MEMBER GUIDE

INDEX

1. History Page 01

2. Membership Page 03

3. Contributions Page06

4. OperationofTopMedOptions Page07

5. Pre-Authorisation Page16

6. Medicine Page18

7. ChronicConditions Page23

8. ManagedHealthcare Page26

- HIV Programme Page 30

- Disease Management Programmes Page 31

-AmbulanceServicesER24 Page34

-OpticalBenefits Page36

-MaternityProgramme Page37

9. PaymentofClaims Page38

10. ResolvingProblemsorQueries Page40

11 Co-PaymentsandDeductibles Page41

12. GeneralExclusions Page42

-DentalExclusions Page44

-OpticalExclusions Page45

-AcuteMedicationExclusions Page46

13. Definitions Page47

14. Abbreviations Page51

1. HISTORYTopMed. Your trusted health partnerTopMedMedicalSchemewasregisteredon24April1972,andhasbeenprovidingacomprehensivebenefitofferingtoitsMembersfor40years.TopMedprovidesawiderangeofaffordableandtransparenthealthcareoptionsespeciallytailoredtosuitcorporateclients,SMEsandprofessionalindividuals.Wehaveaholisticandinnovativeapproachandofferfinancialstability,efficiencyandpersonalservice:customercentricitybeinganessentialcornerstone.Wearepassionateabouthealthcareandpartnerwiththirdpartiestoensurewedeliverthehighestlevelsofexcellentservice.Soundgovernanceandabovestatutorysolvencylevelsensuresthatinachangingandcomplexenvironment,TopMedremainsrelevantinthecurrentprivatehealthcareindustry.OurBoardis100%Memberelected,ensuringthat,atTopMed,ourMembersreallydocomefirst!

TopMedfocusesonofferingawiderangeofproductsthatprovidevalueformoneytoourcustomers

Theoptionsinclude:Traditional,NewGeneration,Hospital,LimitedBenefitsandCapitation-basedoptions

Theoptionsare:TopMedRainbowComprehensive,TopMedProfessional,TopMedPaladinComprehensive,TopMedSavings,TopMedActiveSaver,TopMedHospital,TopMedNetworkandTopMedLimited

We focus on health and wellness through our benefit design Wellness(thepreventativescreeningprogramme) ExtendedMajorMedicalBenefits TraumaBenefits

ClearandTransparentcommunication ComprehensiveandinformativeMemberGuide Veryeffectivemanagedcaretools Excellentadministration

TopMedsfinancialpositionisstrongandstable MinimalimpactofGEMS(lessthan1%exposure) TopMedhasalong-termstabilityandgrowthapproachthroughour

benefitdesignandpartnerships Retentionofexistingclients

Why TopMed?

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OneofthesignificantstrengthsofTopMedMedicalSchemeisthewiderangeofbenefitoptions.Wearehighlycompetitiveinboththecorporateandsmallandmediumenterprise/individualmarkets.

The Key Features of TopMeds Product Range include:

PrivateHospitalisation TopMedWellness-ourPreventativeCareProgramme ChronicMedicationBenefits Day-to-DayBenefits ExtendedMajorMedicalBenefits InternationalTravelCover

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2. MEMBERSHIPWho qualifies as a dependant of a member? Spouse Partnerofprincipalmember Children,adoptedchildren,stepchildrenandfosterchildren Brothers, sisters andparentsof theprincipalmember, if dependenton theprincipalmember for

familycareandsupport.

What proof is required by TopMed of a dependants reliance on the member? Inthecaseofaspouse,amarriagecertificate Inthecaseofapartner,thecompleteddeclarationontheApplicationForm Inthecaseofchildren: legaldocumentsinrespectofadoptionforanadoptedchild acourtorderforafosterchild Inrespectofbrothers,sistersandparentsoftheprincipalmember,aswornaffidavitconfirmingthe

relationshiptotheprincipalmemberstatingthatthefamilymemberisdependentontheprincipalmemberforcareandsupport.

How do I add a new dependant to my existing membership?BycompletinganAmendmentForm,whichcanbeobtainedfromTopMed,ordownloadedfromthewebsite onwww.topmed.co.za. If you are part of a company that belongs to TopMed, please sendyourcompletedAmendmentFormtoyourHRorPayrollDepartment,orifregisteringasanindividualmemberyoumayforwardyourAmendmentFormdirectlythroughtoTopMedorviayourappointedbroker.Pleasecall0860 00 21 58ifyouhaveanyenquiriesaboutyourapplication. What happens in the event of the death of the principal member?Theeldestdependantmaycontinuewiththemembershipastheprincipalmember,withthestatusoftheotherdependantsremainingunchanged,providedthatTopMedreceivesadeathcertificate.Membershipwillcommenceonthedayfollowingthatoftheprincipalmembersdeath,unlessTopMedisinformedthatthedependantschoosetoterminatetheirmembership.BankdetailsshouldbefurnishedtoTopMedtoavoidanyinterruptioninthepaymentofcontributionsandobtainingbenefits.

