2016 Bonitas Brochure Small

Transcription

W62870_adam8evé
Page 1
Bonitas Medical Fund I 0860 002 108 I www.bonitas.co.za
Product
Brochure
2016
You can’t put a price
on experience…
With a proudly South African heritage spanning over 33 years, Bonitas has an intimate understanding of
how the healthcare industry works. Our aim is to make quality healthcare accessible to all South Africans
and add value to their lives.
Affordable and generous, our benefits are designed to give our members more value for money. We have a
wide range of products that are simple to understand so you know exactly what you’re covered for. They’re
also easy to use, ensuring you get the support you need when you need it.
Our members know that when things get tough, we’re there to support them and take care of the little
details so that they can receive the best of care and focus on getting better.
Please note: The information contained in this brochure is subject to approval by the Council for Medical Schemes. Terms, conditions and Scheme rules apply. Version CMS1.
Page 4
INDEX
Medicine management
Page 60
Pharmacy Advised Therapy (PAT) Page 60
Chronic Medicine
Page 60
Pharmacy Direct
Hospital Management
Page 61
Page 62
NetworksPage 63
GP Network Page 63
Specialist Referrals
Page 64
Specialist Network
Page 64
The Standard Select and
BonFit Hospital Network
Page 64
Index
Introduction to Bonitas Page 08
Why choose Bonitas
Page 10
Standard Page 12
Standard Select
Page 18
PrimaryPage 24
BonComprehensivePage 30
BonClassicPage 36
BonSavePage 42
BonFitPage 48
BonEssentialPage 52
Benefit and Process Guides
Page 56
YourHealth Portal
Page 56
MaternityPage 57
Prescribed Minimum Benefits
Page 57
Managed carePage 59
Dental benefits
Page 64
Optical benefits Page 66
Diabetic Program
Page 67
Hip and Knee
Replacement Program
Page 68
HIV/Aids Management
Page 68
Emergency medical services
Page 69
Exclusion List Page 69
How-To GuidePage 76
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A customer-centric approach
At Bonitas, we are committed to
making quality healthcare
accessible to all South Africans.
It is this focus that drives our development
of affordable, generous and easy-tounderstand benefits that offer excellent
value for money.
We strive to give members the best
advice when it comes to choosing the
right product to suit their specific needs
and pride ourselves on superior member
support to ensure that every Bonitas
experience is a great one.
Free flu vaccines & HIV
tests on all options.
The only medical scheme to pay
for dental benefits from risk.
The largest GP network in S.A.
Bonitas brings you more
More experience:
33 years of experience in the healthcare
industry = an intimate understanding of
the needs of South Africans.
That’s why we’re the second largest open medical
scheme in the country.
More support for customers – your
every claim & query is met with superior
support & advice.
More payouts than any other open
medical scheme.
93%
More Added Value
Introduction to Bonitas
More & more members trust us to look after
their healthcare needs.
What
more reason do you need?
Visit our website at www.bonitas.co.za to learn more about our products.
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Why choose Bonitas?
Consider these factors when choosing the right
medical aid plan to suit your specific needs.
Adult Dependant:
Any dependant on your medical aid who is 21 years of age or older.
Assessment of your healthcare needs:
How often do you and your family visit the doctor?
•
•
•
Do you and your family often require medication?
Do you or your dependants need to visit a specialist?
Do you or anyone in your family need extra cover for cancer, HIVAIDS or any
other chronic condition?
Broker assistance:
•
If you haven’t claimed at all or have had few medical expenses and are
unlikely to claim unless a major medical emergency, you will probably
require a low level of coverage. If you have had a large amount of
medical expenses, it is likely that you require a higher level of cover.
Decision to use network
•
Why choose Bonitas
Some plans require that you use a specific GP and hospital network or a
selection of preferred providers in order to claim your expenses. This helps
to keep your costs as low as possible but sticking to the network can be
difficult. If you would prefer to have freedom to use any provider, you may
need to opt for a more expensive plan.
Any dependant on your medical aid who is under the age of 21 years. If your child is a student and is registered on your medical aid, child rates will apply up to and including the last day of the month, in which they turn 24 years of age. You will need to send us valid proof of registration from a recognised tertiary institution for this to apply.
Special dependant:
These include other members of your family that are currently financially dependent on you for care and support, such as grandchildren, parents-in-law and siblings. Your application might be subject to underwriting.
Underwriting:
Your membership may be subject to underwriting which include late joiner penalties, condition specific or general waiting periods. Underwriting affects your benefit date.
A financial advisor or broker can advise on which
plan best suits your needs and your budget.
Cover requirement history:
Child Dependant:
Pro-Ration:
If you join Bonitas during the year, benefits will automatically be pro-rated. This means that you will only have access to a percentage of your benefits based on the month you join us until the next benefit year begins. For example, if you join in June, you will have access to six months’ worth of benefits, which is 50% of the total benefits.
Bonitas rates vs. Private rates
All claims will be paid at the Bonitas Rate. This will vary between 100% and 300%,
depending on the option chosen. Some service providers might charge you
private rates for services. This means you will have to pay the difference yourself. Please check which rate your provider is charging before you receive treatment.
For more information, contact us on 0860 002 108.
• Dependants:
Page 10
If you are single or married with children and wanting peace of mind that your family’s general
medical needs are covered, without having to break the bank then this product is perfect for you.
Overall annual limit (OAL) - Unlimited
MONTHLY CONTRIBUTIONS
Main member
Adult dependant
Child dependant
R2 683
R2 321
R784
Your fourth and subsequent children will be covered free of charge.
IN-HOSPITAL BENEFITS
These benefits include major medical events.
GP consultations
Unlimited, at 100% of the Bonitas Rate
Specialist consultations
Unlimited, at the Specialist network rate:
130% of Bonitas Rate
Pathology
General radiology
Specialised radiology
Unlimited, subject to pre-authorisation
Paramedical services (Allied medical
professions) - speech therapy, occupational
therapy, dietetics
Prosthesis internal and external
R37 900 per family, per year
ICPS is the **DSP for hip and knee
replacements a R5 000 co-payment is
payable when not using the DSP.
Standard
Internal nerve stimulators
Cochlear implants
Mental health hospitalisation
Take home medication (TTO)
R400 per beneficiary, per admission
Physical rehabilitation
Alternatives to hospitalisation
Oncology
Organ transplants
Unlimited, subject to treatment protocols
Renal dialysis
Out-of-hospital claims excluding Network GP consultations will be paid from current
available savings first. Once savings are depleted, claims will be paid from the day-to-day
benefit .
Savings
Main
member
Adult
dependant
Child
dependant
R1 212
R1 056
R360
The day-to-day benefit covers out-of-hospital general radiology, pathology, paramedical
services (such as audiology, physiotherapy, occupational therapy and more) and
specialist consultations, if referred by your family doctor.
Main member only
R4 020
Main member + 1 dependant
R6 140
Main member + 2 dependants
R6 590
R7 110
Main member + 4 or more dependants
R7 600
GP consultations
In network
Out of network
Main member only
R3 580
R1 160
R5 260
R1 790
R5 790
R1 950
R6 100
R2 050
R6 630
R2 210
*Specialist consultations
Paid from available savings, then covered
from day-to-day benefits
Acute medication
General radiology
Pharmacy Advice Therapy (PAT)
Paid from available savings
Pathology
Mental health consultations
R13 600 per family, per year (sub-limit to
mental health hospitalisation, in and out
of hospital consultations)
Standard
Unlimited, at the Specialist non-network
rate: 100% of the Bonitas Rate
OUT-OF-HOSPITAL BENEFITS
Page 12
Paramedical services
R22 400 per family, per year (subject to
pre-authorisation)
Fillings
Benefit for fillings are granted once per
tooth in 365 days
Stoma care products
General medical appliances limit may be
exceeded by R5 600 per year
Hearing aids
R13 700 per family, per two year cycle
(10% co-payment)
Benefit for re-treatment of a tooth is
subject to managed care protocols
Foot orthotics
R3 900 per beneficiary, per year (10%
co-payment)
A treatment plan and x-rays may be
required for multiple fillings
Appliances - wheelchairs, CPAP machines,
etc.
Included in general medical appliances
limit
Root canal therapy and extractions
Benefit is subject to managed care
protocols
Optometry
Vision examination (Iso-Leso members)
R490 per beneficiary, per two year cycle
Plastic dentures and associated
laboratory costs
1 x set of plastic dentures (an upper and a
lower) per beneficiary, per four year cycle
Vision examination (Non Iso-Leso
members)
Specialised dentistry
Covered at the Bonitas Dental Tariff (BDT)
Single vision lenses (glass/plastic)
R160 per beneficiary, per lens, per two
year cycle
Partial metal frame dentures and
associated laboratory costs
1 x partial frame (an upper or a lower) per
beneficiary, per five year cycle
Bifocal lenses (glass/plastic)
year cycle
Multifocal lenses (glass/plastic)
year cycle
Frames
1 x crown per family, per year
Contact lens materials
R1 750 per beneficiary, per two year cycle
HIV/Aids
R27 800 per beneficiary, per year
(if registered on Aid for Aids program)
Benefits for crowns will be granted once
per tooth, per five year cycle
Basic dentistry
Consultations
2 x annual check-ups per beneficiary
(once in 6 months)
X-rays: Intra-oral
protocols
X-rays: Extra-oral
1 x per beneficiary, per three year cycle
Additional benefit may be considered
where specialised dental treatment is
required
Oral hygiene
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Benefit for fluoride is limited to
beneficiaries between ages 5 & 16 years
2 x annual scale and polish treatments per
beneficiary (once in 6 months)
protocols
Crown and bridge and associated
laboratory costs
Periodontics
Maxillo-facial surgery and oral pathology
• Surgery in the dental chair
Hospitalisation (general anaesthetic)
Subject to a DENIS Designated Service
Provider Network
Pre-authorisation is required
requested
Implants and associated laboratory costs
No benefit
Orthodontics and associated laboratory
costs
protocols
Orthodontic treatment is granted once
per beneficiary, per lifetime
On pre-authorisation cases will be
clinically assessed by using an orthodontic
needs analysis. Benefit allocation is
subject to the outcome of the needs
analysis and funding can be granted up to
80% of BDT
Laughing gas in dental rooms
IV conscious sedation in rooms
Scheme exclusions
* Subject to the specialist network.
**Designated Service Provider
Benefit for Orthodontic treatment will be
granted where function is impaired
Benefit will not be granted where
Orthodontic treatment is required for
cosmetic reasons
Only one family member may commence
Orthodontic treatment in a calendar year
Benefit for fixed comprehensive treatment
is limited to individuals between ages 9 &
18 years
protocols
Benefit is limited to conservative, nonsurgical therapy only and will only be
applied to members who are registered on
the Periodontal Program
protocols
A co-payment of R2 000 per hospital
admission applies
Admission protocols apply
General anaesthetic benefits are available
for children under the age of 5 years for
extensive dental treatment
for the removal of impacted teeth. Benefit
is subject to managed care protocols
protocols
protocols
Benefit is limited to extensive dental
treatment
Please refer to the last section herein for
exclusions and www.bonitas.co.za for
Scheme rules & exclusions
CHRONIC BENEFITS
These offer cover for conditions that require medicine on an ongoing basis.
The Standard option offers cover for all of the following 44 chronic conditions.
Cover is limited to R8 250 per beneficiary and R16 500 per family, per year on the
Comprehensive Formulary. This is subject to pre-authorisation. A 40% co-payment will
be required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is
the **DSP for chronic medication.
Once this amount is depleted, you will still be covered for the 27 Prescribed Minimum
Benefits, highlighted below, subject to the use of in-formulary medicine
1.
Acne
16. Crohn’s Disease
31. Hypertension
2. Addison’s Disease
17. Depression
32. Hypothyroidism
3.
Allergic Rhinitis
18. Dermatitis
33. Multiple Sclerosis
4.
Ankylosing
Spondylitis
19. Diabetes Insipidus
34. Narcolepsy
5. Asthma
20. Diabetes Type 1
35. Obsessive Compulsive
Disorder
6.
