitals
The DSPs*10 are State hospitals
The DSPs*10 are State hospitals
Admissions to enhanced State
facilities are subject to preauthorisation
Admissions to enhanced State
facilities are subject to preauthorisation
Admissions to enhanced State
facilities are subject to preauthorisation
100% cover at a State hospital
for PMB admissions only
100% cover at a State hospital for
PMB admissions only
100% cover at a State hospital
for PMB admissions only
Note
Members using a State hospital
for any non-PMB condition
must be admitted as a private
patient and the member will
be personally liable for the
payment of the account
Note
Members using a State hospital
for any non-PMB condition
must be admitted as a private
patient and the member will be
personally liable for the payment
of the account
Note
Members using a State hospital
for any non-PMB condition
must be admitted as a private
patient and the member will
be personally liable for the
payment of the account
Please call 0861 686 278
Please call 0800 225 151
Please call 0800 225 151
*10
11
B E NE FITS G U ID E
BENEFITS
STATE PLUS OWN
CHOICE PLAN
STATE PLUS
NETWORK PLAN
PRIVATE
NETWORK PLAN
MAJOR MEDICAL COVER
16
P
Private hospital
admissions
17
Maternity
18
Hospital
casualties/
emergency
visits
If a State hospital is not accessible
in terms of the set criteria,
authorisation can be obtained
for admission to a hospital on
the Universal private hospital
network*8 as the secondary DSP*10
and payable at the Transmed rate*
If a State hospital is not accessible
in terms of the set criteria,
authorisation can be obtained
for admission to a hospital on
the Transmed private hospital
network*8 and payable at the
Transmed rate*
Paid at the Transmed rate* for
admissions to a hospital on the
Transmed private hospital network*8
The co-payment for the voluntary
use of a non-DSP will be the
amount equal to the difference
between the total cost incurred
in respect of the hospital services,
including all related medical
services, and the cost that would
have been payable to the DSP*10
(State hospital)
The co-payment for the voluntary
use of a non-DSP will be the
amount equal to the difference
between the total cost incurred
in respect of the hospital services,
including all related medical
services, and the cost that would
have been payable to the DSP*10
(State hospital)
Only PMB conditions for major
medical events are covered
Only PMB conditions for major
medical events are covered
Only PMB conditions for major
medical events are covered
No benefit for non-PMB events
No benefit for non-PMB events
Pre-authorisation required
Please call 0861 686 278
100% cover at a State hospital
Pre-authorisation required
Please call 0800 225 151
100% cover at a State hospital
Benefit provided through Universal
Healthcare network
Covered at the negotiated rate at a Covered at the negotiated rate
Transmed private hospital network*8 at a Transmed private hospital
facility
network*8 facility.
Pre-authorisation required
Please call 0861 686 278
A 30% co-payment*12 applies for
the voluntary use of a non-network
hospital
No benefit for non-PMB events
Pre-authorisation required
Please call 0800 225 151
100% cover at a State hospital
Members with confirmed
pregnancies must call 0800 225 151,
to access maternity care plan
benefits
Members with confirmed
pregnancies must call 0800 225 151,
to access maternity care plan
benefits
Members will receive a Transmed
baby bag on delivery confirmation
Members will receive a Transmed
baby bag on delivery confirmation
Paid at 100% of the agreed rate
if life-threatening
Pre-authorisation required
Please call 0800 225 151
Paid at the Transmed rate* if
life-threatening
Pre-authorisation required
Please call 0800 225 151
Paid at the Transmed rate* if
life-threatening
Pre-authorisation required
prior to admission or within
one working day of the
emergency
Pre-authorisation required
prior to admission or within
one working day of the
emergency
Authorisation required
prior to admission or within
one working day of the
emergency
Please call 0861 686 278
Please call 0800 225 151
Please call 0800 225 151
12
For all
our people
2015
BENEFITS
STATE PLUS OWN
CHOICE PLAN
STATE PLUS
NETWORK PLAN
PRIVATE
NETWORK PLAN
MAJOR MEDICAL COVER
No benefit
19
In-hospital
dentistry
Admission protocols apply
Admission protocols apply
Removal of impacted wisdom
teeth only
Removal of all impacted tooth
numbers
Extensive conservative treatment
for children under 8 years
Extensive conservative treatment
for children under 8 years
Certain surgical procedures
(fistula closure)
Certain surgical procedures
(fistula closure)
Only PMB conditions
Only PMB conditions
Procedures are subject to
the availability of funds in the
specialised dentistry limit
Hospitalisation and anaesthetist
are only paid from major medical