When will TopMed have the right to cancel my membership or that of any of my dependants?Ifyouoranyofyourdependants: joinanotherscheme providefalseinformation,orfailtodisclosematerialinformationwhenapplyingforregistration providefalseinformationwhensubmittingaclaim,submitafraudulentclaim,orintentionallyallow

aserviceprovidertodosoonyourbehalf allowanyotherpersontouseyourmembershipcards withoutagoodexplanation,neglecttoinformTopMedthatithaspaidforservicesorsuppliesthat

werenotdeliveredorreceived commitanyotherfraudulentact failtopaycontributionswithin14daysofthedateonwhichtheyaredue failtorepayanadvancewithin28daysfromthedateonwhichitisdue

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When am I entitled to benefits? Youareentitledtobenefitsfromtheinceptiondateofyourmembership,providedthatnogeneralwaitingperiodorcondition-specificwaitingperiodapplies.

Waiting periodWhat is a general waiting period? TopMedmayimposeageneralwaitingperiodofthreemonthsonallbenefitsinrespectofallnewapplicantsanddependantswho: havenotbelongedtoapreviousmedicalschemeformorethan90dayspriortojoiningTopMed; or weremembersofanothermedicalschemeforaperiodofmorethan2years,andjoinedTopMed

within90daysofleavingtheirpreviousmedicalscheme

Nobenefits arepayableduring this period, not even if funded from theMedical SavingsAccount,

exceptinrespectofanytreatmentordiagnosticprocedurescoveredwithinthePrescribedMinimum

Benefits(PMBs),whereapplicable*.

What is a condition-specific waiting period?TopMedmayfurtherimposeacondition-specificwaitingperiodofupto12monthsfromtheinceptiondate of yourmembership, in respect of any pre-existing condition, in respect of any beneficiarieswho:

havenotbelongedtoapreviousmedicalschemeformorethan90dayspriortojoiningTopMedor

havebelongedtoanothermedicalschemeforlessthan2years,andjoinedTopMedwithin90daysofleavingtheirpreviousmedicalscheme

No waiting periods will be imposed on: abeneficiarychangingoptionswithinthescheme achilddependantbornduringtheperiodofmembership

Can I opt to make a payment in lieu of this waiting period, in order to have it waived?No

* If a general waiting period or condition-specific waiting period is imposed, please note that TopMed will not pay for any PMBs if a member has had no previous medical cover or has had a break of cover for more than 90 days.

Inception dateWhat is an inception date? This is thedateonwhich yourmembership andyourdependantsmembership is registered. Your

contributionsarepayablefromyourinceptiondate.

What is the inception date in respect of dependants? Iftheapplicationisreceivedwithin30daysofthenewdependantbecomingeligibleforregistration

(e.g. through marriage, birth or adoption), the inception date will be the date on which thedependantbecomeseligible

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OrthefirstdayofthemonthfollowingtheoneinwhichTopMedreceivesalltheinformationitmayneedinrespectofsuchanapplication

When do my dependants become entitled to benefits?Yourdependantsareentitledtobenefitsfromtheinceptiondate,unlessageneralwaitingperiodand/orcondition-specificwaitingperiodisapplicable,inwhichcasebenefitsarepayableafterthedurationofthegeneralwaitingperiodand/orcondition-specificwaitingperiod. How are pro rata benefits applied? BenefitswillbeappliedproratainrespectofprincipalmembersanddependantswhojoinTopMedafter1Januaryofaparticularyear.Thisappliestoallbenefitsthathaveanannuallimit.

What is Non Disclosure? ThereisaLEGALrequirementtotellTopMed(onjoining)aboutany: Currentconditionsand/ortreatments Previousconditionsand/ortreatments Plannedproceduresand/ortreatmentsFailuretodisclosecanleadtoTerminationofBenefitsand/orMembershipsopleasemakesurethatyoudonotleaveanythingoffyourapplicationformevenifyouthinkitissomethingsmall.

When can I cancel my Membership?Employer GroupsAsamemberofaparticularEmployeryouremployermaycancelyourmembershipasagroupwithatleast3monthswrittennoticetoTopMed.

Individual MembersAsanIndividualmemberyoumaycancelyourmembershipwithatleast1monthswrittennoticetoTopMed.

Network MembersBack-datedterminationswillnotbegrantedformembersontheNetworkOption.

When can I change my option? YoumayonlychangeyouroptiononceayeareffectivefromonthefirstdayofJanuary,aftergivingTopMedatleast30dayswrittennotice. How do I change my option?By completing an Option Change Form, which can be obtained from TopMeds Client ServiceDepartmentorfromthewebsite(www.topmed.co.za).Suchachangewillonlybeallowedonceannuallyon1Januaryofeachyear.

Please note that if you belong to an employer group, your option change form must be returned to your HR or payroll department. Individual members may submit their option changes directly to TopMed via email, fax, the web or by calling Client Services on 0800 00 21 58.

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3. CONTRIBUTIONSHow is my contribution calculated?Afixedamountispayableforeachprincipalmember,irrespectiveofyourage,togetherwithafixedamountforeachadultdependant(21yearsorolder)andeachminordependant(youngerthan21years,toamaximumof3childdependants*)registeredunderyourmembership.NotapplicabletotheTopMedActiveSaverandTopMedNetworkOption.

*Please note that the contributions payable on the Network Option are based on the highest income of either the Principal Member and/or spouse/partner. Proof of income will be validated each year to ensure that you are paying the correct contributions. When are membership contributions payable?Contributionsarepayablemonthlybythethirdofthemonth,effectivefromyourinceptiondate.

