The NetworX Option

Overview

The NetworX option is an affordable healthcare plan with exceptional value for students and low income employees in the corporate sector, offering essential cover within the Universal Healthcare Provider Network.

YOU CAN LOOK FORWARD TO EXCEPTIONAL VALUE AND BENEFITS FROM NETWORX IN 2012

• We cover all your clinically necessary, essential day-to-day primary healthcare benefits e.g. unlimited GP visits, acute and chronic medication, basic radiology and basic pathology
• You receive basic dentistry and optometry benefits
• We offer cover for 27 chronic conditions
• You have access to wellness benefits including preventative screening for blood pressure, glucose, cholesterol, BMI and waist circumference as well as flu vaccinations
• You pay only for the first three child dependants – the rest are free!

Day-to-Day Benefits

Day-to-day services are subject to the utilisation of the Universal Network Designated Service Providers (DSPs). Services rendered by DSPs will be paid at the Agreed Tariff up to specified limits. Some benefits are subject to the Annual Flexi Benefit (AFB). The AFB will be pro-rated if you join later during the year.

Annual Flexi Benefit

Networx	Annual Flexi Benefit
Per beneficiary	R2 120
Per family	R3 180

Day-to-day services paid from the AFB

Benefits	Limits
Specialists	100% of Agreed Tariff (AT), paid from the AFB 2 visits per beneficiary, max 3 per family per annum. Two additional ante-natal visits per pregnancy.  Specialist visits are subject to referral by a DSP network GP, and pre-authorisation of each specialist visit.  Referrals limited to specialists located at DSP Network Hospitals only
Basic dentistry	100% of AT, paid from the AFB.  One consultation per beneficiary per annum. Preventative care, infection control, fillings, extractions and dental x-rays, subject to protocols and list of applicable dental codes. No benefit for out-of-network dental visits/procedures except for PMB emergencies
Specialised dentistry	100% of AT. No benefit unless PMB, subject to protocols.
Optometry	100% of AT, paid from the AFB.  Test -1 p/b every second year.  Lenses, frames and contact lenses - clear plastic single vision (limited to R640) or bi-focal lenses (limited to R800) every second year. No benefit for contact lenses, limited to a range of frames within DSP network
Hospital emergency room/casualty emergency visits (not requiring admissions excluding facility fees	100% of AT, paid from the AFB
GP consultations	100% of AT, unlimited, subject to clinical necessity. Each beneficiary must select a contracted Universal Provider network GP for day-to-day care. Two out-of-area visits per beneficiary per annum are available. Member required to pay the out-of-area provider in cash and claim back. Reimbursement at 80% of the cost of the claim to a maximum of R800 per event (i.e. for the GP consultation and all related costs)
Acute Medication	100% of AT, unlimited if prescribed by a DSP network GP, or by a specialist provided member referred by a DSP network GP. Subject to formulary. No cover for non-formulary medicines unless otherwise pre-authorised. No cover in cases of voluntary use of non-DSPs, or voluntary use of a specialist without referral by a DSP network GP
Specialised Radiology including MRI, CT and PET Scans	PMBs only, subject to pre-authorisation and case management within a DSP Network
Basic Radiology	100% of AT.  Unlimited when clinically appropriate within a DSP Network and subject to referral by a DSP network GP. Limited to list of codes. Subject to case management. No benefit if not referred by a network provider, or by a specialist following referral by a DSP network GP (except when involuntary)
Basic Pathology	100% of AT.  Unlimited when clinically appropriate within a DSP Network and subject to referral by a DSP network GP. Limited to list of codes. Subject to case management. No benefit if not referred by a network provider, or by a specialist following referral by a DSP network GP (except when involuntary)
Auxiliary services	No benefit unless PMB, PMB rules apply, subject to protocols
Clinical psychology	No benefit unless PMB, PMB rules apply, subject to protocols
Psychiatry	No benefit unless PMB, PMB rules apply, subject to protocols
Surgical and medical appliances	No benefit unless PMB, PMB rules apply, subject to protocols. No benefit for hearing aids

Wellness, lifestyle and preventative care benefits paid from risk

Benefits	Limits
Vaccinations
Flu vaccine	1 p/b per year, limited to R70
Lifestyle
Universal 360° check including cholesterol, glucose, blood pressure, BMI, waist circumference, exercise plan, meal plan	1 per year p/b over the age of 21 years, limited to R100 p/b at DSP

Other Benefits

Benefits	Limits
Emergency road-side assistance and ambulance transportation	Unlimited. Preferred Provider.