benefit if procedure is approved
Hospitalisation and anaesthetist
are only paid from major medical
benefit if procedure is approved
Pre-authorisation required
Please call 0800 225 151
Pre-authorisation required
Please call 0800 225 151
20
Radiology
Basic radiology (X-rays)
Subject to case management and
clinical protocols
Basic radiology (X-rays)
Subject to case management and
clinical protocols
Basic radiology (X-rays)
Subject to case management and
clinical protocols
Limited to R6 000 per family per
year in hospital
Advanced radiology (MRI
and CT scans)
In and out of hospital
Advanced radiology (MRI
and CT scans)
In and out of hospital
Only PMB conditions
Only PMB conditions
Only PMB conditions
Pre-authorisation required
Please call 0800 225 151
Pre-authorisation required
Please call 0800 225 151
Pre-authorisation required
Please call 0861 686 278
Subject to case management,
clinical protocols and individual
prostheses limits
Subject to case management,
clinical protocols and individual
prostheses limits
Subject to case management,
clinical protocols and individual
prostheses limits
Refer to annexture C on page 19
Refer to annexture C on page 19
Refer to annexture C on page 19
Only PMB conditions
Only PMB conditions
Only PMB conditions
Pre-authorisation required
Please call 0861 686 278
Pre-authorisation required
Please call 0800 225 151
Pre-authorisation required
Please call 0800 225 151
Advanced radiology (MRI,
CT and PET scans)
Limited to R17 500 per family per
year in and out of hospital
21
Prostheses
13
B E NE FIT S G U ID E
BENEFITS
STATE PLUS OWN
CHOICE PLAN
STATE PLUS
NETWORK PLAN
PRIVATE
NETWORK PLAN
MAJOR MEDICAL COVER
22
Orthopaedic,
surgical and
medical
appliances
23
Organ
transplants
24
Ambulance
services
25
Dialysis
Subject to case management,
clinical protocols and individual
appliances limits
Subject to case management, clinical
protocols and individual appliances
limits
Subject to case management,
clinical protocols and individual
appliances limits
Only PMB conditions
Only PMB conditions
Only PMB conditions
Refer to annexture B on page 19
Refer to annexture B on page 19
Refer to annexture B on page 19
Pre-authorisation required
Please call 0861 686 278
Subject to case management and
clinical protocols
Pre-authorisation required
Please call 0800 225 151
Subject to case management and
clinical protocols
Pre-authorisation required
Please call 0800 225 151
Subject to case management and
clinical protocols
In the case of a bone marrow
transplant, the cost of the
international donor search and
harvesting is limited to R225 000
and in line with the South African
Bone Marrow Registry guidelines
(irrespective of the Rand/Dollar/
Euro exchange rate) and is
subject to PMB regulations
In the case of a bone marrow
transplant, the cost of the
international donor search and
harvesting is limited to R200 000
and in line with the South African
Bone Marrow Registry guidelines
(irrespective of the Rand/Dollar/
Euro exchange rate) and is subject
to PMB regulations
In the case of a bone marrow
transplant, the cost of the
international donor search and
harvesting is limited to R200 000
and in line with the South African
Bone Marrow Registry guidelines
(irrespective of the Rand/Dollar/
Euro exchange rate) and is subject
to PMB regulations
Pre-authorisation required
Please call 0861 686 278
Only PMB conditions
Pre-authorisation required
Please call 0800 225 151
Only PMB conditions
Pre-authorisation required
Please call 0800 225 151
Only PMB conditions
Pre-authorisation required
Please call 0800 115 750
Pre-authorisation required
Please call 0800 115 750
Pre-authorisation required
Please call 0800 115 750
100% cover at a State hospital
100% cover at a State hospital
100% cover at a State hospital
Paid at the agreed rate at a private
facility, up to a limit of R200 000 per
beneficiary per year
If a State hospital is not accessible in
terms of the set criteria, authorisation
is required for treatment at a
Transmed private hospital, payable at
the Transmed rate*
Private hospital paid at the
Transmed rate*
Pre-authorisation required
Please call 0861 686 278
26
Oncology
Pre-authorisation required
Please call 0800 225 151
Paid at the agreed rate at a
State hospital or through the
Independent Clinical Oncology
Network (ICON*11)
Pre-authorisation required
Please call 0800 225 151
Paid at the Transmed rate* at a State
hospital or through the Independent
Clinical Oncology Network
(ICON*11)
Paid at the Transmed rate* at
a State hospital or through the
Independent Clinical Oncology
Network (ICON*11)
A 20% co-payment applies for using
a provider other than an ICON *11
service provider or the State
A 20% co-payment applies for using
a provider other than an ICON *11
service provider or the State