At what stage does my contribution increase when a minor dependant turns 21?Theincreasedcontributionforanadultdependantbecomesdueonthefirstdayofthemonthfollowingthatinwhichyourdependantturns21unlessyourdependantisafulltimestudent.

Students Ifyourdependantisafulltimestudentbetweentheagesof21to24theywillqualifyforthestudentconcessionandcontinuepayingthechildratewhilsttheyarestudying.ProofoffulltimestudyfromtherelevantEducationalInstitutionwillberequiredtobesubmittedtoTopMedbytheendofFebruaryofeachyear.

When do increased contributions become due in respect of a new dependant?Thefirstincreasedcontributionispayablefromthefirstdayofthemonthinwhichyourdependantisadded.

What happens if my contributions fall into arrears?If your contributionsarenotpaid toTopMedwithin14days from thedateonwhich theyaredue,the payment of benefits in terms of your membership is suspended until such time as all arrearcontributionsarereceived.Ifyourcontributionsaremorethan28daysinarrears,yourmembershipwillbeterminatedimmediatelywithoutfurthernotice.

What is a late joiner?Anapplicantortheadultdependantofanapplicantwho,atthedateofapplicationformembership,is 35 yearsorolder,butexcludesanybeneficiarywhoenjoyed coveragewithoneormoremedicalschemesasfromadatepreceding1April2001,withoutabreakinmembershipincoverageexceedingthreeconsecutivemonthssince1April2001.

How do late joiner penalties work?TopMedmay increase the contributions of a late joiner in accordancewith the stipulations of theMedicalSchemesAct.ThenumberofyearswithnomedicalcoverisconvertedintoapercentageasprescribedbytheAct.Thelatejoinerpenaltyamountis,therefore,theprescribedpercentageofthenormalmonthlycontribution.

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4. OPERATION OF TOPMED OPTIONSTopMedprovidesacomprehensivespectrumofoptions,encompassingofNewGenerationSavingsOptions,TraditionalOption,CapitationOption,HospitalOptionandaLimitedOption.

TheflexibilityoftheproductofferingensuresthatthehealthcareneedsofadiverseprofileofindividualscanbecoveredwithintheTopMedMedicalSchemesrangeofoptions.

Formoredetailsoneachoftheoptionsoffered,pleaserefertotheSummaryofBenefitsforeachoptiononthewebsite,www.topmed.co.zaorcallClientServiceson0800002158.

Extended / Threshold Cover(ApplicabletotheTopMedRainbowComprehensive,TopMedProfessionalandTopmedPaladinComprehensiveOptions)

How does the Extended/Threshold Cover work?Athreshold isasetvaluetobereachedbeforeclaimsforday-to-daymedicalexpensesarepaidbyTopMed. Claims for day-to-day expenses are processed andwill accumulate towards reaching thisthreshold.ThisincludesclaimspaidfromyourYearlyLimitandMedicalSavingsAccountorpaidfromyourownpocket.ThevalueaccumulatedtoyourthresholdisbasedontheTopMedTariff(TT),andnotnecessarilytheamountthatyouhavepaid.Onceyouraccumulatedclaimsreachthethresholdvalue(andyouhaveexhaustedyourYearlyLimit),furtherday-to-dayclaimswillbepaidbyTopMedasperthebenefitsstipulatedinyourSummaryofBenefits.YoumayuseyourYearlyLimit/MedicalSavingsAccounttopayforday-to-daymedicalexpensesincurredbeforeyourthresholdisreached,orpayfromyourownpocketshouldyourYearlyLimit/MedicalSavingsAccountbeexhausted.

As noted above only the applicable percentage of the benefit amount, i.e. the TopMed Tariff andnotthecost,willaccumulatetowardsthethreshold,evenifthecostispaidfromyourYearlyLimit/MedicalSavingsAccount.CertainclaimswillNOTaccumulatetowardsthethreshold,evenifpaidfromyourYearlyLimit/MedicalSavingsAccount.

Claimspayat100%ofTT Categorylimitsapplybefore

andafterthreshold

Extended/Threshold Cover

Hospitalisation ChronicMedication MRI/CTScans

OncologyRisk

Claimsaccumulateat100%ofTT.

Claimspayatcost Certainclaimsdonot

accumulate

Yearly Limit/ Medical Savings Account

SelfPaymentGap

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ItisimportanttoremembertocontinuetosubmityourclaimstoTopMedforaccumulationtothreshold,evenifitisduringtheperiodwhenclaimsarepaidfromyourownpocket.

If a Benefit Limit applies before Threshold, how will it affect my benefits after Threshold?For all benefits that have limits, these limits apply before and after the threshold is reached. Thismeansthatifforexample,thereisalimitofR5000onyouracutemedicinesbenefitandyouutilisethefullamountbeforereachingyourthreshold,i.e.duringtheperiodwhenyoupayyourclaimsfromyourYearlyLimit/MedicalSavingsAccount,oryourownpocket,youwillhaveNOBENEFITSforacutemedicinesafterreachingyourthreshold,i.e.duringtheperiodwhenTopMedstartspayingday-to-dayclaims.

How will my threshold be affected if I join on a date other than 1 January?Thetotalthresholdamountiscalculatedonaproratabasis,butwillnotdecreasetolessthan50%ofwhattheamountwouldhavebeenfor12months.Example:Thethresholdforafamilyfor12monthsisR20000 IfthefamilyjoinsTopMedon1July,theirthresholdwillbeR10000(50%ofR20000) EveniftheyjoinTopMedon1December,theirthresholdwillstillnotbelessthan50%ofR20000,

whichisR10000.