Attention Deficit
Disorder
(5-18 Year Olds)
21. Diabetes Type 2
36. Panic Disorder
7.
Barrett’s Oesophagus
22. Dysrhythmias
37. Parkinson’s Disease
8.
Behcet’s Disease
23. Eczema
38. Post-Traumatic Stress
Syndrome
9. Bipolar Mood
Disorder
24. Epilepsy
39. Rheumatoid
Arthritis
10. Bronchiectasis
25. Gastro-Oesophageal
Reflux Disorder
40. Schizophrenia
11. Cardiac Failure
26. Glaucoma
41. Systemic Lupus
Erythematosus
12. Cardiomyopathy
27. Gout
42. Tourette’s Syndrome
13. Chronic Obstructive
Pulmonary Disease
28. Haemophilia
43. Ulcerative Colitis
14. Chronic Renal Disease
29. Hyperlipidaemia
44. Zollinger-Ellison
Syndrome
15. Coronary Artery
Disease
30. Hiv/Aids
Standard
Standard
General medical appliances
Benefit for fissure sealants is limited to
beneficiaries younger than 16 years of
age
Page 14
SUPPLEMENTARY BENEFITS
Glucose test
Cholesterol test
At Bonitas we believe in giving you more. These additional benefits provide cover in or
out-of-hospital and payable from OAL .
Waist to hip ratio assessment
Maternity care
Per event
Body mass index
12 x ante-natal consultations
Wellness extender
R1 400 per family per year
2 x 2D scans
Subject to registration and completion of
health risk assessment per beneficiary
4 x post-natal consultations with a
midwife
Beneficiary may then choose from the
following:
R1 100 for ante-natal classes
GP consultation
1 x amniocentesis
Biokineticist consultation
Infant paediatric benefit
Notes
Dietician consultation
2 x consultations per beneficiary under 1
year of age
2 x consultations per beneficiary between
ages 1 and 2
Childhood illness benefit
Physiotherapy consultation
Wearable devices (subject to approval)
Smoking cessation program (subject to
approval)
Standard
Preventative care
Subject to DSP
Women's health
1 x mammogram female members –
between ages 50 & 74 years,
per two year cycle
Standard
2 x GP consultations per beneficiary
between ages 2 and 12
1 x pap smear - female members between
ages 21 & 65 years, per three year cycle
General health
1 x annual HIV test per beneficiary,
per year
1 x annual Flu vaccine per beneficiary,
per year
Cardiac health
1 x full Lipogram - members 20+ years of
age, per five year cycle
Elderly health
1 x lifetime Pneumococcal vaccine members 65+years of age
1 x annual Faecal Occult blood test members between ages 50 & 75 years
Wellness screening benefit
1 x assessment per beneficiary, per year
at a **DSP
Limited to:
Blood pressure test
Page 15
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If you are married or single with children and looking for an affordable medical aid product that
offers a wide range of benefits, the Standard Select is perfect for you. This option makes use of
our extensive, high-quality Designated Service Provider network of medical professionals.
Out of hospital claims excluding Nominated GP consultations will be paid from current
available savings first. Once savings are depleted, claims will be paid from the day-to-day
benefit.
The GP consultation benefit is subject to nomination of a GP for each beneficiary from
the Bonitas GP network.
Main member
Adult dependant
Child dependant
R2 321
R2 007
R678
Consultations to non-nominated GP will be paid from available savings first and after
depletion the Non Nominated GP benefit.
Savings
These benefits include major medical events and are unlimited subject to network
hospitals. Non network hospitals admissions will attract a 30% co-payment.
Pathology
General radiology
therapy, dietetics
Internal nerve stimulators
Cochlear implants
Oncology
Organ transplants
Renal dialysis
HIV/Aids
Standard Select
130% of the Bonitas Rate
Adult
dependant
Child
dependant
R1 056
R900
R300
Day-to-day benefits to help you stay healthy
services (such as audiology, physiotherapy, occupational therapy and more) and
specialist consultations, if referred by your family doctor.
Main member only
R4 020
R6 140
R6 590
R7 110
R7 600
GP consultations
Nominated GP
Non-Nominated GP
Main member only
R3 580
R1 160
R5 260
R1 790
R5 790
R1 950
R6 100
R2 050
R6 630
R2 210
Standard Select
GP consultations
Main
member
Please note: Each beneficiary must have a nominated GP
Acute medication
Page 18
Standard Select
General radiology
Pathology
required
Oral hygiene
Mental health hospitalisation)
age
pre-authorisation)
beneficiaries between ages 5 and 16 years
Stoma care products
Hearing aids
(10% co-payment)
Foot orthotics
co-payment)
etc.
limit
Optometry
members)
year cycle
year cycle
year cycle
Frames
Basic dentistry
Consultations
(once in 6 months)
X-rays: Intra-oral
protocols
X-rays: Extra-oral
Fillings
cosmetic reasons
protocols
laboratory costs
1 x partial frame (an upper or a lower) per
beneficiary, per five year cycle
laboratory costs
Periodontics
treatment
Scheme exclusions
The Standard Select option offers cover for all of the following 44 chronic conditions.
protocols
Restrictive Formulary. This is subject to pre-authorisation. A 40% co-payment will be
required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is
Benefit is limited to conservative, nonsurgical therapy only and will only be
applied to members who are registered
on the Periodontal Program
protocols
Subject to Bonitas hospital network (Preauthorisation is required)
admission applies
requested
protocols
protocols
CHRONIC BENEFITS
• Surgery in the dental chair
Benefit for fixed comprehensive
treatment is limited to individuals
between ages 9 & 18 years
Provider Network
No benefit
* Subject to the specialist network and specialist referral from the Nominated GP.
costs
protocols
protocols
tooth in 365 days
Page 19
All pre-authorisation cases will be
80% of BDT
for the removal of impacted teeth.
protocols
Benefits, highlighted below, subject to the use of in-formulary medicine.
1.
2.
Acne
Addison’s Disease
3.
4.
5.
Allergic Rhinitis
18. Dermatitis
Ankylosing Spondylitis 19. Diabetes Insipidus
Asthma
20. Diabetes Type 1
6.
Attention Deficit
Disorder
(5-18 Yr Olds)
Barrett’s Oesophagus
Behcet’s Disease
7.
8.
17. Depression
21. Diabetes Type 2
31. Hypertension
32. Hypothyroidism
34. Narcolepsy
35. Obsessive Compulsive
Disorder
36. Panic Disorder
22. Dysrhythmias
23. Eczema
Syndrome
9. Bipolar Mood
Disorder
24. Epilepsy
39. Rheumatoid Arthritis
10. Bronchiectasis
Reflux Disorder
26. Glaucoma
40. Schizophrenia
11. Cardiac Failure
41. Systemic Lupus
Erythematosus
Page 20
12. Cardiomyopathy
27. Gout
28. Haemophilia
Pulmonary Disease
14. Chronic Renal Disease 29. Hyperlipidaemia
15. Coronary Artery
Disease
Syndrome
30. Hiv/Aids
Elderly health
1 x assessment per beneficiary,
per year at **DSP
Limited to:
Blood pressure test
Glucose test
out-of-hospital, and payable from OAL.
Cholesterol test
Body mass index
Maternity care
Per event
2 x 2D scans
midwife
year of age
ages 1 and 2
following:
GP consultation
Standard Select
1 x amniocentesis
Wellness extender
Smoking cessation program
(subject to approval)
between ages 2 and 12
Preventative care
Subject to DSP
Women's health
1 x mammogram female members between ages 50 & 74 years, per two year
cycle
General health
1 x annual HIV test per beneficiary, per
year
1 x annual Flu vaccine per beneficiary, per
year
Cardiac health
Page 21
Standard Select
Notes
Page 22
Notes
If you’re looking for a simple medical aid plan that offers affordable healthcare for you and
your loved ones when you need it, then this product is perfect for you.
HIV/Aids
R21 250 per beneficiary, per year (if
registered on Aid for Aids program)
A co-payment will apply to the following procedures in hospital.
Main member
Adult dependant
Child dependant
R1 719
R1 345
R548
R2 650 Co-Payment
R5 250 Co-Payment
1. Colonoscopy
1. Arthroscopy
1. Back surgery including
spinal fusion
2. Conservative back
treatment
2. Diagnostic laparoscopy
2. Joint replacements
for example Hip and
knee replacements
(except PMBs)
3. Cystoscopy
3. Hysterectomy
(except cancer and
PMBs)
3. Laparoscopic
pyeloplasty
4. Facet joint injections
4. Laparoscopic
appendectomy
4. Laparoscopic radical
prostatectomy
5. Flexible sigmoidoscopy
5. Percutaneous
radiofrequency
ablations
5. Nissen fundoplication
(reflux surgery)
6. Percutaneous
rhizotomies
GP consultations
Unlimited, at the Specialist network
rate:130% of the Bonitas Rate
rate: 100% of Bonitas Rate
Pathology
6. Functional nasal
surgery
General radiology
7. Gastroscopy
R11 150 per family, per year (in & out-ofhospital)
8. Hyseteroscopy (not
endometrial ablation)
Subject to pre-authorisation
9. Myringotomy
therapy, audiology, dietetics
PMB only
Oncology
Organ transplants
PMB only
These benefits cover your day-to-day medical expenses, such as GP and specialist
consultations, dentistry, optometry and more.
Renal dialysis
PMB only
Day-to-day benefits to help you stay healthy
Primary
R1 050 Co-Payment
10. Tonsillectomy and
adenoidectomy
(except PMBs)
11. Umbilical hernia repair
12. Varicose vein surgery
Primary
Page 24
Main member only
R1 800
R3 250
R3 800
R4 100
R4 450
GP consultations
In network
Out of network
Main member only
R1 700
R560
R3 150
R1 050
R3 700
R1 200
R4 000
R1 350
R4 500
R1 550
Covered from day-to-day benefit
Acute medication
General radiology
Pathology
Mental health hospitalisation, in and out
of hospital consultations)
Stoma care products
Hearing aids
Page 25
(10% co-payment)
Foot orthotics
co-payment)
etc.
limit
Optometry
members)
year cycle
laboratory costs
No benefit
R350 per beneficiary, per lens per two
year cycle
No benefit
costs
No benefit
Periodontics
No benefit
CHRONIC BENEFITS
The Primary option ensures that you are covered for the following 27 Prescribed
Minimum Benefits, subject to the use of in-formulary medicine. A 40% co-payment will
be required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct
is the **DSP for chronic medication.
year cycle
Frames
Surgery in the dental chair
1. Addison’s Disease
21. Hypothyroidism
Basic dentistry
Provider Network
protocols
2. Asthma
12. Diabetes Type 1
3. Bipolar Mood Disorder
13. Diabetes Type 2
admission applies
4. Bronchiectasis
14. Dysrhythmias
5. Cardiac Failure
15. Epilepsy
25. Schizophrenia
6. Cardiomyopathy
16. Glaucoma
26. Systemic Lupus
Erythematosus
Pulmonary Disease
17. Haemophilia
8. Chronic Renal Disease
18. HIV/Aids
Consultations
(once in 6 months)
X-rays: Intra-oral
protocols
X-rays: Extra-oral
Oral hygiene
2 annual scale and polish treatments per
Fillings
protocols
age
protocols
protocols
tooth in 365 days
protocols
treatment
Scheme exclusions
Please refer to last section herein for
exclusions and to www.bonitas.co.za for
9. Coronary Artery Disease 19. Hyperlipidaemia
out-of-hospital, and payable from OAL.
Maternity care
Per event
No benefit
2 x 2D scans
midwife
Benefit for root canal includes all teeth
except primary teeth and permanent
molars
Plastic dentures and associated laboratory
costs
20. Hypertension
Primary
Primary
services (such as audiology, physiotherapy, occupational therapy and more) and specialist
consultations, if referred by your family doctor.