A 20% co-payment applies for using
a provider other than an ICON*11
service provider or the State
Benefits are restricted to tier 1
of the South African Oncology
Consortium (SAOC) guidelines
Benefits are restricted to tier 1 of the
South African Oncology Consortium
(SAOC) guidelines
Benefits are restricted to tier 2 and
3 of the South African Oncology
Consortium (SAOC) and a limit of
R250 000 per beneficiary per year
14
For all
our people
2015
BENEFITS
STATE PLUS OWN
CHOICE PLAN
STATE PLUS
NETWORK PLAN
PRIVATE
NETWORK PLAN
MAJOR MEDICAL COVER
Oncology
(continued)
Limit of one PET scan per
beneficiary per year and subject to
the overall radiology limit
Limit of one PET scan per
beneficiary per year
Limit of one PET scan per
beneficiary per year
Oncology medication to be obtained
through the Transmed oncology
pharmacy network
Oncology medication to be
obtained through the Transmed
oncology pharmacy network
Generic reference pricing*6 is
applicable to oncology medication
Generic reference pricing*6 is
applicable to oncology medication
A co-payment applies for obtaining
oncology medication from a nononcology pharmacy network service
provider
A co-payment applies for
obtaining oncology medication
from a non-oncology pharmacy
network service provider
Pre-authorisation required
Please call 0800 225 151
Pre-authorisation required
Please call 0800 225 151
Paid at cost at a State facility or
the HIV YourLife programme as
the DSP
Paid at cost at a State facility or
the HIVYourLife programme as
the DSP
A 20% co-payment*12 applies for
using a non-DSP
A 20% co-payment*12 applies for
using a non-DSP
Generic Reference pricing*6 applies
Generic Reference pricing*6 applies
Pre-authorisation required
Please call 0861 888 300
Pre-authorisation required
Please call 0861 888 300
Cataract surgery will be covered
as per the PMB guidelines as part
of the hospital benefit
The Ophthalmology Management
Group (OMG*15) network and
State facilities are DSPs
The Ophthalmology Management
Group (OMG*15) network and
State facilities are DSPs
Pre-authorisation required
Please call 0861 686 278
A 20% co-payment on the total
hospital and associated provider
costs applies for using a provider
other than an OMG*15 provider or
the State
A 20% co-payment on the total
hospital and associated provider
costs applies for using a provider
other than an OMG*15 provider
or the State
Pre-authorisation required
Please call 0800 225 151
Pre-authorisation required
Please call 0800 225 151
Paid at the Transmed rate* from
the major medical benefit
Paid at the Transmed rate* from
the major medical benefit
Subject to the criteria listed in the
early detection benefit
Refer to annexture A on page 18
Subject to the criteria listed in the
early detection benefit
Refer to annexture A on page 18
Oncology medication to be
obtained through the Universal
oncology medicine network
A 20% co-payment applies for
obtaining oncology medication
from a non-oncology medicine
network service provider
Subject to evidence based clinical
protocols
Pre-authorisation required
Please call 0861 686 278
27
HIV Disease Management
Programme is the DSP
HIV and AIDS
benefit
Subject to compliance with
clinical protocols
Paid at cost at a State facility
(DSP)
A 20% co-payment applies for
using a non-DSP
*12
Please call 0861 686 278
28
Cataract
surgery
29
Early detection
Benefits are available as per
the agreement with Universal
network service
Subject to the criteria listed in
the early detection benefit
Refer to annexture A on page 18
15
BE NE FIT S G U ID E
For all
our people
2015
BENEFITS
STATE PLUS OWN
CHOICE PLAN
STATE PLUS
NETWORK PLAN
PRIVATE
NETWORK PLAN
PREVENTATIVE CARE
No benefit
30
Contraceptive
benefit
The Transmed pharmacy network*7
is the DSP
TheTransmed pharmacy network*7
is the DSP
Paid at the Transmed rate*
Paid at the Transmed rate*
Subject to the contraceptive
formulary
Subject to the contraceptive
formulary
Only female beneficiaries
Only female beneficiaries
A 20% co-payment applies for
using a non-network pharmacy
The Transmed pharmacy network*7
is the DSP
A 20% co-payment*12 applies for
using a non-network pharmacy
TheTransmed Pharmacy Network*7
is the DSP
Paid at the Transmed rate*
Paid at the Transmed rate*
Subject to the flu vaccination
formulary
Subject to the flu vaccination
formulary
Available to all beneficiaries
Available to all beneficiaries
Limited to one vaccination per
beneficiary per year
Limited to one vaccination per
beneficiary per year
A 20% co-payment*12 applies for
using a non-network pharmacy
A 20% co-payment*12 applies for
using a non-network pharmacy
*12
31
No benefit
Flu
vaccinations
16
PRESCRIBED MINIMUM BENEFITS (PMBs)
STATE PLUS
NETWORK PLAN
STATE PLUS OWN
CHOICE PLAN
Hospitalisation
Paid at cost at a State hospital
Hospitalisation
Paid at cost at a State hospital