How will my threshold be affected if I add a dependant to or remove a dependant from my membership?Yourthresholdwillbeadjustedaccordingly.

Pleasenote:Yourcontributionswillchangeonthefirstdayofthemonthinwhichyouaddorremovedependants.

How will my threshold be affected if my dependant turns 21 during the year?Ifyourdependantsstatuschangestoanadultdependantduringayear,yourthresholdwillbeadjustedaccordingly.

Medical Savings Account (TopmedProffesional,TopMedSavings,TopMedActiveSaveroptions)How does a Medical Savings Account work?YourMedicalSavingsAccountisdesignedtocoveryourday-to-dayexpenses.Itworkslikethis: Youcontributeafixedmonthlyamount Thetotalannualamountisavailableinadvanceformedicalexpenses

How much can I contribute towards my Medical Savings Account? Theamountisfixedperoption.RefertotheSummaryofBenefitsperOptionforfurtherdetails.

What can I use my Medical Savings Account for? Medicalservices,includingmedicinethatdonotformpartofyourchoiceofbenefits Medicalservicesrenderedbyaregisteredsupplierthatdonotqualifyforbenefitsintermsofthelist

ofexclusions(Pleaserefertothesectionofthisguidedealingwithexclusions) Medicalservicesforwhichtheannualsub-limithasbeenreached Non-prescriptionSchedule1and2medicines(PAT)arepaidoutat100%ofcost Thedifference,ifany,betweentheallowedbenefits,asdescribedintheSummaryofBenefits,and

theactualcostchargedbyyourserviceprovider.08

What happens to my savings balance at the end of the year?AnypositivebalancewillbetransferredtoyourMedicalSavingsAccountforthefollowingyear.

What happens to my savings balance if I change from a New Generation Option to a Traditional Option, or decide to leave TopMed?Anypositivebalancewillberefundedtoyouafterfourandahalfmonths.However,shouldyouleaveTopMedto joinanothermedicalschemewithaMedicalSavingsAccount,anycreditbalancewillbetransferredtotheothermedicalscheme.

What happens to the debits accrued on the savings balance of a member who leaves TopMed?Shouldtherebeanegativebalance,youwillberesponsibleforrefundingtheamounttoTopMedwithin30daysofnotification.

What happens to my savings balance if I pass away?AnypositivebalancewillbepaidouttoyourestateafterfourandahalfmonthsifyourdependantsdecidenottocontinueasmembersofTopMed.

Please note: In order to have the difference between the cost of branded medicine and the generic equivalents claimed from the Medical Savings Account, you will have to contact the Client Services Department to request the payment, as these benefits will not automatically be allocated from your Medical Savings Account. The full claim must be submitted to TopMed for this to be processed.

Yearly Limit (TopmedRainbowComprehensive,TopmedPaladinComprehensiveoptions)

What is a Yearly LimitAYearlyLimitisaportionofyourmonthlycontributionwhichissetasidetopayforday-to-daybenefitsbeforeyouhavereachedyourannualthresholdlevel.ItissimilartoaMedicalSavingsAccountinthatitisusedtofundday-to-daybenefits.

What can I use my Yearly Limit for?RefertoyourBenefitSummaryfordetailsofclaimsthatcanbefundedfromyourYearlyLimit.

What happens to my Yearly Limit if I leave the Scheme or change to a benefit option that does not have a Yearly Limit?AstheYearlyLimitisconsideredaRiskBenefit,whenyouleavetheSchemeorchangetoaoptionthatdoesnothaveaYearlyLimit,yourYearlyLimitbenefitwillfallawayandthebalanceremainswiththeScheme.

What happens to my Yearly Limit balance at the end of the year?AnyYearlyLimitbalanceattheendoftheyearwillfallawayandyouwillbeallocatedanewbalanceatthebeginningofthenextyear.

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TopMed Network Option

What is a Primary Healthcare Provider?A Primary Healthcare Provider is appointed by TopMed to manage your familys day-to-day basichealthcareneeds,e.g.thetreatmentofflu.

Who is the Primary Healthcare Provider on TopMed?TopMedhasappointedCareCrossHealthtorenderprimaryhealthcareservicestothemembersoftheNetworkOption.CareCrossHealthhasacountrywidenetworkofdoctors,dentistsandoptometristsfromwhomyoumayobtaintheseservices.

TolocateyournearestCareCrossprovider,pleaselogontowww.carecross.co.zafortheinformationanddetailsofCareCrossdoctors.

What are my benefits at a CareCross General Practitioner? ThefirstandmostimportantstepistoensurethatyouselectandconsultwithyourchosenCareCrossGP. YoumayhaveasmanymedicallynecessaryvisitstotheCareCrossGPasyouneedtoremainhealthy. Inhistreatment,theCareCrossGPmayalso:

Provideyouwithacute medicationaccordingtoamedicinelistRegisteryouforchronic medicationforaspecificconditionandaccordingtoamedicinelistPerformsomeminor surgical procedures in the roomsCallforlistedblood tests and x-raysOfferpre and post-natal careincludingoneultrasoundscaninthefirsttrimesterperpregnancy.