1 x amniocentesis
1 x Peadiatric consultations per
beneficiary under 1 year of age
Page 26
ages 1 and 2 years
Notes
between ages 2 and 12 years
Preventative care
Subject to DSP
Women's health
General health
1 x annual HIV test per beneficiary,
per year
1 x annual Flu vaccine per beneficiary,
per year
Elderly health
at a DSP
Primary
Primary
Limited to :
Blood pressure test
Glucose test
Cholesterol test
Body mass index
Wellness extender
following:
GP consultation
Page 27
Page 28
Our premium product, BonComprehensive, is designed to meet the most arduous healthcare
needs. It features extensive and exclusive benefits that cater for young and old alike. This elite
option is perfect for those who appreciate high-quality and superior benefits.
Overall annual limit (OAL) – Unlimited
Main member
Adult dependant
Child dependant
R4 696
R4 428
R956
Adult
dependant
Child
dependant
Savings
R10 632
R10 020
R2 172
Self-payment gap
R3 428
R2 840
R1 308
*Threshold level
R14 060
R12 860
R3 480
Above threshold
benefit
Unlimited
Unlimited
Unlimited
*Not all claims accumulate to the threshold level
GP consultations
Subject to available savings and threshold
GP consultations
Acute medication
General radiology
Pathology
General radiology
Pathology
mental health hospitalisation, for in and
out-of-hospital consultations.)
Physical therapy
Prosthesis external
Internal nerve stimulator
Stoma care products
Cochlear implants
Hearing aids
(10% co-payment)
Foot orthotics
co-payment)
Oncology
etc.
limit
Biological drugs
HIV/Aids
Organ transplants
Unlimited
Renal dialysis
Paramedical services - speech therapy,
occupational therapy, audiology, dietetics
Prosthesis internal
BonComprehensive
BonComprehensive
Main
member
Page 30
Optometry
Limited to R2 740 and subject to available
savings and threshold
Basic dentistry
Paid from available savings and/or
threshold benefit
Consultations
X-rays: Intra-oral
X-rays: Extra-oral
Oral hygiene
protocols
Cost of implant components is limited to
R2 205 per implant
costs
protocols
per beneficiary per lifetime
age
All pre-authorisation cases will be
100% of BDT
tooth in 365 days
Scheme exclusions
29. GastroOesophageal
Reflux Disorder
49. Pemphigus
10. Bipolar Mood
disorder
30. Generalised anxiety
disorder
50. Polyarteritis nordosa
11. Bronchiectasis
31. Glaucoma
51. Post-traumatic stress
syndrome
12. Cardiac failure
32. Gout
52. Psoriatic Arthritis
13. Cardiomyopathy
33. Haemophilia
53. Pulmonary interstitial
fibrosis
protocols
14. Chronic obstructive
pulmonary disease
34. HIV/Aids
54. Rheumatoid arthritis
treatment
15. Chronic renal disease
35. Huntington’s disease
55. Schizophrenia
16. Coronary artery
disease
36. Hyperlipidaemia
56. Systemic lupus
erythematosus
17. Crohn’s disease
37. Hypertension
57. Systemic sclerosis
18. Cystic Fibrosis
38. Hypoparathyroidism
58. Tourette’s syndrome
19. Depression
39. Hypothyroidism
59. Ulcerative colitis
20. Deep Vein
Thrombosis
40. Multiple sclerosis
syndrome
Please refer to www.bonitas.co.za for
CHRONIC BENEFITS
The BonComprehensive option offers generous and extensive cover for all of the 60
chronic conditions listed below.
This is limited to R11 850 per beneficiary and R23 600 per family, per year on the
Comprehensive Formulary. This is subject to pre-authorisation.
cosmetic reasons
protocols
laboratory costs
1.
Acne
21. Dermatomyosis
41. Myasthenia Gravis
2.
Addison’s disease
22. Dermatitis
42. Narcolepsy
Paid from available savings and/or
threshold benefit
Benefit for fixed comprehensive
treatment is limited to individuals
between ages 9 & 18 years
3.
Allergic rhinitis
23. Diabetes insipidus
43. Neuropathies
4.
Ankylosing spondylitis
24. Diabetes Type 1
protocols
44. Obsessive
compulsive disorder
5.
25. Diabetes Type 2
45. Osteoporosis
protocols
Attention Deficit
Disorder
(5-18 year olds)
6.
46. Paget’s disease
Alzheimer Disease
(early onset)
26. Dysrhythmias
7.
Asthma
27. Eczema
47. Panic disorder
8.
Barrett’s oesophagus
28. Epilepsy
48. Parkinson’s disease
2 x partial frames (an upper and a lower)
per beneficiary, per five year cycle
protocols
Crown, bridge and associated laboratory
costs
Periodontics
3 x crowns per family, per year
protocols
Benefits, highlighted below.
Behcet’s disease
BonComprehensive
BonComprehensive
protocols
1 x treatment every 6 months per
beneficiary
Page 31
protocols
protocols
Fillings
9.
2 x implants per beneficiary, per five year
cycle
1 x consultation per beneficiary every 6
months
required
requested
Page 32
Limited to :
Blood pressure test
out-of-hospital payable from OAL.
Glucose test
Notes
Cholesterol test
Body mass index
Maternity care
Per event
2 x 2D scans
midwife
1 x amniocentesis
Preventative care
Subject to DSP
Women's health
1 x mammogram female members between ages 50 & 74 years, per two year
cycle
BonComprehensive
Men's health
PSA test - between ages 55 & 69 years,
who are considered to be at high risk
Children's health
1 x TSA test for infants below 1 month
following:
GP consultation
BonComprehensive
Wellness extender
approval)
Childhood immunisations according to
the EPI schedule
General health
year
1 x annual flu vaccine per beneficiary, per
year
Cardiac health
Elderly health
1 x annual faecal occult blood test members between ages 50 & 75 years
1 x lifetime bone density screening female members 65+ years of age
Page 33
at a **DSP
Page 34
If you have a family with children or perhaps your children are already all grown up and have
moved out of your home, this option offers a comprehensive medical plan with a wide range
of medical benefits for you and your loved ones.
Biological Drugs
Organ transplants
Renal dialysis
Main member
Adult dependant
Child dependant
R3 260
R2 799
R805
consultations.
Savings
These benefits include major medical events such as hospitalisation, oncology treatment
and more.
GP consultations
professions) - speech therapy,
physiotherapy, occupational therapy,
audiology, dietetics
BonClassic
rate:100% of the Bonitas Rate
(in & out-of-hospital)
ICPS is the **DSP for hip and knee
replacements, a R5 000 co-payment is
payable when not using the DSP
R351 900 per family, per year at the
Preferred Provider
Main
member
Adult
dependant
Child
dependant
R5 532
R4 752
R1 368
GP consultations
Subject to available savings
Acute medication
General radiology
BonClassic
Pathology
General radiology
Oncology
(10% co-payment and protocols apply)
Pathology
mental health hospitalisation limit and for
in and out of hospital consultations)
Physical therapy
Stoma care products
limit
Hearing aids
R14 500 per family, per three year cycle
(10% co-payment)
Foot orthotics
(10% co-payment)
Appliances - wheelchairs, CPAP
machines, etc.
limit
Page 36
HIV/Aids
Unlimited, at 100% of the Bonitas Rate (If
registered on Aid for Aids program)
Main member only
R2 550 per year
R3 900 per year
R4 500 per year
R4 800 per year
Main member + 4 dependants or more
R5 150 per year
Optometry
protocols
laboratory costs
protocols
R4 800 per family, per year. Covered at the
Bonitas Dental Tariff (BDT)
2 x partial frames (an upper and a lower)
per beneficiary, per five year cycle
members)
year cycle
Crown; bridge and associated laboratory
costs
Subject to DENIS Designated Service
Provider Network
year cycle
year cycle
(A bridge comprises 2 or more crown
units. Each crown is payable from the
available crown and bridge benefit)
Frames
Basic dentistry
R4 000 per family, per year. Covered at the
Bonitas Dental Tariff (BDT)
protocols
requested
No benefit
Consultations
(once in 6 months)
costs
X-rays: Intra-oral
protocols
X-rays: Extra-oral
Oral hygiene
protocols
Cases will be clinically assessed by using
an orthodontic needs analysis. Benefit
allocation is subject to the outcome of
the needs analysis and funding can be
granted up to 100% of BDT
cosmetic reasons
Benefit for fluoride treatment is limited
to beneficiaries between ages 5 & 16
years
Fillings
Page 37
age
tooth in 365 days
Periodontics
orthodontic treatment in a calendar year
These offer cover for conditions that require medication on an ongoing basis.
protocols
admission applies
for the removal of impacted teeth. Benefit
is subject to managed care protocols
protocols
protocols
treatment
Once this amount is depleted, you will still be covered for the 27 Prescribed
Maxillo-facial surgery
Scheme exclusions
**Designated Service Provider
BonClassic offers generous and extensive cover for the below 59 chronic conditions.
Restrictive Formulary. This is subject to pre-authorisation. A 40% co-payment will be
required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is
1.
2.
Addison’s Disease
Alzheimer’s Disease
3.
4.
Angina
Ankylosing Spondylitis 24. Diabetes Type 1
5.
6.
Asthma
Attention Deficit
Disorder
(In 5-18 Year Olds)
7. Barrett’s Oesophagus
8. Benign Prostatic
Hypertrophy
9. Bipolar Mood Disorder
10. Bronchiectasis
21. Cushing Syndrome
22. Depression
25. Diabetes Type 2
26. Dysrhythmias
27. Eczema
28. Emphysema
12. Cancer
29. Epilepsy
Reflux Disorder
31. Generalised Anxiety
Disorder
32. Glaucoma
13.
14.
15.
16.
33.
34.
35.
36.
11. Behcet’s Disease
Cardiac Arrhythmias
Cardiac Failure
Cardiomyopathy
Chronic Bronchitis
Gout
Haemophilia
Hiv/Aids
Hormone
Replacement Therapy
37. Hyperlipidaemia
Pulmonary Disease
18. Chronic Renal Disease 38. Hypertension
19. Coronary Artery
39. Hypoparathyroidism
Disease
40. Hypothyroidism
CHRONIC BENEFITS
41. Infective Endocarditi
42. Ischaemic Heart
Disease
44. Obsessive compulsive
disorder
45. Osteoporosis
46. Paget’s Disease
47. Panic Disorder
48. Paraplegia And
Quadriplegia
50. Polyarteritis Nodosa
BonClassic
BonClassic
Paramedical services - speech therapy, occupational therapy,
audiology, dietetics
Benefit for fixed comprehensive treatment
is limited to individuals between ages 9 &
18 years
protocols
Syndrome
52. Pulmonary Interstitial
Fibrosis
54. Schizophrenia
55. Scleroderma
56. Systemic Lupus
Erythematosus
Page 38
At Bonitas, we believe in giving you more. These additional benefits provide cover in or out
of hospital
a health risk assessment per beneficiary
following:
Maternity care
Per event:
Wellness extender
GP consultation
2 x 2D scans
midwife
1 x amniocentesis
Preventative care
Subject to **DSP
Women's health
1 x mammogram for female members between ages 50 & 74 years, per two year
cycle
Notes
year
BonClassic
BonClassic
General health
year
Cardiac health
Elderly health
1 x Faecal Occult blood test - members
between ages 50 & 75 years, per
beneficiary, per year
1 x lifetime Bone Density screening female members 65+ years of age
at a **DSP
Limited to :
Blood pressure test
Glucose test
Cholesterol test
Body mass index
Page 39
Page 40
Take total control of your benefits with BonSave - the flexible option that lets you decide how
to use your savings. Designed to offer you cover when you need it most, while allowing you to
customise your cover according to your needs, BonSave offers extensive hospital cover.
