EXPLORER 2012 BENEFIT SUMMARY

Issued 10/11

EXPLORER 2012 BENEFITS

IN-HOSPITAL BENEFITS
CATEGORY
Hospitalisation

LIMIT
R500 000 PMF unless PMBs apply at Designated Service Provider 100% of negotiated tariff

Benefit Parameters
Pre-authorisation required prior to admission. Including accommodation, medication, materials and operating theatres, failing which a co-payment of R500 per admission will be payable. Intensive care/ High care unit is limited to 15 days. Medicine on discharge (TTOs) R300 PB per event. Emergency transport only. Pre-authorisation required by phoning ER24 on 084 124 Pre-authorisation required prior to treatment. Private nursing and Step-down facilities. Consultations and Procedures. Pre-authorisation required prior to admission. Confinements including accommodation, medication, materials, anaesthetist, gynaecologist and pediatrician. No benefit Blood tests, x-rays, etc. Treatment in hospital only

Emergency Services Hospitalisation Alternatives GPs and Specialists Maternity In Hospital Dentistry Radiology and Pathology General Physiotheraphy Prosthesis (Surgical) To-Take-Out Medication (TTO)

Unlimited R12 500 PMF Included in Hospitalisation Limit Unlimited at Preferred Provider only Included in Hospitalisation Limit. Unlimited at Preferred Provider only Included in Hospitalisation Limit. No benefit Unlimited at Preferred Provider only Included in Hospitalisation Limit. Preferred Provider only Included in Hospitalisation Limit. No benefit R300 PB per event Included in Hospitalisation Limit.

Subject to formulary.

MAJOR MEDICAL EXPENSES

CATEGORY
Appliances Chronic Medication

LIMIT
R3 675 PMF at Preferred Provider only Unlimited at Preferred Provider only

Benefit Parameters
Including wheelchairs, oxygen and cylinders. Pre-authorisation required and only if part of in hospital treatment. Subject to Pre-authorisation, formulary and compliance with Preferred Provider Disease Management Programme. Pre-authorisation / case treatment management required. All services In-and-Out of hospital, including medication and chemicals. Subject to PMBs. Subject to enrolment and compliance with Prime Cure HIV/AIDS Programme. Pre-authorisation and enrolment on the Programme required. All services In-and-Out of hospital including medication and chemicals. Includes Specialised Radiology (MRI, CT Scan) In-and-Out of hospital at Preferred Provider only. Included in Hospitalisation Limit. Services rendered in hospital, Subject to Hospitalisation Limit.

Dialysis

Unlimited at Preferred Provider only Subject to PMBs Unlimited R23 100 PMF at Preferred Provider only Benefits Pre-authorised through ICON 2 Scans PMF R10 000 PMF

HIV/AIDS Oncology

Specialised Radiology & Pathology In-hospital Referred by Specialist

PB = Per Beneficiary

PMF = Per Member Family

This information is a guide only and does not replace the rules of the Scheme. In the event of any discrepancy between the summary and the rules, the rules will prevail. All benefits are covered at the Suremed Scheme Tariff based on the National Health Reference Price List (NHRPL) unless otherwise stated. All benefits are annualised unless specified and pro-rated according to joining date.

DAY-TO-DAY EXPENSES
CATEGORY
Acute Medication

Subject to category limits and use of Preferred Providers only (Prime Cure accredited)

LIMIT
Unlimited if prescribed by nominated provider

Benefit Parameters
In accordance with Prime Cure acute medication formulary. Acute medication prescribed by a specialist out of hospital no benefit. Non-formulary medication not covered.

Chronic medication Dentistry General Dentistry Specialised Dentures

Unlimited if prescribed by nominated provider Chronic Disease List conditions only. In accordance with Prime Cure medication Subject to registration through Prime Cure formulary. Unlimited through Prime Cure provider No benefit Benefits through Prime Cure dentist 1 set of Acrylic dentures PMF per 24 month cycle 1 PB per year Authorisation required : 0861 665 665 Members over 21 only. Prime cure approved list of codes. Paid at 80% upon proof of payment of 20% member levy. Submit claims to Prime Cure. Emergency pain and sepsis treatment and extractions only. Prime Cure approved dental codes. One consultation PB per year.