What is acute medication?Itismedicationthatisusedforashortperiodoftimetohelpyourecoverfromacommonillness,suchasinfluenza(flu).DispensingGPswillprovideyouwiththismedicationwhenyouconsultwiththem.SomeCareCrossGPs(Scripting)willgiveyouaprescriptionwithwhichyouareabletoobtainyouracutemedicinesatanyMedikredit-enabledpharmacy.

What do I do if I have a chronic condition?ConsultyourCareCrossGPtoconfirmthediagnosisandforthecompletionofachronicapplicationformwhichmustbesubmittedtoCareCross.Onapprovaloftheapplication,youwillbeinformedwhereyoumaycollectyourmedication.Ifthereisnoapprovedpharmacyclosetoyou,yourmedicationwillbedeliveredtoeitheryourworkoryourhomeaddress.

What is acute medication?Itismedicationthatisusedforashortperiodoftimetohelpyourecoverfromacommonillness,suchasinfluenza(flu).DispensingGPswillprovideyouwiththismedicationwhenyouconsultwiththem.SomeCareCrossGPs(Scripting)willgiveyouaprescriptionwithwhichyouareabletoobtainyouracutemedicinesatanyMedikredit-enabledpharmacy.

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What do I do if I have a chronic condition?ConsultyourCareCrossGPtoconfirmthediagnosisandforthecompletionofachronicapplicationformwhichmustbesubmittedtoCareCross.Onapprovaloftheapplication,youwillbeinformedwhereyoumaycollectyourmedication. Ifthereisnoapprovedpharmacyclosetoyou,yourmedicationwillbedeliveredtoeitheryourworkoryourhomeaddress.

What other benefits do I have? Youarealsoentitledtobasicdental benefitssuchasfillings,extractionsandcleaning. Inaddition,youhaveaccesstooptical benefitsthatofferachoicebetweenspectaclesandcontact

lenses.Thisbenefitisavailabletoeachbeneficiaryevery24months. Theseservicesareonlyobtainable fromCareCross-contractedprovidersandsubject toCareCross

protocols.

Do I and my dependants have to visit the same CareCross-contracted GP?No,eachofyoucanchoosetheCareCrosscontractedGPthatisnearesttoyou.ItisimportantthatonceyouchooseaGPthatyouarecomfortablewith,thatyoucontinuetoconsultwithyourchosenGPonly.Thisisthebestwayforyourhealthtobemanagedeffectively.

What must I do in an emergency after hours or if I am on holiday and not close to the CareCross Provider I selected? CareCrossbenefitsmakeprovisionforafterhoursemergenciesorvisitsoutsideofthenetwork.This

benefitislimitedto3visitsperfamilyperannumtoamaximumofR1100perfamilyperannum. Youhavethefollowingoptions:

YoumayvisitanyCareCross-contractedornon-contractedGPclosetoyou Alternatively,youmaygotoanemergencyroomatthenearestprivateorpublichospital. (SeeSummaryofBenefitsfordetails).

Pleasenotethatyouwillhavetopayupfrontfortheserviceobtainedoutsideofthenetwork. Youmay,however,claimbackthecostsfromCareCrosssubjecttothebenefitlimitandCareCrossrates.

Will I have to pay when visiting CareCross providers?No,aslongasyourcontributionshavebeenpaid,youmayvisitCareCrossProvidersasoftenasmedicallynecessarywithouthavingtomakeanypaymentsforCareCrossservices.Sometimesyoumayrequiremedication,bloodtestsorx-raysthatarenotcoveredunderyourNetworkoption.YourGPwillinformyouwhenyourequiresuchtreatmentandyouwillhavetopayfortheseyourself.

What must I do if I need to see a Specialist? SpecialistBenefitsareprovidedbyCareCrosssNetworkofSpecialists,subjecttoobtaininga

referralfromyourCareCrossGP. YouwillneedtocontacttheCareCrossReferralCentreon0860 102 183toobtainthenecessary

referralnumberbeforevisitingthespecialistasperyourPMBTreatmentPlan.IfyouarenotreferredbyyourchosenCareCrossGP,ordonotseeaSpecialistontheNetwork,TopMedwillpay70%oftheTTandyouwillberequiredtopaythebalancetoyourSpecialist.

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What Specialist Benefits are provided? SpecialistbenefitislimitedtoR800perfamily. SpecialistservicesaresubjecttoreferralbyaNetworkGPtoaNetworkSpecialistandpre-authorisation. AnyradiologyorpathologycalledforbytheNetworkSpecialistwillalsobepaidfromthisbenefit.

ShouldyoureceiveanyothertreatmentfromaSpecialist,otherthanthebenefitslistedabove,youwillbeliableforthefullcostofthattreatment.

What must I do if I have to go to hospital?If you and/or any of your dependants have to be admitted to a private or provincial hospital, youmust obtain an authorisation (PAR) by contacting0860 00 21 58. TopMedwill pay the cost of yourhospitalisation,andthecostsofthetreatmentyoureceivewhilstinhospitalat100%oftheagreedtariffifyouwerereferredbytheCareCrossGPorSpecialist.(PleasenoteiftheadmittingproviderisaNetworkProvider,TopMedwillpay100%oftheTT).IfyourproviderisnotaNetworkProvider,TopMedwillpay70%oftheTT,andyouwillberequiredtopaythebalancetoyourprovider.