Main member
Adult dependant
Child dependant
R1 908
R1 478
R572
R2 650 co-payment
R5 250 co-payment
1. Colonoscopy
1. Arthroscopy
spinal fusion
treatment
2. Joint replacements for
example Hip and
knee replacements
(except PMBs)
3. Cystoscopy
3. Laparoscopic
Hysterectomy (except
cancer and PMBs)
3. Laparoscopic
pyeloplasty
4. Laparoscopic
appendectomy
prostatectomy
5. Percutaneous
radiofrequency
ablations
(reflux surgery)
6. Functional nasal
surgery
6. Percutaneous
rhizotomies
BonSave
GP consultations
Pathology
General radiology
professions) - speech therapy,
occupational therapy, audiology, dietetics
PMB only
Oncology
Organ transplants
Unlimited, subject to treatment
protocols
Renal dialysis
PMB only
BonSave
R1 050 co-payment
7. Gastroscopy
8. Hyseteroscopy (not
9. Myringotomy
adenoidectomy
(except PMBs)
Page 42
consultations, optometry and more.
Savings
Main member
Adult
dependant
Child
dependant
R3 672
R2 844
R1 104
Page 43
GP Consultations
Acute medication
General radiology
Pathology
HIV/Aids
authorisation)
Stoma care products
Fillings
protocols
At Bonitas, we believe in giving you more. These additional benefits provide cover in or
out-of-hospital.
age
protocols
Maternity care
Per event
tooth in 365 days
protocols
treatment
Scheme exclusions
Benefit for root canal includes all teeth
except primary teeth and permanent
molars
CHRONIC BENEFITS
laboratory costs
Specialised Dentistry
No benefit
No benefit
Hearing aids
No benefit
Crown, bridge and associated laboratory
costs
Foot orthotics
co-payment)
No benefit
etc.
limit
costs
No benefit
Optometry
Periodontics
No benefit
Basic Dentistry
Consultations
(once in 6 months)
X-rays: Intra-oral
protocols
X-rays: Extra-oral
1 x amniocentesis
1. Addison’s disease
20. Hypertension
2. Asthma
21. Hypothyroidism
3. Bipolar Mood disorder
12. Diabetes Type 1
4. Bronchiectasis
13. Diabetes Type 2
5. Cardiac failure
14. Dysrhythmias
6. Cardiomyopathy
15. Epilepsy
25. Schizophrenia
16. Glaucoma
26. Systemic lupus
protocols
18. HIV/Aids
admission applies
9. Coronary artery disease
19. Hyperlipidaemia
17. Haemophilia
Antenatal classes limited to R1 050 per
pregnancy
year of age
The BonSave option ensures that you are covered for the following 27 Prescribed
Minimum Benefits, subject to the use of in-formulary medicine A 40% co-payment will
be required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct
is the **DSP for chronic medication.
midwife
pulmonary disease
2 x 2D scans
protocols
ages 1 and 2 years
Subject to DSP
Preventative care
Women's health
ages 21 & 65 years, per three years cycle
General health
year
1 x annual flu vaccine, per beneficiary, per
year
Elderly health
1 x lifetime Pneumococcal vaccine members 65+ years of age
1 x annual faecal occult blood test members between ages 50 & 75 years
erythematosus
BonSave
BonSave
With BonSave, Dental is covered from risk and therefore doesn’t have any impact on your
savings. (exclusive to BonSave)
Oral hygiene
required.
at DSP
Limited to:
Blood pressure test
Page 44
Glucose test
Cholesterol test
Body mass index
Wellness extender
Notes
following:
GP consultation
BonSave
BonSave
Page 45
Page 46
If you are young and healthy and just looking for peace of mind knowing that you and your
family are covered for major medical events, as well as having access to savings for essential
day-to-day medical needs, this option is perfect for you.
Main member
Adult dependant
Child dependant
R1 598
R1 238
R479
R1 050 co-payment
R2 650 co-payment
R5 250 co-payment
1. Colonoscopy
1. Arthroscopy
spinal fusion
treatment
example Hip and
knee replacements
(except PMBs)
3. Cystoscopy
3. Laparoscopic
cancer and PMBs)
3. Laparoscopic
pyeloplasty
4. Laparoscopic
appendectomy
prostatectomy
5. Percutaneous
radiofrequency
ablations
(reflux surgery)
6. Functional nasal
surgery
6. Percutaneous
rhizotomies
These benefits include major medical events. Major medical expenses are unlimited
subject to the use of network hospitals. Non-network hospitals admissions will attract a
30% co-payment.
GP consultations
Unlimited , at the Specialist network rate:
BonFit
7. Gastroscopy
8. Hysteroscopy (not
Pathology
General radiology
9. Myringotomy
adenoidectomy
(except PMBs)
PMB only
Oncology
Organ transplants
Renal dialysis
PMB only
Page 48
Scheme exclusions
CHRONIC BENEFITS
Savings
Main
member
Adult
dependant
Child
dependant
R2 880
R2 232
R864
The BonFit option ensures that you are covered for the following 27 Prescribed Minimum
Benefits subject to the use of in-formulary medicine A 40% co-payment will be required if
you decide to use a non-DSP to obtain your medication. Pharmacy Direct is the **DSP for
chronic medication.
GP Consultations
20. Hypertension
Acute medication
2. Asthma
21. Hypothyroidism
General radiology
3. Bipolar disorder
12. Diabetes Type 1
Pathology
4. Bronchiectasis
13. Diabetes Type 2
HIV/Aids
5. Cardiac failure
14. Dysrhythmias
6. Cardiomyopathy
15. Epilepsy
25. Schizophrenia
16. Glaucoma
26. Systemic lupus
Stoma care products
Hearing aids
No benefit
Foot orthotics
etc.
Optometry
Basic dentistry
Subject to available savings and dental
managed care protocols
Maternity care
Consultations
Per event
X-rays: Intra-oral
2 x 2D scans
X-rays: Extra-oral
Oral hygiene
midwife
Fillings
laboratory costs
year of age
No benefit
1 x consultation per beneficiary between
ages 1 and 2
17. Haemophilia
18. HIV / Aids
19. Hyperlipidaemia
erythematosus
BonFit
pulmonary disease
At Bonitas, we believe in giving you more. These additional benefits provide cover in or
out-of-hospital and payable from OAL.
1 x amniocentesis
Page 49
1 x GP consultation per beneficiary
Preventative care
Women's health
General health
year
1 x annual flu vaccine per beneficiary, per
year
Elderly health
1 x lifetime Pneumococcal vaccine members 65+ years of age
at a **DSP
Limited to :
Blood pressure test
Glucose test
BonFit
Cholesterol test
Body mass index
Wellness extender
following:
GP consultation
Page 50
Notes
BonEssential is the ideal plan for healthier families and individuals who only really need cover
for major medical events. BonEssential offers top-quality hospital cover at affordable prices with
added Prescribed Minimum Benefits when you really need them.
Main member
Adult dependant
Child dependant
R1 316
R1 007
R386
R2 650 co-payment
R5 250 co-payment
1. Colonoscopy
1. Arthroscopy
spinal fusion
treatment
2. Diagnostic Laparoscopy
example Hip and
knee replacements
(except PMBs)
3. Cystoscopy
3. Laparoscopic
cancer and PMBs)
3. Laparoscopic
pyeloplasty
4. Laparoscopic
Appendectomy
4. Laparoscopic Radical
Prostatectomy
5. Percutaneous
Radiofrequency
Ablations
5. Nissen Fundoplication
(Reflux Surgery)
6. Percutaneous
rhizotomies
MAJOR MEDICAL BENEFITS
BonEssential
GP consultations
Unlimited at the Specialist network rate:
6. Functional nasal
surgery
Unlimited at the Specialist non-network
7. Gastroscopy
Pathology
General radiology
8. Hysteroscopy (not
9. Myringotomy
adenoidectomy
(Except Pmbs)
PMB only
Oncology
Organ transplants
Renal dialysis
PMB only at **DSP
HIV/Aids
BonEssential
R1 050 co-payment
11. Umbilical hernia
repair
Page 52
CHRONIC BENEFITS
The BonEssential option ensures that you are covered for the following 27 Prescribed
Minimum Benefits subject to the use of in-formulary medicine. A 40% co-payment will be
required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is the
**DSP for chronic medication.
Elderly health
at a **DSP
Notes
Limited to:
Blood pressure test
Glucose test
20. Hypertension
Cholesterol test
2. Asthma
21. Hypothyroidism
Body mass index
3. Bipolar mood disorder
12. Diabetes Type 1
4. Bronchiectasis
13. Diabetes Type 2
5. Cardiac failure
14. Dysrhythmias
6. Cardiomyopathy
15. Epilepsy
25. Schizophrenia
16. Glaucoma
26. Systemic lupus
17. Haemophilia
18. HIV/Aids
19. Hyperlipidaemia
erythematosus
R700 per family per year
following:
GP consultation
At Bonitas we believe in giving you more. These additional benefits provide cover in or outof-hospital, and payable from OAL.
BonEssential
BonEssential
pulmonary disease
Wellness extender
approval)
Maternity care
Per event
2 x 2D scans
midwife
1 x amniocentesis
Preventative care
General health
year
year
Page 53
Page 54
Benefits & Process Guides
All about our processes and partners
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The YourHealth Portal
The YourHealth Portal is an exciting online educational web and mobile health portal that
gives you as a beneficiary access to an abundance of resources in order to help you make
better health choices and to be well informed. The portal includes e-tutorials and educational
articles, tools and quizzes, and so much more, all housed in an easy to use online space.
Easily accessible through the secure member zone, you will have access to the following:
• E-tutorials - covering topics such as asthma, backache, healthy eating, depression, diabetes,
hypertension, smoking cessation, stress, weight loss and work place health. Weekly stepby-step emails with practical advice, motivating case studies and a short questionnaire to
help you to assess your understanding
What do I need to register?
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Membership number
ID number
Email address
A username and Password
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The YourHealth Portal
Maternity
Prescribed Minimum Benefits
Managed care
Medicine management
-- Pharmacy Advised Therapy (PAT)
-- Chronic Medicine
-- Pharmacy Direct
Hospital Management
Networks
-- GP Network
-- Specialist Reffarls
-- Specialist Network
-- The Standard Select and BonFit Hospital Network
Dental benefits
Optical benefits
Diabetic Program
Hip and Knee Replacement Program
HIV/Aids Management
Exclusion List
• Wellness programs including fitness and nutrition programs - personalised interactive diet
and fitness programs with week-by-week dietary and exercise guidelines, based on a profilesetting questionnaire. Your performance is tracked and displayed
• Pregnancy program - regular electronic communication to assist moms and dads during this
“journey through life”
• A to Z database of diseases and conditions
• Condition Centres (provide disease related information and articles on a number of
important chronic conditions)
• Databases of symptoms, medication, first aid and wellness
• Self-assessment tools
How to register on Member Zone to access the YourHealth Portal
• Visit the Bonitas website at www.bonitas.co.za
• Go to the top right hand corner of the page and click on “Login/Registration”
• This will take you to the “Account Login Page” where you can either sign in or create a new
account
If you are already registered to log into the secure area where you can view personal
information:
• Fill in your username and password and click on “Sign in” to access your account
• Click on “YourHealth Portal”
If you are not registered to log into the secure area where you can view personal
information:
•
•
•
•
Click on “Register”
Click on “Members”
Fill in your membership number and click “Validate Code”
Confirm or choose from the list of members/dependants to indicate your status and name
and click “Select”
Page 56
• Enter your chosen Username and validate with your email address
• Create a password and confirm your password
• Read through the terms and conditions and then click “Create Account” to complete the
process
• Click on “YourHealth Portal”
Maternity
The Scheme will supply every pregnant member with a mother and baby gift pack when
registered on the maternity program.
How do I register?
Register by either logging on to the Bonitas website or contacting the call centre.
-- Go to www.bonitas.co.za in order to login onto the member zone.
-- Call 0860 002 108 between 8:30am and 4:00pm Monday to Friday to register for
your mother and baby gift pack. This number is not available on public holidays or
weekends
What information do I need when I apply for the mother and baby gift pack?
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Membership number
Name and surname
Contact details
Delivery address
Alternative delivery address
Date of expected delivery
Please note: In order to ensure that you receive your mother and baby gift pack, the courier
company will be in contact with you to arrange a suitable date and time for delivery.