In the case of an emergency or if a State
hospital is not accessible in terms of the
set criteria, authorisation will be
considered for admission to a hospital on
the Universal private hospital network*8
as secondary DSP*10 and paid at the
negotiated cost*
In the case of an emergency or if a State
hospital is not accessible in terms of
the set criteria, authorisation will be
considered for admission to a hospital on
the Transmed private hospital network*8
as the secondary DSP*10 and paid at the
negotiated cost*
The co-payment*12 for the voluntary
use of a non-DSP will be the amount
equal to the difference between the total
cost incurred in respect of the hospital
services, including all related medical
services, and the cost that would have
been payable to a State hospital (DSP)
The co-payment*12 for the voluntary
use of a non-DSP will be the amount
equal to the difference between the total
cost incurred in respect of the hospital
services, including all related medical
services, and the cost that would have
been payable to a State hospital (DSP)
The DSP*10 for day-to-day services is
Universal Healthcare
Pre-authorisation required
Please call 0800 225 151
PRIVATE
NETWORK PLAN
Hospitalisation
Paid at cost if the Transmed private
hospital network*8 is used
A 30% co-payment applies for the
voluntary use of a non-network hospital
Pre-authorisation required
Please call 0800 225 151
Pre-authorisation required
Please call 0861 686 278
No benefit
Care plan services
Paid at cost
Care plan services
Paid at cost
Supplier of own choice may be used
Obtain from GP or specialist network
Other services
Paid at 100% at an out-patient State facility
Other services
Paid at 100% at a State facility
Pre-authorisation required
Please call 0800 225 151
Pre-authorisation required
Please call 0800 225 151
ADDITIONAL BENEFITS
24-hour health advice line
Please call 0800 115 750
24-hour health advice line
Please call 0800 115 750
17
24-hour health advice line
Please call 0800 115 750
BE NE FITS G U ID E
For all
our people
2015
ANNEXURE A
EARLY DETECTION BENEFIT
SCREENING TEST
RELATED CONDITION
FREQUENCY
Lipogram (basic test)
Cholesterol
One test per year for all
beneficiaries over the age of 25
Glucose (finger prick)
Diabetes mellitus
One test per year for all
beneficiaries over the age of 25
Prostate-specific antigen (PSA)
level
Prostate cancer
One test per year for males
over the age of 50
Pap smear
Cervical cancer
One test per year for females
over the age of 18
Mammogram
Breast cancer
One test every two years for
females over the age of 40
Voluntary counselling and
testing (VCT) – Elisa
HIV – adults
One test per year for all
beneficiaries over the age of 16
Quantitative polymerase chain
reaction (qPCR)
HIV – newborns
Once in a lifetime
18
ANNEXURE B
ORTHOPAEDIC, SURGICAL AND MEDICAL APPLIANCES
APPLIANCES
LIMITS
1 Wheelchairs shall only be supplied for
beneficiaries with the following conditions:
- paraplegia
- quadriplegia
- advanced multiple sclerosis
- spina bifida following severe cerebrovascular
accident (CVA)
- bilateral leg amputations
2 Hand prosthesis
R3 200 for non-motorised wheelchair
(once every five years)
Or
R5 500 for motorised wheelchair
(once every five years)
3 Arm prosthesis
R26 000 (once every 10 years)
R10 000 (once every 10 years)
4 Above knee prosthesis
R54 000 (once every 10 years)
5 Below knee prosthesis
R38 000 (once every 10 years)
6 Silicone sleeve replacements for all artificial limbs R9 500 (once every 10 years)
7 Back brace following surgical procedures
R7 700
8 Walking aids
R1 600
Please note: These appliances are only reimbursed for PMB conditions on ALL benefit plans
ANNEXURE C
INTERNAL PROSTHESES
PROSTHESES
1 Pacemaker and leads
2 Pacemaker (double chamber)
3 Partial hip replacement
4 Total hip replacement
5 Total knee replacement
6 Shoulder replacement
7 Spinal fusion
8 Cardiac stents (per stent)
9 Grafts (per graft)
10 Cardiac valves (per valve)
11 Hernia mesh (umbilical repair)
12 Hernia mesh (other)
13 Non-specified items
14 Pacemaker plus defibrillator
SUB-LIMITS
R38 000
R43 000
R19 000
R41 000
R38 000
R41 000
R34 000
R18 000
R22 500
R25 000
R11 000
R5 500
R21 000
R96 500
COMBINED ANNUAL
SUB-LIMIT
R54 000 per beneficiary per year
R96 500 per beneficiary per year
Please note: These prostheses are only reimbursed for PMB conditions on ALL benefit plans
19
EX GRATIA
i
Ex gratia is an additional financial
benefit that members can apply for.
The applicant should prove beyond
reasonable doubt that he/she is
experiencing financial difficulty as a
result of his/her health.
WHAT YOU NEED TO
KNOW ABOUT THE
APPLICATION PROCESS
•The submission of an ex gratia
application is not a guarantee that
assistance will be granted.
•The committee won’t consider
any advance payment of medical
treatment.