What must I do in case of an emergency?Ifinanemergencyyouareunabletoobtainauthorisationpriortobeingrushedtohospital,forexampleinthecaseofanaccident,youand/oryourfamilyhavetwoworkingdaysfromthetimethatyouareadmittedtoinformTopMedthatyouareinhospital.

Note: For a detailed breakdown of the information you need to supply and obtain when applying for a PAR, please refer to page 16 (Pre-Authorisation) in this Member Guide.

How are my claims paid? Services rendered at CareCross providers: YouwillnotreceiveanaccountforanyCareCrossservices.Theproviderwillsendtheaccount

directlytoCareCross. Services rendered at a Specialist (out-of-hospital): ThisaccountmustbesubmittedtoCareCross. Services rendered at a hospital: Submithospital-relatedclaimstoTopMed. Note: All claims must reach TopMed or CareCross for payment within 4 months from the end of

the month in which treatment was rendered. After these 4 months, the claims become stale and will no longer be paid by TopMed or CareCross.

For more information on claims, please refer to page 38 (Payment of Claims) in thisMember Guide.

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When do I have to pay my contributions?Contributionsarepayablemonthlyinadvance.Ifcontributionsarenotpaidwithin14daysfromthedatethattheyaredue,yourmembershipwillbesuspended.Ifyourcontributionsremaininarrearsformorethan28days,yourmembershipwillbecancelledimmediately,withoutfurthernotice.

Note:FormoreinformationonContributions,pleaserefertopage06(Contributions)inthisMemberGuide. Are benefits allowed in respect of foreign claims?No.

Is HIV/AIDS covered?Yes.TheCareWorksHIV/AidsProgrammeassistsmembers livingwithHIV/Aids toaccessquality careandtomakeoptimaluseofthebenefitsavailabletothem.Theprogrammewillincludethenecessarypathologytests,anti-retroviralmedication(ifrequired),doctorsconsultations,information,counsellingandadvice.

ToaccessthesebenefitsyoushouldcontactCareWorkson0860 10 11 10 to register on the programme.

Are dialysis and organ transplants covered?TheseconditionarecoveredinapublichospitalunderthePrescribedMinimumBenefits(theminimumbenefitsTopMediscompelledtoofferintermsoftheMedicalSchemesAct,1998).

Are benefits paid for confinements in a private hospital?Yes,butbenefitsarelimitedtooneconfinementperfamilyperyearinaprivatehospitalANDthemothermust obtainpre-authorisationfortheadmission,within24-48hoursoftheadmission.

Important things to rememberAlways take your TopMed membership card with you when visiting a CareCross provider. KnowyourCareCrossGPsroomhoursNormalbusinesshourstoamaximumof MondaytoFriday:09:00to17:00 Saturdays:09:00to11:00 Not required to be openafterhours,SundaysorpublicholidaysProtocolsandformularylistsapplyYouarenot requiredtopaycashforCareCrossservicesincludedinyourbenefitoptionAskyourdoctoriftests/medicinesarecoveredAskquestionsifyouareunsure

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In-Hospital and Specialist Claims (deductiblesandexclusionsmayapply) AdmissionviaCareCrossGPand/orCareCrossSpecialist

In-Hospital Benefit at

Any Hospital

LimitedtoR1million

(Pre-authorisa-tionis

required)

Ambulance/ER24(084124)

InHospitalProceduresandConsultsSubjecttousingtheCareCrossNetworkofSpecialists

X-Rays

BloodTests

AllHospitalandInHospitalSpecialistclaimsmustbesubmittedto:POBox1462Durban4000

Call TopMed on0860 00 21 58 for Hospital Authorisation

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YOut-of-Hospital / Day-to-Day BenefitManagedbyCareCross(claimstobesubmittedtoCareCross)

DoctorVisitsConsultations

X-RaysBasicOnly-asperaformularylist. MustberequestedbytheCareCrossGP

BloodTestBasicOnly-asperaformularylist.MustberequestedbytheCareCrossGP

BasicDentistryPrimaryExtractionsFillings,Sepsis,FlourideTreatment,CleaningOnesetofplasticden-turesevery24monthswitha20%co-payment(SubjecttoNetworkprotocolsanduseofaNetworkDentist)

MedicationPrescribedbytheCareCrossGPanddispensedbytheCareCrossGPorpharmacy

AcuteMedicationtobeobtainedfromyourCareCrossdoctorPATlimitedtoR195peryearmaxofR65perevent(max.of3eventsperyear)approvedChronicMedicationprescribedbyyourCareCrossproviderandobtainedordeliveredbyCareCrossnetworkpharmacy

Optical1consultationperbeneficiaryperannum1pairsingle/bi-focalwhitelensesevery24months-SubjecttoNetworkprotocolsanduseofaNetworkProvider

Your CareCross GP is the key to your

day-to-day benefits. All services to be obtained via the

CareCross Network of Providers

Physiotherapy,SpeechTherapyandOccupationalTherapyNO BENEFIT

Out-of-Network / Emergency visits:Limitedto3visitsperfamilytoamaximumofR1100perfamilyperyear.(MembertopayandclaimbackfromCareCross)

HIV / AIDS Registration with CareWorks 0860101110(subjecttoclinicalprotocols)

Out-of-HospitalSpecialistBenefit(LimitedtoR800perfamilyandsubjecttoreferralfromaCareCrossNetworkGPtoaCareCrossNetworkSpecialist.)