Prescribed Minimum Benefits (PMB)
By law, all medical aids are required to fund the diagnosis, treatment and care of any
Page 57
emergency medical condition and a list of 270 groups of conditions known as Diagnosis and
Treatment Pairs, which includes 27 common chronic conditions known as Prescribed Minimum
Benefit conditions.
• Pregnancy and childbirth
• Haematological, infectious and miscellaneous systemic conditions
• Mental illness
Which PMB conditions are covered by Bonitas?
Chronic conditions
Emergency medical conditions
The following 27 conditions must be covered:
An emergency medical condition means the sudden and, at the time, unexpected onset of
a health condition that requires immediate medical treatment and/or an operation. If the
treatment is not provided, the emergency could result in damage to bodily functions, serious
and lasting damage to organs, limbs or other body parts, or even death.
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Diagnosis and Treatment Pairs (270 medical conditions)
The Regulations of the Medical Schemes Act provide a long list of conditions identified as
Prescribed Minimum Benefit conditions. The list is in the form of Diagnosis and Treatment
Pairs (DTPs). A DTP links a specific diagnosis to a treatment and indicates how these PMB
conditions should be treated.
Please note: It is not always possible to diagnose a condition before admitting a patient for
treatment. However, if doctors suspect that the patient suffers from a condition that is a PMB
condition, the medical fund will need to approve treatment in order for it to be paid correctly.
Schemes may request that the diagnosis be confirmed with supporting evidence within a
reasonable period of time.
The 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of
ailments that can be divided into 15 broad categories:
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Brain and nervous systems
Eye
Ear, nose, mouth and throat
Respiratory system
Heart and blood vessels
Gastrointestinal
Liver, pancreas and spleen
Musculoskeletal
Skin and breast
Endocrine, metabolic and nutritional
Urinary and male genital system
Female reproductive system
Addison’s disease
Asthma
Bipolar Mood Disorder
Bronchiectasis
Cardiac failure
Cardiomyopathy
Chronic obstructive pulmonary disorder
Chronic renal disease
Coronary artery disease
Crohn’s disease
Diabetes insipidus
Diabetes mellitus type 1
Diabetes mellitus type 2
Dysrhythmias
Epilepsy
Glaucoma
Hemophilia
HIV/Aids
Hyperlipidemia
Hypertension
Hypothyroidism
Multiple sclerosis
Parkinson’s disease
Rheumatoid arthritis
Schizophrenia
Systemic lupus erythematosus
Ulcerative colitis
Did you know? PMB diagnoses may not legally have Scheme Specific Exclusions applied to
them. For example, if you contract septicaemia after cosmetic surgery, Bonitas has to provide
healthcare cover for the treatment of the septicaemia because it is a PMB condition. The cost
of the cosmetic surgery would however, remain uncovered, as this is on the Exclusion List.
Do I need to apply for Prescribed Minimum Benefits?
Although the process is mostly automated and these conditions are identified through the
ICD-10 (diagnosis) codes reflected on your claims, you can apply for Prescribed Minimum
Benefits by calling the call centre or by logging into www.bonitas.co.za
How will PMB’s be covered?
As per legislation, you will be provided with at least the minimum treatment needed for you
PMB condition. Your Fund will pay costs in full for PMB treatment only received from our DSP’s.
This will be paid from your available benefit limits first, then your treatment will be covered
from risk. For example, radiology services will be paid from your Radiology annual sub-limit.
Once your benefit limits are reached, further services clinically appropriate for your PMB
condition will continue to be paid from a risk pool.
If further treatment is needed for your condition, your treating doctor will need to submit
clinical motivation for assessment and approval.
How can I avoid rejected PMB claims?
Check that your doctor (or any other medical service provider) has placed the correct ICD-10
code on your invoice. ICD-10 codes provide accurate information on your diagnosis and help
the Scheme to decide what benefits you are entitled to and how these benefits should be
paid.
ICD-10 codes must also be provided on medicine prescriptions and referral notes to other
healthcare providers (e.g. pathologists and radiologists) who are not able to make a diagnosis,
therefore they require the diagnosis information from your referring doctor in order for their
claims to be paid correctly by the Scheme.
Did you know?
Medical Schemes are obliged by law to treat information about members’ conditions as
confidential.
What do I do if my PMB claim is rejected?
In the event of your PMB claim being rejected, you can contact the Bonitas call centre to
query the rejection. Once diagnosed, please keep all your supporting documents on file as the
consultant may ask for this information when advising on your claim.
Page 58
At Bonitas we strive to create the best experience for you and your loved ones during your
pregnancy by providing you and your unborn child with the necessary health information and
support.
Managed care
Oncology Benefit Management
What is managed care?
This program offers you emotional support through social workers and clinical staff and
manages your oncology benefits, on your behalf, by liaising with your treating doctor
regarding your treatment plan and, where possible, matching it to your available benefits.
The term “managed care” describes a range of techniques that aim to reduce instances of high
cost treatment and hospitalisation that are caused by a medical condition, sometimes due to
complications or deterioration, which could have been avoided or improved through quality
care and support. By looking at both the type of treatment you are receiving from your doctor
and the cost thereof, we aim to improve the quality of care while managing your benefits more
effectively. Each Managed Care program has specific criteria and protocols which are followed.
The aim of these programs is to ensure that you get good quality medical care while managing
your benefits carefully, thereby also minimising the clinical and financial risk to the Scheme.
In some cases, we have agreements with doctors, hospitals and healthcare professionals to
provide you with a range of services at a reduced cost. With your consent, we work closely
with your doctors to help your benefits stretch further and make sure that you are supported
more than adequately.
Our Managed Care programs put you on the path to wellness by supporting you through your
treatment. They cover everything from chronic medicine, to the long-term treatment of a
condition like diabetes and emergency hospitalisation.
Which Managed Care programs do Bonitas offer?
We offer a variety of programs that coordinate care for everything from back ailments to
oncology.
Chronic Medicine Management
This program ensures that you are covered for the treatment of a list of chronic diseases and
provides you with quick and easy methods to update your medicine. It also ensure you aren’t
paying too much for your medicine by working together with the pharmaceutical industry
to regulate medicine prices, to keep track of new products and generics and negotiate
dispensing fees.
Hospital Benefit Management
This program will help you to pre-authorise your hospital stay and support you through the
process to make sure that you know what to expect when you’re admitted and discharged. It
will ensure that your benefits are managed effectively.
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Bonitas has partnered with The Independent Clinical Oncology Network (ICON) of dedicated
specialist oncologists who subscribe to the ICON culture of patient-centric and ethical
cancer care. The network represent 80% of the private practising oncologists with a national
geographic footprint. The partnership with Bonitas focuses on the enhancement of every
aspect of quality of care including patient-centeredness, clinical outcomes and affordability of
care.
Disease Management through Integrated Care
This program supports you through your prescribed treatment to ensure you are getting the
best care and doing what you can to get better. A team of health coaches help you to identify
the areas you need to improve on, offer you advice on your condition and work together with
your treating doctor to give you the best support possible.
The Bonitas Back Rehabilitation Program
If you are diagnosed with certain back and neck conditions, you will be provided with advice
on the most appropriate care, as well as have access to physiotherapists and doctors, where
clinically appropriate, that will help you to manage and improve your condition.
Contact details:
Chronic Medicine Management
• Call: 0860 002 108
• Email: [email protected]
Hospital authorisations
• Call: 0860 002 108
Oncology management
• Call: 0860 100 572
Medicine Management
Apply via telephone
Pharmacy Advised Therapy (PAT)
Call 0860 002 108 and follow the voice prompts. Once you select the appropriate option your
call will be routed through to a consultant who will guide you through the process.
What is PAT?
Apply online
You don’t always have to go to a doctor to get medicine. Your pharmacist can recommend and
dispense certain medicines without a doctor’s prescription.
• Go to www.bonitas.co.za and log in as a member.
• Go to “Clinical Information” and click on “Online Chronic Application”.
• Follow the prompts on the system and once all information has been captured click on
“View Summary”. You can print this screen for your records.
• Click on “Submit” and a reference number will be provided for follow up on the progress of
the application.
When is it useful?
If you have a mild sore throat, cold, a mild cough or anything similar, ask your pharmacist to
dispense appropriate medicine and to clearly write “PAT” on your claim.
Why do it?
The cost of this claim is deducted from your normal day-to-day benefit or savings accounts.
You don’t have to pay for this out of your pocket and you save on the cost of a consultation
with your doctor.
Chronic medicine
Chronic medicine is medication used on an ongoing basis to treat certain chronic health
conditions.
Did you know? Common chronic conditions include heart disease, diabetes, hypertension,
arthritis, asthma and osteoporosis.
How do I apply for the chronic medicine benefit?
You, your doctor or pharmacist may apply for chronic registration. You will need to have the
following information on hand:
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•
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•
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Your membership number
The beneficiary’s date of birth
The ICD 10 code
The doctor’s practice number
The medicine details
Some chronic medication may require additional clinical information.
What happens after I register on the program?
• Once registered and your application has been approved, you will receive a Medicine Access
Card listing the medicines to be paid from your Chronic Medicine benefit.
• If the medicine authorised differs from the medicine requested, a letter of explanation will
be attached to your access card and a copy will be sent to the prescribing doctor.
• ou will need a repeat script from your doctor for the medicines listed on the card.
Please note: The access card is not a prescription and cannot be used to have medicines
dispensed. Your doctor determines the number of repeats and will advise you how often
he needs to see you to monitor your condition. Whenever you need to have your medicine
dispensed, produce a valid doctor’s prescription together with the access card. The duration of
authorisation varies from medicine to medicine. Some medicines may be authorised ongoing,
whilst others may only be authorised for a limited period.
Types of formularies
There are two types of formularies:
• Restrictive Formulary
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Restrictive formularies provides access to a restrictive range of medicines to treat
your chronic condition.
You will not have a co-payment for medicines on this formulary if they are authorised
and obtained from the Designated Service Provider.
• Comprehensive Formulary
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--
Provides access to a wider range of medicines to treat your chronic conditions.
If you choose to use a medicine that is not on the formulary allowed by your option, you may
have to pay a co-payment upfront. Your co-payment may be substantial if the cost of your
medicine is higher than listed on the Medicine Pricing List. A co-payment may also apply if you
are required to use a Designated Service Provider and choose not to. Both formularies include
alternative products that will not require a co-payment to be made, so if you do not wish to
incur any co-payments, discuss alternative therapies with your treating doctor and ensure
that you obtain your medicine through a Designated Service Provider.
When you apply for chronic medicine, you are approved for treatment of your chronic
condition and not a specific medicine only. This means that when you need to change or add
a new medicine for your condition, you can do this quickly and easily at your pharmacy with
your new prescription without having to contact us. Each condition is allocated a basket of
medicine for its treatment. The quantity of each medicine in the basket is limited to the most
commonly prescribed monthly dose.
You do need to contact us on 0860 002 108 if:
• You have a medicine that is not in your condition’s basket
• If you are diagnosed with a new condition
• You require higher quantities than those in the basket
You do not need to update us with your new medicine if:
• Your medicine is in the basket
• You change to another medicine in the basket
• You need a quantity or dosage of a medicine that is listed in the basket.
Please note: Pre-approved medicine in the basket will still be subject to the Medicine Pricing
List and formulary co-payments.
pharmaceutical services available. Pharmacy Direct has the capability to deliver medication
to members and dependants residing at different addresses. Patients are advised by SMS,
telephone or email of delivery.
An electronic copy of documentation is acceptable. However, by law you are required to send
your original prescription for any schedule 5 and 6 medicine to be obtained from Pharmacy
Direct.
Hospital Management
Members are required to register with Pharmacy Direct in addition to applying for chronic
medication.
How soon can I expect delivery of my medication?
All hospital stays must be pre-authorised (including emergencies). It is best to do this at least
two days before you go to hospital.
Contact details:
Practice number:
Fax:
Queries:
Aid for AIDS:
Email:
Website:
0126225
086 611 4000/1/2/3
0860 027 800
0860 103 810
[email protected]
www.pharmacydirect.co.za
How do I register with Pharmacy Direct?