Emergency Dental Visit GPs

Unlimited at nominated Prime Cure provider Beneficiaries to nominate a provider.Visits to be pre-authorised from 7th visit. 2 Doctor changes PB in accordance with Prime Cure protocol per year. Out of network visits. 1 PB / 2 PMF Limited Beneficiaries may only see one GP at a time to R700 per event paid at 80%. Member to pay and claim back. Emergency medical conditions only* 1 PB per year 8 visits PMF Member to pay and claim back. Pre-authorisation required with 72 hours after the visit. Flu injections. At Prime Cure provider or Prime Cure pharmacy only. Upon referral from nominated provider. Pre-Authorisation required through PROVIDENCE 0860 08 08 88 or (041) 395 4545 2 x 2D scans per pregnancy 1 Eye test PB per year. Frame from selected range. 1 Pair of spectacles PB per 24 month cycle. Contact Lenses no benefit. In accordance with Prime Cure Radiology and Pathology approved list of codes.

Emergency Visits Immunization Specialists Maternity Optometry

Unlimited at Prime Cure provider Unlimited at Prime Cure Optometrist

Radiology and Pathology

Unlimited. On referral from your nominated provider only

* Emergency medical condition : the sudden, and at the time unexpected, onset of a life-threatening health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily part of organ or part, or would place the persons life in serious jeopardy.

PB = Per Beneficiary

PMF = Per Member Family

At Suremed Health our focus is on providing our members with clinical and financial solutions to ensure that you receive the most efficient and cost effective medical care possible. To make the task of clearly understanding the procedures and benefits as easy as possible we have selected a number of very important pieces of information which you should read through and keep on hand for easy reference. ABOUT SUREMED EXPLORER

If there is any aspect you do not understand please refer to your broker or to the schemes administrators.We would like to ensure that your association with the scheme is a long, healthy and pleasant experience.

Suremed Health Explorer is a unique plan which answers the call for medical aid cover and offers cover for both in-hospital and primary healthcare benefits. The Suremed Health Explorer Plan delivers these services through a network of accredited Prime Cure Medical Centres, doctors and preferred provider hospitals. A list of the current network providers can be obtained from Primecure, (Tel: 086 166 5665, Website: www.primecure.co.za), the Administrator PROVIDENCE Healthcare Risk Managers (PROVIDENCE), or your broker.

GENERAL INFORMATION

WAITING PERIODS
Please take note of your benefit date as indicated on your membership card. This is the date from which you qualify for benefits from Suremed Health. This may well differ from your joining date which is the date from when your contributions are due.

TERMINATION OF MEMBERSHIP
Members are advised that unless they terminate their membership in writing, before the last working day of the month, prior to the month of termination, they will remain liable for the contributions. Therefore it is in your best interest to confirm that such termination has been received by the scheme and acknowledged. The notice period required is contained in the Schemes rules.

MEMBERSHIP
Please ensure that your details and those of your dependants listed on your membership card are correct. Should you require any amendments to your card, contact your broker or PROVIDENCE Healthcare Risk Managers (PROVIDENCE) for the relevant form. Where a child is born, the contributions for membership will be due from the first day of the following month in which the child is born. The same procedure will apply in the case of an adopted child. Students studying at a recognised institution may continue membership to the age of 25 as a child dependant, provided that documentation certifying their age and status is produced each year. All other children over the age of 21 may remain on the scheme if financial dependency is proved for support from the main member, but will be charged at the same rate as an adult dependant.

WEBSITE

The Suremed Health website provides a number of features. Please log on to www.suremedhealth.co.za for more information

HOW DO YOU CLAIM?

Please submit all Day-to-Day claims (non-specialised) to: Central Office: Prime Cure Centurion 128 Oak Avenue, Highveld Technopark, Centurion Tel: Fax: Email: 012 665 8500 012 665 8604 Info@PrimeCure.co.za Private Bag X141 Centurion 0046

USEFUL TIPS TO REMEMBER

When you need to see a Prime Cure Practitioner: If you make an appointment at your selected Provider, you are less likely to queue for service.You will need to show your medical scheme card AND your ID book. Remember to always take both with you. When you need to see a Specialist Doctor: You will need a referral and authorisation from your PROVIDENCE Office: 0860 08 08 88

Please submit all Hospital, Specialists, Specialised Radiology and Pathology claims to: PROVIDENCE: PROVIDENCE Health Care Risk Managers P O Box 1672, Port Elizabeth, 6000 Customer Care: 086 008 0888 or 041 395 4545

IMPORTANT: You need to submit your claim within a four month period - starting from the date of treatment. It is YOUR responsibility to ensure that your doctor / service provider submits the claim in time with the correct information reflected. The best way of checking is to refer to your claims statement or the Suremed Health website.