SpecialistReferralfromyourCareCrossGPtoaNetworkSpecialist.BenefitlimitedtoR800perfamily

For any queries call CareCross on 0860 103 491or e-mail: topmed@carecross.co.za

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5. PRE-AUTHORISATION (PAR)

What is pre-authorisation (PAR)?Pre-authorisation(PAR)isthepriorapprovalofanyplannedadmissiontoahospital,includinganassociatedtreatmentorprocedure(includingdentalprocedures)performedbyamedicalpractitionerordentistduringhospitalisation.

Please note that a PAR is merely a confirmation that the proposed clinical procedure or treatment is medically necessary and is not a guarantee that benefits will be paid.

MRIscans,CTscansandradio-isotopestudies,whetherduringhospitalisationornot,requirepre-authorisation.PleasenotethatthefollowingproceduresdoNOTrequireaPAR,andthatbenefitsinrespectofthesewillbepaidfromyouroptionsradiologybenefits: Dexascans CTbonemineraldensitystudies CTguidedrenalbiopsy MRIscanlowfieldperipheraljointexaminationoffeet,handsandelbowsindedicatedlimbunits.

When must I apply for a pre-authorisation reference number (PAR)? ApplicationforaPARshouldbemadeforanyprocedurerequiringareservationforadmissiontoahospitalorifcertainscansorradio-isotopestudiesareplanned.IfyouareunsureiftheprocedurerequiresaPAR,itisrecommendedthatyoucallthePre-AuthorisationDepartmentforadviceon0860 00 21 58.

ApplicationforaPARshouldbemadeassoonaspossible,preferablywhenadmissionisconfirmedbyyourdoctor.Youneednotapplyforauthorisationmorethanonemonthinadvance.

Itisrecommendedthatapplicationbemadeatleasttwodaysaheadofaplannedprocedure,incasemoreinformationisrequiredfromyourdoctor.Intheeventofanemergencyadmissiontohospitaloveraweekendoratnight,youmayapplyforaPARfromthePre-authorisationDepartmentwithintwoworkingdaysfollowingtheadmissionorscan.

Visits to a hospitals out-patient facility in the event of Trauma (not applicable to treatments which form part of Case Management)Pleasenotethatvisitstothedoctoratahospitalsout-patientorcasualtydepartmentwillnotbefundedfromyourhospitalbenefit.Forthisreason,somehospitalsmayrequirethatyoupaycashforthesevisits.Inthisevent,youmaysendthedetailedaccountandproofofpaymenttoTopMedandyouwillberefundedaccordingtoyouroptionsday-to-daybenefits(pleaserefertotheSummaryofBenefitsforyourparticularoptionformoreinformation).

What happens if I fail to apply for a PAR?IfnoPARisobtainedorifaPARisobtainedlate,nobenefitswillbepaidbyTopMed.

How do I contact the Pre-authorisation Department to obtain a PAR?Forallpre-authorisationscall 0860 00 21 58

16

What information should I provide when applying for a PAR? Membershipnumberanddependantcode Patientsfullname DateofadmissionPLUSthedateoftheprocedure.(Thisisparticularlyimportant,aswedonot

routinelyauthorise pre-operativeproceduresthedaypriortoplannedsurgery-thismustbeappliedforandmotivated.)

Surnameandinitialsofattendingdoctororserviceprovider(practicenumber,ifavailable) Telephonenumberofattendingdoctororserviceprovider Nameofhospitaltowhichthepatientwillbeadmitted. Thereasonfortheadmissiontohospitalortheplanneddiagnosticprocedure Askyourdoctorforafulldescriptionof: thereasonforadmission theassociatedmedicaldiagnosisandtheapplicableICD-10codetheplannedprocedure,aswellastheproceduralcodesandtariffshe/sheintendstouse

What information must I obtain when calling the Pre-authorisation Department? TheuniquePARnumber Theinitiallengthofstayinanapprovedhospital Theapprovedcodes

What must I do if I stay in hospital longer than the initial length of stay approved by the Pre-authorisation Department?Afamilymember,yourdoctororahospitalstaffmembermustimmediatelyinformthePre-authorisationDepartment,andtheclinicalindicationsfortheextendedstaywillbeevaluated.AnextendedlengthofstaymustbeauthorisedtoqualifyforbenefitsasnoretrospectivePARswillbegranted.

How will the medicine I receive on discharge from hospital be paid for?Youwillqualifyforamaximumofsevendayssupply:ThisbenefitwillbepaidfromRisk(exceptfortheNetworkoption).Pleasenotethatevenifyouhaveachronicmedicineauthorisation,themedicinedispensedwhenyouleavethehospital,willalwaysbepaidforfromRisktoamaximumofsevendayssupply.Ifyouhaveachronicmedicineauthorisation,youshouldobtainyourmedicinefromaDSPretailpharmacy.