• Ensure you’ve applied for chronic medicine.
• Visit www.pharmacydirect.co.za to download the application form, complete all relevant
sections and fax it to 086 611 4000/1/2 or email it through to [email protected].
• Alternatively, you can call Pharmacy Direct on 086 002 7800 to register an online
application.
• Please fax a copy of the original repeat prescription for all medication required to 086 611
4000/1 or email to [email protected]. If you do not have the prescription, please
contact your doctor.
Please note: An electronic copy of all documentation is acceptable. However, you are required
to send your original prescription for schedule 5 and 6 medicine to Pharmacy Direct.
How do I order medication?
Please fax a copy of the original repeat prescription for all medication required to 086 611
4000/1/2 or
Pharmacy Direct
E-mail to [email protected]. If you do not have a valid, repeat prescription, please
contact your doctor.
Pharmacy Direct is the Designated Service Provider (DSP) for chronic medication. Medicine
is delivered to your home, place of work or to the nearest Post Office, depending on your
choice. A large number of our patients are based in rural areas where there are no other
Please note: By law, medication can only be dispensed once a pharmacy is in possession of a
valid prescription. It remains the responsibility of the patient to obtain his/her prescription
from the prescribing doctor and to forward this to Pharmacy Direct and to Chronic Medicine
Management for chronic authorisation.
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Please note: Before medication can be sent, to new or existing Pharmacy Direct users,
Pharmacy Direct would engage in certain interventions to ensure good pharmacy practice.
Case
Dispatch Time
Note
Delivery Time
First time delivery
of urgent/lifethreatening
medication
24-48 hours until
dispatch
Dependant on
whether chronic
authorisation is
already in place
24-72 hours,
depending on
location
First time delivery
of other chronic
medication
3-5 working days
until dispatch
Dependant on
whether chronic
authorisation is
already in place
24-72 hours,
depending on
location
Dependant on
whether chronic
authorisation is
already in place
24-72 hours,
depending on
location
Delivery of
medication where
a new, valid
prescription has
been received
3-5 working days
until dispatch, or
as per automated
existing dispense
dates
Pre-authorisation for hospital admission
No account will be paid unless pre-authorisation is obtained. In cases of emergency, preauthorisation can be obtained 48 hours after the emergency.
On the Standard Select and BonFit options, a 30% co-payment will apply to all non-network
and non-authorised hospital admissions, except in the case of an emergency.
How do I apply for pre-authorisation?
You can apply for pre-authorisation in one of these ways:
• Online
Log in to www.bonitas.co.za and click on the pre-authorisation button. Follow the prompts.
• Email
Email all the relevant information to [email protected].
• Telephone
Call 0860 002 108 between 8:30am and 4:00pm Monday to Friday to pre-authorise your
hospital stay. This number is not available on public holidays or weekends.
What information do I need when I apply for pre-authorisation?
Medication is automatically dispensed on a 28-day cycle. Pharmacy Direct uses an advanced
scheduling and planning system to deliver medication to patients on a monthly basis.
Did you know? By law, prescriptions are only valid for six months. Therefore, patients don’t
need to re-order medication each month, but rather, update their prescription every six
months.
Pharmacy Direct contact details:
Fax:
Queries:
Email:
Website:
086 611 4000/1/2/3
0860 027 800
[email protected]
www.pharmacydirect.co.za
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Membership number
Beneficiary name and date of birth
Date of admission and the proposed date for the operation
Name of the doctor and their telephone and practice numbers
Name of the hospital with their telephone and practice numbers
All the relevant procedure codes
All the relevant associated medical diagnosis codes
Are there any other treatments/procedures that I need pre-authorisation for?
You will also need pre-authorisation for the following:
• Renal clinic admissions for dialysis
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Disease Authorisation
•
•
•
•
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•
Procedures in doctor’s rooms instead of hospitalisation
Physical rehabilitation care in rehabilitation facilities
Drug and alcohol rehabilitation care in specific facilities
Hospice admissions
Oxygen therapy at home
All specialised radiology
What happens in the case of an emergency treatment/admission to hospital over a
weekend, public holiday or at night?
Failure to obtain pre-authorisation for a planned event or authorisation on the first working
day after an emergency event will mean that you are liable for the full account according to
the rules of the Scheme.
Will I receive any communication about my pre-authorisation?
You will receive a letter confirming your pre-authorisation by email or post. This letter
contains a number of disclaimers printed at the end. Please make sure you take note of these
disclaimers as they reflect the Scheme rules. If you are unclear, please discuss the disclaimers
with your treating doctor.
Why are some requests for pre-authorisation declined?
Specialist referrals
Some of the pre-authorisation requests may be declined if:
Your GP should be the first person to advise you about your healthcare needs. Not only does
your GP understand your illness, but he/she also knows which type of specialist is best for you
to see. The GP will assist you in consulting with the right specialist should you need to, saving
you both time and money.
• The planned procedure is not covered by your benefit option as specified in the Scheme
rules.
• The planned procedure is not in line with the acceptable treatment standards for a
particular medical condition.
• The appropriate clinical information has not been received.
• The membership is inactive or similar issues with membership status.
Case Management
While you are in hospital, case managers ensure that appropriate care is provided at all times
and that appropriate discharge planning takes place where clinically indicated and where
benefits are available. This takes place according to the Scheme rules, clinical protocols and
funding guidelines.
When extended length of stay or level of care is requested, the case manager will request
supporting information to be able to make an informed clinical decision. If there is any doubt
at all, a medical advisor will assist and motivation might be requested from your treating
provider, if needed. All changes in initial approvals are communicated to the hospital and
treating provider. With long-term cases, your family members may also be involved.
You will also need to keep note of:
• The unique pre-authorisation number
• The initial approved length of stay
• The status of all the codes
What happens if I have to stay in hospital for longer than the initial approved length of stay?
Ensure that your doctor, the hospital case manager or a family member emails
[email protected] to inform the case management department of the extended
length of stay. If there is a clinical reason for the stay, your Fund will approve the extra days. If
not, you will be liable for the costs of the non-approved days and treatment.
Networks
GP (General Practitioners) Network
Bonitas offers the largest GP network in South Africa, providing you with access to over 7 000
GPs countrywide. We’ve negotiated special rates with these GPs to ensure that you won’t have
any co-payments and that your benefits last longer. Members on the Standard and Primary
options are advised to use the Bonitas GP Network for all their GP visits.
Members on the Standard Select option will be required to nominate their GP per beneficiary
from our network on the application form or contact the call centre.
Do co-payments still apply on procedures performed in-hospital?
How do I find a doctor on the Bonitas GP Network
Any procedure that is stipulated in the Scheme rules as attracting a co-payment will still
attract a co-payment whilst in-hospital. Your diagnosis or treatment plan will not change this.
• Call us on 0861 002 108 or use the ‘Find a doctor’ tool on our website - www.bonitas.co.za
or use the SMS locator facility.
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Please remind your GP to call the call centre to obtain an automated specialist referral
authorisation number, via the IVR (Interactive Voice Response) system. On BonClassic,
Standard, Standard Select, Primary and BonFit, female members may visit the gynaecologist
once a year without referral. Members may also visit the ophthalmologist and oncologist
without referral.
Specialist Network
At Bonitas, we constantly strive to give you access to affordable, quality healthcare. That’s
why we’ve partnered with various healthcare professionals to create the Bonitas Specialist
Network, which gives you access to over 2 000 specialists nationally.
If you are a member on the Standard, Standard Select, Primary, BonSave, BonClassic, BonFit
and BonEssential Options, the Specialist Network will provide you with access to specialist
services at a negotiated tariff for both in and out-of-hospital costs. The benefit of this
initiative will result in your claim being paid in full without you being responsible for any
shortfall.
If you have a Prescribed Minimum Benefit condition and your day-to-day benefit limits have
been exhausted, you can continue to consult with a specialist within the Bonitas Specialist
Network without incurring any co-payments. Services for these conditions will be subject to
the guidelines as contained within the Medical Schemes Act.
How do I find a specialist on the Bonitas Specialist Network?
Visit www.bonitas.co.za and use the provider locator tool.
Alternatively, call us on 0860 002 108 or email us at [email protected].
The Standard Select and BonFit Hospital Network
The Standard Select and BonFit options offers members access to the best quality private
hospitals on the extensive hospital network list.
Visit www.bonitas.co.za and use the hospital locator tool.
Alternatively, call us on 0860 002 108 or email us at [email protected].
Dental benefits
DENIS is a fully accredited managed care organisation that manages your dental benefits.
There is a pre-defined benefit per procedure, which is paid at the published Bonitas Dental
Rate (see www.denis.co.za for the list of dental rates).
Your dentist will also be able to provide information regarding your benefits, as DENIS supplies
all dentists with a Chair side & Benefit Guide, which illustrate the dental benefit management
methodology and benefits. Benefits for dentistry are paid on a fee for service basis. This
means that for every procedure done by a dentist, there is a fee that is charged. These fees
may differ from dentist to dentist. Your fund pays a benefit for each procedure, which may
differ from the fee charged by your dentist. It is your right to negotiate this difference with
your dentist.
Dental benefits are paid at the Bonitas Dental Tariff (BDT) and are dependent on the plan
you’re on.
Hospitalisation and certain specialised dentistry procedures and treatment must be preauthorised.
Please note:
• Procedures and treatment not pre-authorised will not attract a benefit, with the exception
of crown and bridge procedures where a 20% penalty will apply if authorisation is applied
for after the treatment has been done.
• A co-payment of R2 000 is applicable on all hospital admissions for dentistry on the
Standard, Standard Select, BonSave, Primary, Bonfit and BonEssential options.
• Failure to pre-authorise orthodontic treatment will result in payment only from the date
of authorisation for the remaining months of treatment, provided that the treatment is
clinically indicated.
• Penalties do not apply to emergency hospital admissions.
• Co-payments for Orthodontics are levied on the Standard and Standard Select Option.
• A benefit for Crown & Bridgework on the Standard & BonClassic Options is subject to a
DENIS Designated Service Provider Network.
• All conservative, out-of-hospital services on the BonCap Option are subject to a DENIS
Designated Service Provider Network.
• Dental benefits are subject to managed care protocols and interventions, which may
include the requirement of treatment plans and/or radiographs prior to benefit application.
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In this case, you must contact the pre-authorisation call centre on the first working day after
the incident.
Dental Wellness Program
As a Bonitas member, you are automatically a member of the Dental Wellness Program. You
will receive various treatment-related information leaflets and oral screenings, advice and
dental products will be provided at your company’s wellness days. Visit www.denis.co.za for
more information.
How do I find a DENIS Network Provider?
Visit www.denis.co.za and use the “find a dentist” tool.
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•
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Hospital practice number
Anaesthetist practice number
Treating clinician
Hospital admission date
Procedure code(s) with ICD10 code(s) and where relevant the applicable tooth numbers
Main complaint as to why the procedure is needed
If applicable, medical report of special medical conditions
X-rays are needed if a 54 practice applies for the removal of impactions
To pre-authorise the following specialised dental benefits, please use the relevant email
contact details:
Post the original copies of your dental claims to Private Bag X 1 Century City 7446, Cape Town
or email [email protected]
• Crown and bridge procedures – Email [email protected]
• Orthodontics – Email [email protected]
• Implants – Email [email protected]
Please ensure the following details are clearly visible:
Alternatively, you can fax the details to 0866 770 336.
•
•
•
•
•
•
•
For more details on the pre-authorisation requirements for the above-mentioned
specialised dental benefits, please visit www.denis.co.za
Your membership number
The dentist’s details and practice registration number
The correct dependant name and code (see your membership card)
The treatment date
The relevant procedure codes
The tooth numbers (if applicable)
The relevant ICD-10 codes
The Periodontal Program
This benefit is only available to those members on the Standard, Standard Select, BonClassic
and BonComprehensive Options.
How do I apply to the Periodontal Program?
Which specialised dental benefits need to be pre-authorised?