VITAL INFORMATION
Following are a few important quick references relating to the Suremed Health Explorer Option and the services provided.

SCHEME ADMINISTRATOR
Suremed Healths administration is contracted to PROVIDENCE Healthcare Risk Managers. The staff and management team at PROVIDENCE have extensive experience in the industry. The procedures and systems offered by our administrator not only comply with the required financial management and reporting standards, as prescribed by the Registrars office, but are also geared to offer the information and high service support requirements of the scheme on behalf of its service providers and members alike.

PROVIDENCE CUSTOMER CARE - 0860 08 08 88 or (041) 395 4545

HIV and AIDS MANAGEMENT PROGRAMME

This programme covers comprehensive HIV and AIDS Management including HIV testing and staging, anti-retroviral and opportunistic infections preventive medication, laboratory tests and counselling and support. Confidentiality is guaranteed. In order to access your benefits you must register through a Prime Cure Provider and comply with the Disease Management Plan. If you have any query related to the HIV and AIDS programme or need to identify a Prime Cure provider in your area, call 0861 66 56 65 option 7.

PRIME CURE HIV/AIDS MANAGEMENT PROGRAMME: 0861 66 56 65

DAY-TO-DAY BENEFITS
The Preferred Provider for primary healthcare benefits is Prime Cure.You and your registered dependants have immediate access to all of these benefits through the accredited Prime Cure network of providers. Besides offering quality healthcare, these providers offer the following additional advantages: No limits through your nominated General Practitioner No accounts Primary healthcare services rendered outside of the accredited Prime Cure Providers, will not be covered by Suremed Health, except in the event of an emergency (see Emergency Benefit) and you will need to pay for the service yourself and then claim back from Prime Cure. A list of the Prime Cure network of providers is available from their call centre on 0861 66 56 65 (www.primecure.co.za) or PROVIDENCE customer care centre on 0860 08 08 88.

EMERGENCY AFTER-HOURS BENEFITS

In the event that you require emergency medical assistance after-hours or when you are away from home, you will be entitled to services to a maximum of R700 per event, with an overall annual limit of 1 event per beneficiary to a maximum of 2 events per family. A 20% co-payment per event will be applicable. You will be required to pay up-front and submit the detailed account and proof of payment to Prime Cure for a refund (80% of the approved tariff).

PRIME CURE CUSTOMER CARE: 0861 66 56 65

SECONDARY AND SPECIALIST CONSULTATIONS

A benefit of 8 visits per family is available in respect of out-of-hospital specialist consultations.You will be referred to a specialist by your nominated provider only when clinically indicated and subject to authorisation by Suremed Health. Please note that only visits authorised by the PROVIDENCEs office (0860 08 08 88 or 041 395 4545) will be considered for this benefit. Services not authorised by PROVIDENCE or not referred by your nominated provider will not be funded and will be for your own account.

PROVIDENCE CUSTOMER CARE - 0860 08 08 88

EMERGENCY SERVICES - ER24

Suremed Health offers you the nation-wide services of the ER24 emergency medical service, providing full cover for you and all of your registered dependants. With a 24-hour communication centre, staffed by a team of qualified nursing sisters, paramedics and registered doctors, you are guaranteed the best in the emergency support. Once the initial call is made, ER24 will assess your medical condition and, if necessary, dispatch the appropriate vehicle (ground or air), staff and equipment directly to your location. They will transport and arrange admission to the nearest hospital. This service only applies to emergency situations. If you make use of a different service provider in the case of an emergency, please notify ER24 within 48 hours. Upon hospitalisation, please inform the hospital of this preferred arrangement with ER24, in case of a transfer between hospitals.