•Members are requested to
provide full details of the financial
assistance required, including cost
involved and motivation for the
necessity of expenses.
•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.
•The decision of the committee is
final and no further
correspondence regarding the
application will be considered
once the decision has been
announced.
HOSPITALISATION
STATE PLUS NETWORK PLAN
All management and authorisations will be
provided by Universal Healthcare.
Major medical cover is unlimited for PMB
admissions when obtained from a State facility.
Admissions for non-PMB conditions, even at a
State facility, will be treated as a private
admission for the member’s own account.
All hospitalisation is provided through State
and enhanced State facilities. The co-payment
for the voluntary use of a non-DSP facility is
the amount equal to the difference between
the total cost incurred in respect of the
hospital admission, including all related
medical services, and the cost that would
have been payable to a State facility (DSP).
An application form can be obtained
from www.transmed.co.za or
from the Customer Service
Department on 0800 450 010.
If a State facility is not accessible in terms of
the set criteria, authorisation will be
considered for admission to a hospital on the
Universal private hospital network as the
secondary DSP.
HOW TO SUBMIT YOUR
APPLICATION
E-mail
[email protected]
Post
Ex Gratia Committee
Private Bag X50
Braamfontein
2017
STATE PLUS OWN CHOICE PLAN
Major medical cover is unlimited for PMB
admissions when obtained from a State facility.
20
BE NE FITS G U ID E
For all
our people
2015
Admissions for non-PMB conditions, even at a
State facility, will be treated as a private
admission for the member’s own account.
All hospitalisation is provided through State
and enhanced State facilities. The co-payment
for the voluntary use of a non-DSP facility is
the amount equal to the difference between
the total cost incurred in respect of the
hospital admission, including all related
medical services and the cost that would
have been payable to a State facility (DSP).
If a State facility is not accessible in terms of
the set criteria, authorisation will be
considered for admission to a hospital on the
Transmed private hospital network as the
secondary DSP.
P
WHEN CAN MEMBERS USE A
PRIVATE HOSPITAL?
Members on the State Plus Own Choice and
State Plus Network plans can use a private
hospital for PMB conditions in the event of an
involuntary admission when the required
treatment is not reasonably available in a State
facility. In such cases, members should only use
hospitals that form part of the Transmed
private hospital network*6.
Involuntary admission
• The service was not available from the State
facility (DSP) or could not be provided
without an unreasonable delay.
• Immediate medical or surgical treatment for
a PMB condition was required under
circumstances where a member could not
reasonably obtain the treatment from a State
facility (DSP).
• There was no State facility (DSP) within a
reasonable distance to the member’s
ordinary workplace or home.
• It was for an emergency PMB condition.
An emergency is defined in terms of the
Medical Scheme’s Act and the rules as the
sudden, and at the time, unexpected onset of a
health condition that requires immediate
medical or surgical treatment, where failure to
provide medical or surgical treatment would
result in serious impairment to bodily functions
or serious dysfunction of a bodily organ or
part, or would place the person’s life in serious
jeopardy.
If the service is not available in a State facility
(DSP), pre-authorisation for admission to a
secondary facility will be considered by the
Care Manager who is available 24-hours a day.
21
BE NE FITS G U ID E
For all
our people
2015
authorisation will be considered for admission
to an alternative hospital, subject to case
management and clinical protocols for
emergency admissions for PMB conditions only.
The Care Managers will gladly assist by guiding
you to the most appropriate hospital.
The Fund will cover the admission costs in the
alternative facility, subject to pre-authorisation,
case management and other managed
healthcare interventions.
Please call 0800 225 151 to obtain preauthorisation or for more information and guidance.
Example
Voluntary admission
Please note: The following is an example of
a co-payment calculation and is not based on a
specific case or an indication of the difference
in cost in an actual case.
• A service that was available in a State facility
(DSP), but the member opted to use a
non-DSP (private facility).
FACILITY
Co-payment for the voluntary use of a non-dsp
facility
TOTAL ADMISSION COST
State hospital
Transmed private hospital network
Non-network private hospital The co-payment for the voluntary use of a
non-DSP facility is the amount equal to the
difference between the total cost incurred in
respect of a hospital admission, including all
related medical services, and the cost that
would have been payable to a State facility (DSP).
R15 000
R28 000
R32 000
Based on the table above, the following will
apply:
• If a member uses a State hospital, the full
admission cost of R15 000 is covered by the
Fund.
• If the member uses a facility on the Transmed
private hospital network on a voluntary basis,
Note that the costs at a non-network hospital
are much higher than at a DSP. If a State facility
is not accessible in terms of the set criteria,
22
P
MAJOR MEDICAL BENEFITS AT PRIVATE
FACILITIES FOR STATE PLUS OWN CHOICE
AND STATE PLUS NETWORK PLANS
The following services may be obtained in private
facilities subject to compliance to certain criteria:
• dialysis
• cancer treatment
• radiation therapy
• other PMB services that some State hospitals
are unable to provide.