•
•
•
•
•
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Crown and bridge procedures
Orthodontics
Implants
Hospitalisation
Intravenous Conscious Sedation
Periodontics
How do I get pre-authorisation for these specialised dental procedures?
To pre-authorise dental procedures in hospital or under IV Conscious Sedation, please call
0860 336 346.
Please have the following information on hand:
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Submit your CPITN score (supplied to you by your dental practitioner), together with your
Periodontal treatment plan to [email protected], or alternatively, fax it to 0866 770 336.
Once authorisation has been obtained, cover for the treatment is subject to Scheme rules,
exclusions and benefit protocols.
What happens if my procedure is not pre-authorised?
• Procedures and treatment not pre-authorised will not attract a benefit and thus not be paid
by the Scheme, with the exception of crown and bridge procedures where a 20% penalty
will apply if authorisation is applied for after the treatment has been done.
• Failure to pre-authorise orthodontic treatment will result in payment only from the date
of authorisation for the remaining months of treatment, provided that the treatment is
clinically indicated.
• Penalties do not apply to emergency hospital admissions. Co-payments for Orthodontics
are levied on the Standard and Standard Select options.
How do I find an Iso-Leso Optical Provider?
If you have any questions regarding your nearest Iso-Leso Provider, you can contact Iso-Leso at
the following contact details.
Contact details:
Contact details:
Call:0860 336 346
Fax:0866 770 336
Email:[email protected]
Claims: [email protected]
Hospital authorisations: [email protected]
Orthodontic and implant authorisations:
[email protected]
Crown and bridge authorisations:
[email protected]
Periodontal authorisations:
[email protected]
Optical benefits
Your optical benefits depend on the plan you have chosen.
Our preferred provider for optical benefits is Iso-Leso. Their respected national network of
optometric practices has a reputation for delivering high quality service and products to
its patients and members of medical Schemes. They offer medical aid members substantial
savings on clear single vision, bifocal and multifocal quality spectacle lenses. Their mission is
to ensure the viability and stability of the optometric environment for all role players.
The Iso-Leso philosophy is to encourage participation of all registered optometrists in the
provision of optometric services. As the Iso-Leso provider base is diverse and includes private
practitioners, group practices and optometric franchisees, we have a fair representation of
the choices that Bonitas members face in seeking optometric care.
In addition, Iso-Leso has embarked on improving the quality of professional services with the
Practitioner Enhancement Program. This initiative is designed to accredit optometrists who
invest in their professional standards of practice.
This ultimately translates into a higher level of the quality of care for the Bonitas member.
Your available savings may be used for Optical benefits.
You can visit a non-network provider, however, your plan’s optical benefit is limited to the IsoLeso tariff. This means you may have to make a co-payment.
Call:
0860 10 30 50 / 60
Email:[email protected]
Each beneficiary is entitled the following benefit over a 24-month cycle commencing on 1
January 2015:
Either:
One consultation and, if the required prescription is not less than 0,50DS or 0,50DC or the
required reading addition is greater than 0,75DS
How do I submit claims to DENIS?
One pair single vision lenses or;
One pair flat top bifocal lenses or;
One pair multifocal lenses or;
A spectacle frame to the value of the specific benefit option
Or:
One consultation and contact lenses to the value of specific benefit option
Please note:
• Services not covered by the matrix are for the members’ portion and should be paid directly
to the practice, or can be refunded from available savings.
• Please note that claims older than 4 months from the date of service will not be accepted
for payment.
• The practice is not entitled to collect the unpaid portion for the above products from the
patient unless they are:
-- Lens enhancements and add-ons (tints, ARC etc.)
-- The difference on the frame value over the specific plan maximum benefit
-- The difference on the contact lens value over the specific plan maximum benefit
• All tariffs are inclusive of VAT.
• Mobile Practice claims will only be paid if confirmation of registration as a mobile practice
by HPCSA is supplied.
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• Spectacle lens prescriptions must be included in both paper and electronic claims. Please
contact your service provider for assistance in this regard.
• Payment for materials will be declined under the following circumstances:
-- Where no script is indicated
-- Where no ICD 10 codes are indicated
-- Where the script is less than 0.50 D sphere or 0.50 D cylinder (with no sphere) in both
eyes in the case of spectacles
-- Invoices that do not comply with VAT legislation requirements
-- Where the claim is older than 4 months from the date of service
Bonitas Medical Fund has partnered with the Centre for Diabetes and Endocrinology to
provide excellent care to members with diabetes.
Eye screening (ophthalmologist), and foot screening (podiatrist) services are also important
components – these are made available by Bonitas via their normal funding mechanisms.
Your diabetes medication is important. The CDE, in conjunction with your treating doctor
and a CDE endocrinologist, will ensure that your diabetes prescription is optimized for your
diabetes treatment. Importantly, you will have your diabetes medication sent directly to you
by the Bonitas preferred provider, Pharmacy Direct. This valuable service makes it convenient
for you and ensures you always receive what you need for your diabetes care in a timeous
manner.
If you wish to remain with the doctor who is currently treating your diabetes, ask him / her to
contact the CDE central office in Houghton, Johannesburg. They will then provide information
and the doctor will be trained and accredited as a “preferred provider” within the “Centre for
Diabetes” network.
How do I join the CDE?
The CDE is a holistic, multi-specialist Diabetes Centre in Houghton, Johannesburg. The Centre
manages diabetes by using a team approach that includes diabetes specialists, diabetes
educators, a dietician, podiatrists, a clinical psychologist, as well as exercise specialists if
necessary. In addition, the Centre trains healthcare professionals in the principles and practice
of good diabetes care and acts as the central office for a nationwide network of over 240
affiliated “Centres for Diabetes”. These accredited centres are contracted to provide all the
benefits of the diabetes management program, which is a complete diabetes management
package.
Members on all options who have diabetes can join the Centre for Diabetes and Endocrinology
by:
The CDE has won numerous awards over the last 20 years for their excellence and they are
acknowledged as world-class providers of diabetes care. Join now to optimise your diabetes
health!
There is no joining fee and no charge for your diabetes care services.
The CDE program includes:
• consultations with a doctor who has received further training in diabetes management (a
minimum of two per year)
• diabetes education to supplement your knowledge in diabetes and to enable you to “selfmanage” your diabetes more effectively
• annual consultations with a registered dietician
• access to the best and most appropriate medicines for diabetes
• a diabetes 24 hour emergency hotline
• a diabetes specialist (endocrinologist) supporting your treating doctor regarding your
treatment as well as care support from a CDE case manager.
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• Calling them on 011 053 4400 to join the program.
• Asking your doctor to refer you to the nearest CDE Centre where you can register on the
program.
How much does it cost?
If your Bonitas GP Network doctor is not a CDE accredited doctor, they are still able to
participate. This means that you should be able to stay with your current Bonitas GP network
doctor if you wish. The CDE will facilitate this if required.
Contact details:
Tel:
Fax:
Email:
Website:
(011) 053 4400
(011) 728 6661
[email protected]
www.cdediabetes.co.za
Hip and Knee Replacement Program
ICPS (Improved Clinical Pathway Services) is a group of orthopaedic surgeons that specialise
in performing hip and knee replacements according to standardised clinical care pathways.
These care pathways have been developed in accordance with evidence based outcomes to
ensure that the quality of the hip and/or knee replacement is of highest standard and to
ensure the best health outcomes.
ICPS uses a multidisciplinary team dedicated to assist with rapid and successful recovery and
keeping the patient as comfortable as possible during the healing period.
How to access and orthopaedic surgeon on the ICPS program
Call the Bonitas call centre on 0860 00 2108 where you will be given the details of an ICPS
orthopaedic surgeon closest to you.
Following your consultation with the ICPS orthopaedic surgeon and if the decision for surgery
is made, an application for an authorisation number will be arranged on your behalf by the
admin staff of the practice. This will allow you access to the ICPS program and ensure payment
in full (subject to your prosthesis benefit) with no co-payment for the procedure. The ICPs
surgeon will give you a booklet providing you with information on the ICPS program.
The program is applicable to all members on the Bonitas Standard, Standard Select and
BonClassic options.
ICPS will assist with your hospital pre-authorisation should an operation be required. To
alleviate the admin burden of submitting accounts, ICPS will submit one account to Bonitas for
payment which will include:
•
•
•
•
All hospital costs
Surgeons and anaesthetist fees
Prosthesis (subject to prosthesis benefit)
Physiotherapist (pre-, intra-, and post-operative)
Should you choose not to use an ICPS orthopaedic surgeon and are admitted for hip or knee
surgery you will be liable for a R5 000 co-payment on admission to the hospital. If you are on
the Standard Select option you are only allowed to use ICPS facilities.
The program has been established to assist you in taking an active part in planning your care
and recovery for hip or knee surgery as well as ensuring financial peace of mind.
HIV/Aids Management
South Africa’s leader in HIV/Aids management and care, Aid for AIDS is a revolutionary,
integrated approach to HIV/Aids management that has been delivering excellence since 1998.
Our approach is to act as a care-coordinator between the funder, doctors, pathology labs,
pharmacies and patients. Supported by a team of worldwide-respected clinicians in their
field. Backed by a custom IT system that has become the gold standard in HIV/Aids disease
management and we enable the optimal care of patients with an end-to-end solution.
Our program is designed to meet the needs of patients and equip them with the treatment
and tools to lead normal, fulfilled lives. We empower funders to guard against the financial risk
posed by unmanaged HIV/Aids in their employee or member populations. Shaped over years
of clinical research and expertise, our methods are considered as the industry standard by
healthcare professionals globally.
It is very important to register on the program as soon as you know your status.
Diabetic Program
Your plan has a benefit amount specifically for HIV/Aids-related medication. This benefit
amount is used to pay for:
• Antiretroviral therapy (ART)
• Medication to protect you against illnesses such as TB and flu
• Regular monitoring tests
Aid for AIDS offers a complete HIV/Aids disease management program to both members and
beneficiaries:
• Medication to treat HIV (including drugs to prevent mother-to-child transmission and
infection after sexual assault or needle-stick injury) at the most appropriate time
• Treatment to prevent opportunistic infections like certain serious pneumonias and TB
• Regular monitoring of disease progression and response to therapy
• Regular monitoring tests to detect possible side-effects of treatment
• Ongoing patient support via a team of trained and experienced counsellors
• Clinical guidelines and telephonic support for doctors
• Help in finding a registered counsellor for face-to-face emotional support
Even if you do not need ART because it is still too early, it is important to register on the
program in order to have access to all the other benefits that will assist in keeping you healthy.
Strict confidentiality
Every effort is made to keep members’ HIV status confidential. The staff members at our Aid
for AIDS unit have all signed confidentiality agreements and work in a dedicated unit. They
Page 68
use separate telephone, fax, email and private mailbag facilities. Patients need to use these
facilities to maintain confidentiality.
How do I register with Aid for AIDS?
If you are HIV-positive, you must register with Aid for AIDS as soon as possible in order to make
use of this benefit.
What happens after I have registered?
A highly qualified medical team will check your medical details and, if necessary, discuss
cost-effective and appropriate treatment with your treating doctor. Once treatment has been
agreed upon, you and your doctor will be sent a detailed treatment plan, which explains the
approved medicine, as well as the regular tests that need to be done to ensure that the drugs
are working correctly and safely.
Contact details:
Call:
Fax:
Email:
Website:
Mobi-site:
Please call me:
0860 100 646
0800 600 773
[email protected]
www.aidforaids.co.za
www.aidforaids.mobi
083 410 9078
ER24 is the designated service provider for all emergency medical services for Bonitas
members and their registered dependants.
This benefit includes:
• Emergency medical response by road or air to the scene of the medical emergency
Page 69
•
•
•
•
•
•
Transfer to the closest appropriate medical facility by road or air
Inter-hospital transfers (subject to authorisation) in accordance with Scheme rules
Medical information and assistance hotline
Trauma counseling and referral to appropriate healthcare professionals as required
Member/dependant validation
Medical information and assistance hotline where trained personnel provide trauma
counseling, medical advice in emergencies and HIV counseling
What do I need to do in the case of a medical emergency?