MEDICAL EMERGENCY TRANSPORT CALL 084 124

HOSPITAL BENEFIT MANAGEMENT
WHAT IS HOSPITAL PRE-AUTHORISATION?
In the unfortunate event of hospitalisation, you will be required to obtain authorisation from PROVIDENCE before you are admitted. If you are unsure whether the procedure you will be undergoing requires pre-authorisation, please verify with PROVIDENCE.

HOW DO YOU OBTAIN PRE-AUTHORISATION?

Phone the Clinical Risk Management team on 0860 08 08 88 or (041) 395 4545

INFORMATION YOU MUST HAVE READY FOR PRE-AUTHORISATION

Patients membership number The patients full name, age and dependant number Surname and initials of the attending doctor (plus practice number if available) Date and time of admission to hospital The reason for admission to hospital The associated medical diagnosis The planned procedures as well as the tariff codes that the doctor intends to use Your doctor will assist in providing the above information.

WHAT HAPPENS IF YOU STAY LONGER IN HOSPITAL THAN THE INITIAL APPROVED LENGTH OF STAY?
Should you require extra days in hospital, your doctor or the hospitals case manager must inform PROVIDENCE immediately to ensure continued benefits. If there is a clinical reason for the stay, PROVIDENCE will approve the extra days, subject to benefit parameters. It is important to remember that there must be a clinical indication or medical reason for the extra stay.

WHAT HAPPENS IN THE EVENT OF AN EMERGENCY HOSPITAL ADMISSION?

Should pre-authorisation not be obtained, there will be a co-payment of R500. In the event of an emergency, admission over a weekend, or on a public holiday, PROVIDENCE must be notified of admission to hospital on the first working day.

HOSPITAL PRE-AUTHORISATION: 0860 08 08 88 or (041) 395 4545

CHRONIC MEDICATION
All chronic medication is subject to a registration process by a Prime Cure contracted network GP. After the GP has diagnosed the member with a chronic illness, the practitioner can register the members chronic medication by faxing the completed chronic application form to 0866-764-374. Some chronic medication needs to be registered from the first dispensing. This medication would require additional information like a lipogram or lab results in order for the medication to be approved. Most of the chronic medication that does not require additional information can be obtained on the acute benefit for the first dispensing until the registration process is completed. After completion of the application process you can obtain your first months chronic medication at a selected pharmacy on the Prime Cure pharmacy network (including Clicks, MediRite,Virtual Care, Dischem or Medipost Courier Pharmacies). Therafter, the member will have the choice of either obtaining chronic medication on a monthly basis from the network pharmacy, or from a courier pharmacy who will deliver the medication to your local post office or your network doctor.

WHAT IS A FORMULARY?
A further cost management feature on acute and chronic medication, is the utilisation of a formulary which is an approved list of medication for which the scheme is prepared to pay. Please note that these cost-containment initiatives, which have been approved by a team of highly qualified medical experts, in no way affect the well-being of our members and their families but rather are implemented to ensure that benefits are more efficiently utilised. If all our members use their benefits wisely, the Scheme will continue to grow and be in an ever-improving position to deliver the value-for-money as it does at present.

CHRONIC DISEASE LISTING

Chronic medication for the following disease listing are considered as Prescribed Minimum Benefits (PMBs) and referred to as Chronic Disease Listing (CDL) in your benefit summary. Addisons Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy Chronic Obstructive Pulmonary Disorder Chronic Renal Failure Coronary Artery Disease Crohns Disease Diabetes Insipidus Diabetes Mellitus Type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinsons Disease Rheumatoid Arthritis Schizophrenia Systematic Lupus Erythematosis Ulcerative Colitis HIV/AIDS

The Scheme pays for this medication in accordance with the Formulary. Chronic medication for ailments not on the CDL is covered by your generous acute medication benefit in accordance with the Acute Medication formulary.

PRESCRIBED MINIMUM BENEFITS (PMBs)

WHAT ARE PMBs?
PMBs are a set of defined benefits in the Medical Schemes Act (The Act) aimed at ensuring that all medical scheme members have access to certain minimum health services. They ensure cover for costs related to the diagnosis, treatment and care of: Any medical condition which meets the Acts definition of an emergency, a limited set of 270 medical conditions and 26 chronic conditions defined in the Chronic Disease Listing (CDL).

ARE THERE ANY LIMITATIONS THAT CAN BE APPLIED TO PMBs?