The following criteria apply:
• pre-authorisation must be obtained for the
services above
State Plus Own Choice plan: 0800 225 151 and
State Plus Network plan: 0861 686 278.
ONCOLOGY TREATMENT
The oncology benefits are restricted to tier 1 of
the South African Oncology Consortium (SAOC)
guidelines.
The DSP for oncology treatment is the
Independent Clinical Oncology Network (ICON)
of private oncologists. Should a member consult
an oncologist outside this network, a 20%
co-payment will be applicable to all services
received from the non-network oncologist and
related costs (radiology and pathology, etc.).
CATARACT SURGERY
The Fund has a contract with the Ophthalmology
Management Group (OMG) Limited for the
delivery of clinically appropriate and cost-effective
cataract surgery for members on the State Plus
Own Choice and Private Network plans.The
Fund reimburses the providers with a global fee
for this type of surgery.
the member’s co-payment will be equal to
the difference between the State hospital’s
admission cost and the Transmed private
hospital network’s admission cost (R28 000 –
R15 000 = R13 000).
• If the member uses a non-network private
hospital on a voluntary basis, the member’s
co-payment will be equal to the difference
between the non-network private hospital’s
admission cost and the State hospital’s
admission cost (R32 000 - R15 000 = R17 000).
The global fee covers the following:
•the consultations where the diagnoses are
made; and
•the procedure, surgeon and anaesthetist fees,
equipment hire, hospital account and related
post-operation visits for a period of one month.
If a contracted OMG doctor is accessible and the
member voluntarily uses a non-contracted
specialist in a private facility, the member will be
liable for a 20% co-payment on the total cost of
the procedure.
PRIVATE NETWORK PLAN
Members have access to the Transmed private
hospital network for admissions for major
medical events.Visit the www.transmed.co.za
to view the hospitals on the Transmed private
hospital network.
23
State Plus Network members please
contact Universal on 0861 686 278 for
benefit information.
B E NE FIT S G U ID E
For all
our people
2015
PRESCRIBED MINIMUM BENEFITS
In terms of healthcare legislation all medical
schemes must provide benefits for certain
conditions within prescribed guidelines.These
benefits are known as the prescribed minimum
benefits (PMBs) and consist of the following:
• The 270 diagnosis and treatment
pairs (DTPs) PMBs - Hospital PMBs
These are conditions for which schemes
need to provide a benefit in hospital as
well as out-of-hospital diagnosis and
treatment.
• The 26 chronic disease list (CDL)
PMBs - Chronic PMBs
These are conditions for which schemes
also need to provide a benefit for chronic
medication.
CHRONIC MEDICATION
What is a chronic condition?
A chronic condition is a disease that requires
life-sustaining medication to be taken
continuously for extended periods - normally
longer than three months. A few examples of
chronic conditions are diabetes, asthma, high
blood pressure (hypertension), epilepsy, cardiac
failure, high cholesterol (hyperlipidaemia),
Parkinson’s disease, thyroid dysfunction and
rheumatoid arthritis.
conditions.The list is compiled to ensure that
you receive the most appropriate, cost-effective
and safest treatment for your chronic
conditions.
WHAT IS THE CHRONIC
DISEASE LIST (CDL)?
(Standard condition list applies)
CDL includes 26 common chronic
conditions and medical schemes have to
provide cover for the diagnosis, treatment
and care of these conditions.
What is a chronic medication
formulary?