•
•
•
•
•
Call 084 124
Provide your name and the telephone number you are calling from
Provide a brief description of the incident and the severity thereof
Provide the address/location (road name, number and nearest crossroad)
Do not hang up until ER24 has all the details
Please note: When you join Bonitas, you will receive specially designed ER24 car stickers.
Please ensure that these are attached to your vehicle as described in the letter sent with the
stickers.
If you use another service provider, a 40% co-payment will apply. Ensure that ER24 is informed
of this and that the account is submitted to [email protected] no later than 30 days after the
date of service.
Exclusion list
Certain holistic procedures
• Aromatherapy
• Art therapy
• Ayurvedics
• Herbalists
• Iridology
• Reflexology
• Sleep therapy
• Therapeutic Massage Therapy
Appliances, devices and procedures not scientifically proven
• Back rests and chair seats
• Bandages and dressings (except medicated dressings)
• Cardiac assist devices – e.g. Berlin Heart
• Diagnostic kits, agents and appliances unless otherwise stated (except for diabetic
accessories)
• Humidifiers, ionisers and air purifiers
• Orthopaedic shoes and boots
• Pain relieving machines, stethoscopes and blood pressure monitors
• Oxygen hire or purchase, unless authorized
• Portable oxygen cylinders and Portable oxygen concentrators
Specific reproductive technology and procedures
• Medical and surgical treatment for infertility
• 3D and 4D maternity scans
• Anabolic steroids and immuno stimulants unless Prescribed Minimum Benefits
• Contraceptives (including oral, parenteral, foams and IUCDs)
• Erectile dysfunction and loss of libido treatment (medical or surgical)
• Gender reassignment medical or surgical treatment
Cosmetic procedures and items
• Breast augmentation
• Breast reconstruction - unless mastectomy following cancer and pre-authorised
• Cosmetic items such as moisturisers, sunscreen and shampoos, except for the treatment of lice,
scabies and other microbial infections and coal tar products for the treatment of psoriasis
• Epilation
• Electric toothbrushes
• Cosmetic effect contact lenses
• Contact lens accessories and solutions
• Keloid surgery and revision of scars except for functional impairment
• Optical devices which are not regarded by the relevant managed healthcare program, as clinically
essential or clinically desirable, except on BonSave and BonComprehensive Options
• Rhinoplasties for cosmetic purposes
• Sunglasses
Dentistry
• Appointments not kept
• Behavior management
• Caries susceptibility and microbiological tests
• Cost of Mineral Trioxide
• Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments
• Crown and bridge procedures for cosmetic reasons and associated laboratory costs
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Crowns or crown retainers on wisdom teeth (3rd molars)
Dental bleaching
Dental testimony including Dento-legal fees
Diagnostic dentures and associated laboratory costs
Direct and indirect pulp capping procedures
Dolder bars and associated abutments on implants including the associated laboratory
costs
Electrognathographic recordings, pantographic recordings and other such electronic
analyses
Emergency crowns that are not placed for the immediate protection in tooth injury and
Enamel micro abrasion
Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and
fluorosis
Fissure sealants on patients 16 years and older
Full mouth rehabilitations and associated laboratory costs
Gold foil restorations
High impact acrylic
Implants on wisdom teeth (3rd molars)
Intramuscular or subcutaneous injection
Invisible retainer material
Multiple hospital admissions
Nutritional and tobacco counseling
Oral hygiene evaluation and/or instructions
Orthodontic re-treatment and any related Laboratory costs
Orthognathic (jaw correction) and other orthodontic related surgery and any related
Hospital cost including associated Laboratory costs
Ozone therapy
Perio chip placement
Pontics on 2nd molars
Porcelain veneers and inlays and associated laboratory costs
Procedures that are defined as unusual circumstances and procedures that are defined as
unlisted procedures
Professionally applied fluoride for beneficiaries 16 years and older
Provisional crowns and associated laboratory costs
Provisional dentures and associated laboratory costs
Pulp tests
Resin bonding for restorations that are charged as a separate procedure to the restoration
Root canal therapy on primary (milk) teeth and on wisdom teeth (3rd molars)
Snoring appliances and associated laboratory costs
Special reports
• Call 0860 100 646 and ask for an application form. All calls are strictly confidential.
• You may also pre-register yourself on the program where you will receive guidance on how
to continue on the program to receive the benefit.
• You and your doctor must complete the application form and return it to Aid for AIDS by
using the confidential, toll-free fax-line number on the form or via email.
Page 70
Dietary and nutritional supplements
• Food and nutritional supplements including baby food and special milk preparations unless
prescribed for life-threatening malabsorption disorders and if registered on the relevant
managed healthcare program
• Slimming preparations for obesity
• Smoking cessation and anti-smoking preparations, except for benefits paid from
wellness extender
• Tonics, multi-vitamins, supplements and mineral combinations (except for registered
products that include haemotonics and those for use by infants and pregnant mothers)
Medical and clinical protocols
• All benefits for clinical trials unless pre-authorised by the relevant managed healthcare
program
• Appointments which a beneficiary fails to keep
• Autopsies
• Balloon Sinuplasty on Primary, BonEssential, BonClassic and BonSave Options
• Bilateral gynaecomastia
• Bone densitometry performed by a GP or specialist not included in the Scheme credential list
• Carmustine Wafers for the treatment of malignant Gliomas
• Chiropractor benefits in hospital
• Cryo-storage of fetal stem cells and sperm
• CT colonography for screening
• Genioplasties as an isolated procedure
• Holidays for recuperative purposes
• Hyperbaric oxygen therapy (except for anaerobic life-threatening infections, Diagnosis
Treatment Pairs 277S and specific conditions pre-authorised by the relevant managed
healthcare program)
• MDCT Coronary Angiography for screening
• Medicines used specifically to treat alcohol and drug addiction, unless it is a PMB
• MRI scans ordered by a GP, unless there is no reasonable access to a relevant specialist
• Organ and bone marrow donations to a person who is not a member or dependant on Bonitas
• Otoplasties
Page 71
• Pectus excavatum / carinatum
• Positron Emission Tomography, except on BonComprehensive and PET plus PET-CT for
screening on all options
• Robotic assisted surgery
• Screening that has not been pre-authorised or is not in accordance with the Scheme’s protocols
• Specialised radiology procedures where pre-authorisation is not made or declined
• Surgical treatment for obesity (excluding certain bariatric surgical procedures performed
for life threatening morbid obesity by a multidisciplinary team in accordance with an
agreed protocol in a credentialed centre of excellence when pre- authorised, but not
including post-operative plastic and reconstructive surgery)
• Uvulo-palatal pharyngoplasty (UPPP and LAUP)
• X-rays performed by chiropractors
Termination of Bonitas membership
• Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue
grafting and the hemisection of a tooth
• The cost of dental materials for procedures performed under general anaesthesia
• The cost of gold, precious metal, semi-precious metal and platinum foil
• The metal base to full dentures and associated laboratory costs
• The polishing of restorations
• Where the only reason for admission to hospital is dental fear and anxiety
• Where the only reason for the admission request is for a sterile facility
Notes
Your membership will be terminated if you no longer pay your contributions. You may also
leave Bonitas after giving one calendar month’s written notice.
If you leave Bonitas and join a Scheme with a savings account, the full amount available in
your savings account will be transferred to that of your new Scheme. This will take place after
a waiting period of five months. If you do not join another medical Scheme, or if the medical
Scheme you are joining does not have a savings account, the full balance in your savings
account will be paid to you.
Please note: Your refund is taxable and must be declared in your annual income tax return. If
you leave Bonitas during the year, the savings amount due to you will be pro-rated according
to the number of months you were a member of Bonitas. If claims at that stage exceed the
pro-rated value, you will have to pay the shortfall.
Page 72
Page 74
Page 73
Notes
Notes
How-To Guide
Use these helpful tips on how to get the most out of your Bonitas medical aid membership.
2. Check your account and receipt
Do you have a question for us?
Make sure that your membership number is clearly indicated on both the account and the
receipt.
Contact the call centre on 0860 002 108 or email [email protected]. Please include your
membership number in all correspondence with us.
How To:
Change your personal details
You must let us know if any of your details change within 30 days of the change. This includes
changes to:
• Your marital status
• Dependants on your medical aid
• Your contact details
•
•
•
•
•
•
•
Your name and initials
Your medical aid number
The treatment date
The name of the patient as shown on your membership card
The amount charged
The tariff
The ICD-10 code
Please check that prescriptions for medicine show all your details. Also check that the correct
amount of medicine dispensed is shown on the claim. If the pharmacy omits any of these
details, we will not be able to process your claim.
3. Send us a copy of the account and receipt
Change your banking details
Please post all claims to:
If your banking details change, please let us know immediately. If your medical aid is a
deduction on your salary you will also need to inform your employer’s payroll department
immediately. You will need to send us your latest bank statement and a copy of your ID to
validate the change.
Bonitas Claims Department
PO Box 74
Vereeniging, 1930
Submit claims in 4 easy steps
How-To Guide
Simply contact the call centre on 0860 002 108 or email the changes through to
[email protected]
Please ensure that your account shows the following:
Or email:
[email protected]
Submit your claims
4. Check that your claim has been paid
You must send us your claims within four months of receiving treatment or they will not be
paid. Submit claims quickly and easily by following these simple steps.
We pay claims weekly. A statement will be sent to you, by post or email at the end of the
month showing your claims. You can also log in to the website to view the status of your
claims.
1. Ensure your bank details are correct
Claims refunds are only paid into a bank account via electronic transfers. Please contact the
call centre on 0860 002 108 if you need to update your banking details.
Report fraud
Fraudulent use of membership cards (I.e. letting other people use your membership card) is
illegal. It results in increased costs that affect all members. Phone our toll-free fraud hotline
on 0860 002 108 to report cases of fraud or abuse of Bonitas.
Page 76
How-To Guide
Notes
Use the Bonitas website
How-To Guide
How-To Guide
If you have internet access, you will be able to log into a secure area to view your statements,
claims history, monthly contribution, personal information and much more. You will also be
able to view your benefits and update certain personal details. Visit www.bonitas.co.za and
follow the steps to register.
Page 77
Page 78
Visit one of our walk-in centres
Resolve queries; get a new membership card and so much more at our walk-in centres.
Pretoria
Northam
Port Elizabeth
Kathu
Ground Floor, Benstra
Building,473B Church
Street, Arcadia,
Pretoria
180 Botha Street,
Northam
Block 6, Greenacres
Office Park, 2nd
Avenue, Newton Park,
Port Elizabeth
6 Rietbok Street,
Kathu, Northern Cape
Vereeniging
Bloemfontein
Roodepoort
Polokwane
36 Merriman Avenue,
Ground Floor, Vereeniging
Shop C7, 1st Floor,
Middestad Centre,
c/o Charles and West
Burger Street,Bloemfontein
37 Conrad Road,
Florida North,
Roodepoort
Ground Floor, Bonitas
House, 22 Hans van
Rensburg Street,
Polokwane
Secunda
Rustenburg
Lephalale
Cape Town
Grand Palace, Unit 82,
2302 Heinis Street,
Secunda
141 Fatima Bhayat
Street,Rustenburg
Onverwacht Business,
Mienie Building, Block C,
Walter Sisulu Avenue,
Lephalale
The Icon Building, Ground
Floor, Corner Lower Long
Street andHans Strydom
Avenue,Cape Town
Durban
3rd Floor, 67 Old Fort
Road, Durban
CONTACT
Call our customer service team
on 0860 002 108
Available between 08:30am and 4:00pm, Monday to Friday the Bonitas
Call Centre is here to help you with everything you need.
You can:
•
•
•
•
Visit us online
Visit our website at to learn more about our products.
You can also join us on Facebook and get health tips,
benefit information and much more.
www.bonitas.co.za I www.facebook.co.za/BonitasMedicalFund
Get hospital and specialised radiology authorisation
Authorise chronic medicine
Get a tax certificate
Resolve queries
Page 80

2016 Bonitas Brochure Small

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