Exclusionss

The following in-hospital procedures are not covered on the NetworX option, unless it is a PMB:

Dentistry, back and neck surgery, hip and knee replacement, cochlear implants, auditory brain implants and internal nerve stimulators, Nissen fundoplication (reflux surgery), treatment for obesity, skin disorders and functional nasal problems, elective caesarean section, refractive eye surgery, brachytherapy for prostate cancer, fibreodenosis.

Cover for Chronic Conditions

The NetworX option offers extensive cover for 27 CDL conditions.

If you suffer from one of the chronic conditions on the list, you need to register with Mediscor in order to qualify for the chronic benefit.

Chronic medication is subject to the core formulary and the Universal Care Medicine Formulary (FRP). Chronic medication is unlimited, only if prescribed by a DSP network provider and dispensed within a network pharmacy or dispensing DSP doctor. Any voluntary use of chronic medicine prescribed by out-of-network providers and any non-formulary medicines are for the member’s own account, unless pre-authorised by the medical advisor. PMB rules apply.

In-hospital Benefitss

Benefits	Limits
Overall Annual Limit (OAL)	• PMB's unlimited. • Non PMB's limited to R270 000 p/b and R550 000 p/f
Private hospitals and nursing homes	100% of AT, subject to OAL pre-authorisation and private network of hospitals
TTO medication (take home medication)	Limited to 7 days supply, subject to OAL
GP and specialist cost	100% of AT, subject to OAL
Surgical prosthesis and electronic nuclear devices	PMB's. Subject to pre-authorisation and protocols and OAL
Radiology and Pathology	100% of AT, subject to OAL
MRI, CT Scans/PET scans	100% of AT, subject to OAL, pre-authorisation required
Physiotherapy in hospital	100% of AT, subject to OAL
Organ transplants, renal dialysis (includes transportation of the organ, surgically related procedures, professional fees and services, as well as immunosuppressant drugs)	100% of AT, subject to OAL, PMBs only, subject to pre-authorisation, protocols, and DSP
Sport injuries	100% of AT, subject to OAL, including professional sport
Emergency room/casualty	100% of AT, subject to OAL, for emergency medical conditions and injuries resulting from accidents or trauma

Alternatives to Hospitalisation

The NetworX option offers cover for step-down nursing facilities, Hospice and rehabilitation. Cover is subject to pre-authorisation, protocols and case management, and OAL.

Prescribed Minimum Benefits (PMB)

• Subject to Scheme protocols
• Hospitalisation – 100% AT at DSP, unlimited
• Medication – CDL conditions are unlimited subject to a formulary and dispensed by a DSP
• Medical management in and out of hospital – 100% AT, subject to protocols and treatment by DSP
• HIV/AIDS – subject to registration on HIV/AIDS programme, subject to protocols, failing which a R3 000 limit will apply

Contributions Table

Salary (Rand)	Principal	Adult	Child
0 - 500	R318	R318	R174
501 - 3 150	R420	R420	R246
3 151 - 5 250	R540	R540	R318
5 251 - 7 850	R708	R708	R408
7 851+	R1 572	R1 572	R564

Glossary

• AT - Agreed Tariff
• PMB - Prescribed Minimum Benefit
• AFB - Annual Flexi Benefit
• CDL - Chronic Disease List
• P/B - Per Beneficiary
• P/F - Per Family
• DSP - Designated Service Provider