A chronic medication formulary is a list of
medication approved by the Fund for chronic
24
CHRONIC CONDITIONS COVERED
PMB CHRONIC DISEASE LIST (CDL)
PMB DIAGNOSIS AND TREATMENT PAIRS (DTPs)
Hospital PMBs with chronic component
Covered on all plans
Chronic PMBs
Covered on all plans
Addison’s disease
Asthma
Bipolar mood disorder
Bronchiectasis
Cardiac (heart) failure
Cardiac (heart) dysrhythmias
Cardiomyopathy disease
Chronic obstructive lung disease
Chronic renal disease
Coronary artery disease
Crohn’s disease
Diabetes insipidus
Diabetes mellitus type I
Diabetes mellitus type II
Epilepsy
Glaucoma
Haemophilia
Hyperlipidaemia (cholesterol)
Hypertension
Hypothyroidism
Multiple sclerosis
Parkinson’s disease
Rheumatoid arthritis
Schizophrenia
Systemic lupus erythematosis
Ulcerative colitis
Additional benefits for medical management of CDL
conditions will be provided through a generic care plan
Anaemia (iron deficiency)
Benign prostatic hypertrophy
Cerebrovascular disorders (stroke)
Cushing’s syndrome
Depressive mood disorders
Endometriosis
HIV/AIDS
Hyperthyroidism
Hypoparathyroidism/hyperparathyroidism
Menopausal syndrome
Paraplegia/quadriplegia
Pemphigus
Peripheral artheriosclerotic disease
Pituitary malfunction
Post-traumatic stress disorder
Schizo-affective disorders
Thrombocytopaenia purpura
Thrombotic disorders
Valvular heart disease
SUMMARY OF DESIGNATED SERVICE PROVIDERS (DSPs) FOR
CHRONIC AND ONCOLOGY MEDICATION AND FORMULARIES
BENEFIT
CATEGORY
CHRONIC
MEDICATION
DSPs
ONCOLOGY
MEDICATION
DSPs
CHRONIC
FORMULARY
STATE PLUS
NETWORK PLAN
STATE PLUS OWN
CHOICE PLAN
PRIVATE
NETWORK PLAN
Universal network pharmacies
•Clicks pharmacy group
(including Clicks Direct
Medicines [CDM] pharmacy)
•Chronicare, Scriptnet and Alpha
Pharm pharmacy network
including Dis-Chem pharmacies
•Medipost
Transmed pharmacy network
•Clicks pharmacy group (including
Clicks Direct Medicines [CDM]
pharmacy)
•MediRite pharmacy group
(pharmacies in Shoprite/
Checkers stores)
•Chronicare, Scriptnet and Alpha
Pharm pharmacy network
including Dis-Chem pharmacies
Transmed pharmacy network
•Clicks pharmacy group
(including Clicks Direct
Medicines [CDM] pharmacy)
•MediRite pharmacy group
(pharmacies in Shoprite/
Checkers stores)
•Chronicare, Scriptnet and Alpha
Pharm pharmacy network
including Dis-Chem pharmacies
Universal oncology medicine
network
Transmed oncology pharmacy
network
•Clicks Direct Medicines (CDM)
pharmacy
Transmed oncology pharmacy
network
•Clicks Direct Medicines (CDM)
pharmacy
Universal chronic condition list and
formulary
• This formulary only covers the PMB
CDL conditions
PMB core condition list:
PMB core medicine formulary
•This formulary only covers the
PMB conditions
PMB core condition list:
PMB core medicine formulary
•This formulary only covers the
PMB conditions
25
MEMBERSHIP
Transmed Medical Fund is a medical
scheme open to employees and
pensioners of the Transnet Group, its
subsidiaries and former subsidiaries.
DEPENDANTS
In terms of the Fund’s rules, the
following persons may be registered
as dependants, provided that they are
not a member or a registered
dependant of a member of any other
medical scheme.
Your spouse
This refers to a member’s wife,
husband and partner. If you are
divorced, your former spouse cannot
be registered as a dependant.
Your immediate family/
spouse’s immediate
family
This refers to a parent, brother or
sister in respect of whom the
member/spouse is liable for family
care and support.
Your children
This refers to a member’s natural
child, stepchild, a legally adopted child,
an illegitimate child, a child in the
process of being legally adopted or
placed in foster care, a child for whom
the member has a duty to support or
a child placed in the custody of the
member or his/her spouse or partner.
*Dependants older than 21 years who are
financially dependent on the member, will pay
adult contributions.
**Child contributions are payable for a
maximum of four dependants.
**Child dependants older than 21 who are
studying fulltime and financially dependent on
the member, will pay child contributions until
the age of 24 (proof of registration at an
accredited institution will be required).
DEPENDANTS OF DECEASED MEMBERS
The dependants of a deceased member, who are
registered with the Fund as dependants at the time of the
member’s death, will be entitled to membership of the
Fund without any new restrictions, limitations or waiting
periods.
MEMBERSHIP AMENDMENTS
A member must complete a membership amendment
form and submit it to the Fund within 30 days of the
change, in the following instances:
• When you register/cancel the membership of dependants.
• When a member divorces his/her spouse.
• The Fund requires notification of the date of divorce
within 30 days of the divorce.
• A former spouse cannot remain a dependant and their
membership must be terminated from the date of the
divorce.
• When registered dependants no longer quality as
dependants.
• When there are any changes to a member’s residential
and/or postal address, e-mail address, fax number, cell
phone number or other telephone numbers and
banking details.
CONTINUATION OF MEMBERSHIP
Members shall retain their membership of the Fund with
their registered dependants, if any, in the event of retiring
from the employment of the employer or if employment
is terminated by the employer on account of age, ill health
or a disability.
The Fund shall inform the members of their right to
continue membership and of the contribution payable from
the date of retirement or termination of their employment.
Unless members inform the Fund in writing of their desire
to cancel their membership, they shall continue to be
members of the Fund subject to these rules.
TERMINATION OF MEMBERSHIP
Ceasing employment
When members terminate their employment with a
participating employer, membership shall continue until
the last day of the calendar month in which employment
is terminated, provided that the full contribution due is
paid to the Fund.