Although no limit can be applied to the management of PMBs, a medical scheme can manage the costs of PMBs with certain mechanisms: Schemes can ensure the provision of services for PMBs take place at specific providers known as Designated Service Providers (DSPs), schemes can implement risk management tools such as formularies for medication or clinical protocols that include clinical entry criteria (diagnostic or laboratory tests confirming the diagnosis). Members who have never belonged to a medical scheme or allowed a break in membership of more than 90 days are not eligible for unlimited cover of PMBs during either a 3-month waiting period and/or 12-month waiting period on pre-existing conditions. This includes emergency admissions during the 3-month general waiting period.

WHAT ARE DESIGNATED SERVICE PROVIDERS (DSPs)?

A scheme can appoint DSPs for the management of PMB conditions. In terms of The Act the DSP must include public hospitals. The scheme must ensure that the DSP is able to provide the required service. If not, then the scheme must make arrangements for an alternative provider. If you elect not to make use of the schemes elected DSP, you are still entitled to the service for the PMB condition, but funding will be subject to the normal scheme rules which means that and applicable co-payments will apply and the claims will be paid strictly at the scheme-approved Suremed Tariff. Please note that in this situation you may be liable for a co-payment if a provider overcharges. That is why it is important to discuss your providers fees prior to any procedure.

HOW DO I APPLY FOR COVER FOR PMBs?

Identifying valid PMB conditions on diagnosis information alone is not always appropriate, therefore there is an application/authorisation process that is required. This can either be done before a single event or recurring events (like chronic medication) or after an event such as an emergency. There is also an appeals process for members to query the funding of PMB claims. The appeals committee reviews the case and will contact the member with feedback. Information on PMBs is also available on the Council for Medical Schemes (www.medicalschemes.com) website. Should you require information on the location of the nearest DSP, please contact PROVIDENCE the Clinical Risk Management team or our customer care team.

DESIGNATED SERVICE PROVIDERS

A scheme can appoint DSPs for the management of PMB conditions. In terms of The Act the DSP must include Public Hospitals. The scheme must ensure that the DSP is able to provide the required service, if not, the scheme must make arrangements for an alternative provider. If you elect to not make use of the schemes elected DSP, you are still entitled to the service for the PMB condition, but funding will be subject to the normal scheme rules, which means that any applicable co-payments will apply and the claims will be paid at the scheme approved tariff, so you may be liable for a co-payment if a provider overcharges. That is why it is important to discuss your providers fees prior to any procedure.

SCHEMES EXCLUSIONS LIST

In the common interests of the majority of our members and with a view to managing down spiralling medical inflation, the scheme, in consultation with its various specialist consultants, excludes the treatment of certain conditions and procedures. The following is a summary of excluded conditions, procedures and services.
Appliances to treat headaches Autopsies Back rests and chair seats Beds and mattresses Bilateral gyneacomastia in patients under the age of 18 Blepharoplasty Blood pressure monitors Breast augmentation, breast reduction Breast reconstruction unless post cancer and with prior approval Contact lens and solutions Contraception except tubal ligation and vasectomy Electric tooth brushes Epilation for removal of hair Erectile dysfunction and loss of libido Erythropeitin unless pre-authorised Food and nutritional supplements Gender re-alignment Genioplasties Holidays for recuperative purposes Humidifiers Hyperbaric oxygen treatment except for PMB Infertility treatment in specialised and academic units Ionizers and air purifiers Keloid removal except for burns and functional impairment Labial frenectomies for patients over the age of 18 Medical appliances and devices not scientifically proven Organ donations to anyone other than a member or dependant of the scheme Orthodontic treatment for patients over 21 Otoplasties Pain relieving machines, e.g. TENS and APS Refractive surgery unless provided for in Annexure B Removal of tattoos Revision of scars Rhinoplasties Sunglasses and repairs to frames Telephone consultations Travelling expenses Uvulopalatopharingoplasty

CONTRIBUTIONS 2012
Monthly Income
R0 500 R501 R4 500 R4 501 R7 000 R7 001 R9 000 R9 001 Plus

Principal Member
R295 R492 R603 R852 R1 260

Adult Dependant
R295 R492 R603 R852 R1 260

Child Dependant
R243 R243 R243 R243 R309