Resignation
Members may terminate their membership by giving one
calendar month’s written notice.This will also terminate
the membership of their registered dependants. All rights
to benefits will cease except for claims in respect of
services rendered prior to resignation.
26
WAITING PERIODS
The Fund applies a waiting period, which is often
referred to as underwriting.
The rules of the Fund stipulate two types of
waiting periods to be imposed when a member/
dependant joins the Fund:
1. a general waiting period of three months
2. a condition-specific waiting period of 12 months
for certain pre-existing conditions (e.g. nine
months for an existing pregnancy).
LATE-JOINER PENALTIES
Medical schemes can impose late-joiner penalties
on individuals who join after the age of 35 and
who have never been members of or haven’t
belonged to a medical scheme for a specified
period of time. Depending on the number of years
that they have not belonged to a medical scheme,
late-joiner penalties will be added to members’
monthly contributions. It is worked out as a
percentage of the contribution and can range from
5% to 75%. Late-joiner penalties are applied to
discourage members from only joining medical
schemes when they are older or ill, as this will
make medical schemes unaffordable.
UPDATE YOUR BANKING DETAILS
Fraud risk has forced Transmed to stop any
refunds to members by cheque. It is therefore of
the utmost importance that you ensure your
banking details are updated with the Fund. If you
have not received a refund in the past year or if
your banking details have changed recently, you
must ensure that the updated details reach
Transmed within 30 days of the change, as
stipulated in the Transmed Rules. The Fund will
not be liable if the member has neglected to
follow this rule and money is deposited into an
incorrect bank account.
For your convenience, banking details can be updated
by calling the Customer Service Department. All calls
are recorded. We also have a dedicated mailbox
[email protected] for electronic
submissions. Please remember to include your
membership number in the communication.
COMPLAINT AND DISPUTE
RESOLUTION PROCESS
Transmed takes pride in delivering excellent
service and strives to have open
communication with its members.
HOW TO CLAIM
All accounts must reach the Fund not later than
the last day of the fourth month following the
month in which the services were rendered.
Claims received after this date will not be paid.
Please note that there is a formal complaint
and dispute resolution process that can be
followed when you are dissatisfied with
services rendered by the Fund.
ENSURE THAT ALL ACCOUNTS
CONTAIN THE FOLLOWING DETAILS
Any enquiry must first be directed to the
Administrator of the Fund.This can be done by
calling the Customer Service Department toll
free on 0800 450 010 or by sending an
e-mail to [email protected].
• your membership number
• your initials and surname
• the patient’s name and dependant code as it
appears on the principal member’s membership
card
• the date on which the service was rendered
• the name and practice number of the service
provider
• the referring doctor’s practice number (on
specialist accounts)
• the tariff code(s)
• the required ICD-10 code
• the patient’s ID number or date of birth.
Should you not be satisfied with the
response to your enquiry, you can e-mail
[email protected].
Should you still not be satisfied with the
response to your enquiry, you can direct
your complaint to the Fund at
[email protected].
If your complaint is still not resolved, you can
contact the Regulator, who will evaluate your
complaint as an independent entity.
HOW TO SUBMIT YOUR CLAIM
Fax: 011 381 2041/42
E-mail: [email protected]
Post:
Transmed Claims Department
PO Box 32931, Braamfontein 2017
!
COMPLAINTS DEPARTMENT AT THE
COUNCIL FOR MEDICAL SCHEMES
Customer Care: 0861 123 267
E-mail: [email protected]
27
For all
our people
IMPORTANT CONTACT DETAILS
STATE PLUS
NETWORK PLAN
STATE PLUS OWN
CHOICE PLAN
PRIVATE
NETWORK PLAN
Universal Healthcare
0861 686 278
[email protected]
0800 450 010
enquiries@
transmed.co.za
0800 450 010
enquiries@
transmed.co.za
Membership and
contributions
0800 450 010
0800 450 010
0800 450 010
Hospital and
major medical
pre-authorisation
Universal Healthcare
0861 686 278
0800 225 151
0800 225 151
Disease
programmes
Universal Healthcare
0861 686 278
0800 225 151
0800 225 151
Ambulance
authorisation
0800 115 750
0800 115 750
0800 115 750
Universal Healthcare
0861 686 278
HIV YourLife
programme
0861 888 300
HIV YourLife
programme
0861 888 300
24-hour health
advice line
0800 115 750
0800 115 750
0800 115 750
Optical services
Universal Healthcare
0861 686 278
PPN
0860 103 529
0800 450 010
Customer
Service
Department
HIV/AIDS
Website address
www.transmed.co.za
Transmed mobile application
www.transmed.co.za/app
Postal address
Transmed Medical Fund, PO Box 32931, Braamfontein 2017
Physical address
Metropolitan
28 Health Building, 101 De Korte Street, Braamfontein