17

6. MEDICINEChronic Medicine Benefit The ChronicMedicine Benefit is a benefit that coversmedicine for a specified list of conditionsaccording to your option(Refer to page 23). These conditions have been selected according toclinicalandactuarial criteria.Thismeans thatalthoughaconditionmaybedefinedaschronic, itmaynotmeet the criteria for cover fromyourChronicMedicineBenefit. TopMed covers the 26PrescribedMinimumBenefit (PMB)ChronicDisease List (CDL) conditions at 100%of theAgreedTariff (MRP applies), provided that thesemedicines are obtained from the Schemes DesignatedServiceProviders (DSPs),andsubjecttoTopMeds formularies,whichareamendedfromtimetotime.ShouldyouchoosenottoutiliseTopMedsDSPsand/orutilisemedicinesthatarenotpartoftheformularies,TopMedwillonlypaya70%benefit,andyouwillberequiredtopaythebalance.

AccesstotheChronicMedicineBenefitissubjecttoclinicalentrycriteria.Theseentrycriteriaareinlinewithevidence-basedpracticesandlegislativerequirements.TheChronicBenefitconsultantsuseevidence-basedguidelinesandprotocolstoclinicallyassesseachapplicationforchronicbenefitsandensurethatthedrugsusedareappropriate,costeffectiveandprescribedinthecorrecttherapeuticdosages.

How do I apply for a Chronic Medicine Benefit? (excludingNetworkOption) ThetreatingdoctormustcontactMediscoron0860 00 21 58toregisteranewchroniccondition.

Thisinvolvesaclinicaldiscussionastowhethertherequestmeetsallthenecessaryclinicalentrycriteria.

Ifthecriteriaaremet,thechronicconditionwillberegistered.Eachchronicconditionhasalistofmedicationthatisclinicallyappropriatetotreatthiscondition.ThisexcludescertainhighcostingmedicationsthataresubjecttomotivationandapprovalbyaClinicalCommittee.

Chronic Registration Process (excludingNetworkOption)OnceyourdoctorhasdiagnosedyourchronicconditionandcodestheconditionaspertherelevantICD-10coding(refertopage19),yourdoctorneedstocontactMediscoron0860 00 21 58 to register yourchroniccondition. Alldiagnosticandentrycriteriapertainingtothechronicconditionwillberequestedincluding

theICD-10code. TheChronicConsultantwillevaluatetheinformation,basedontheclinicalentrycriteria,andif

appropriatewillprovidetheauthorisationtoyourdoctor. Inaddition,youwillreceivealetterofconfirmation,providingyouwiththedetailsofthechronic

condition/medicationapproved. Onceyourdoctorhasprovidedyouwithyourscriptyouwillneedtoprovideacopytoeitheryour

pharmacyorTopMedsDSPstoobtainyourmedication(refertopage19). ShouldyourmedicationnotbeapprovedaspartofyourChronicMedicineBenefit,theChronic

Consultantwilladviseyourdoctoraswellassendyoualetter,advisingyouoftherejection.

18

Oncetherequesthasbeenapproved,youwillreceivealetterindicatingyourauthorisedchronicdiagnosisandmedication.Yourprescriptionmustbetakentoyourserviceprovider(pharmacist),thereafterclaimscanbesubmittedfortheapprovedcondition.OncetheperiodofauthorisationhasexpiredandthereisnochangeinthemedicinerequiredforthespecificconditionyourdoctororpharmacistcancontacttheMediscoron0860 00 21 58toreinstateyourauthorisation.Thesamecanbedonewhenanychangesoradditionstoacurrentauthorisationarerequired.

ChronicconsultationsandmedicationwillonlybepaidfromyourChronicMedicineBenefitifregistrationof the chronic condition is approved. If registration of the chronic condition is declined, chronicconsultationsandmedicationmaybepaidfromyouracutemedicinebenefitorYearlyLimit/MedicalSavingsAccount.

1 2 3 4 5Chronicconditiondiagnosedandneedsmedical

treatment

Doctorprescribesmedicineand

confirmsformularyandoptionbenefitswithmemberwhere

possible

ProvidertocontactMediscor

0860002158oremailpre-auth@mediscor.net

Mediscorwilladviseoninformationneededto

registercondition(e.g.script,

diagnosticcodesandsupportingdocuments)

MediscorwillcheckbenefitsandformularyforyourOptionandRegisteraccordingly

OK

5 STEP CHRONIC REGISTRATION PROCESS

Why the telephonic process?TopMedwillautomaticallyreimbursedoctorsaone-offamountpayableattheTopMedTariffforfullycompletingatelephonicrequestforchronicmedicinebenefitsaspartofyourMajorMedicalBenefitswhichdoesnotcounttowardsyourannualconsultationlimit.ThispaymentwillbemadeforapplicationsfordiseaseconditionswhichareconsideredChronicConditions.Pleasenotethatthispaymentisonlyapplicable for the first application of a condition. Members are encouraged to advise doctors andpharmaciststousetheshare-callnumbertoregisternewconditionsandupdatechangestoanexistingchronicauthorisation.

Advantages: Simple,paperlessandon-lineauthorisationprocess. Immediateregistrationontothechronicmedicinebenefitandthusreal-timeclaiming. Aclinicaldiscussionwithyourproviderthusensuringthebesttreatmentforthemember. Nolongformstobefilledoutorcompletedbyyourdoctor.

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Important points to note

ICD-10 Codes-Everymedicalconditionanddiagnosisisallocatedaspecificcode,whichisreferredtoastheICD-10code.TheICD-10codingsystemensuresthatclaimsarepaidoutofthecorrectbenefit.

Whatthismeansisthateveryserviceprovider/doctorwillneedtosubmitavalidandappropriateICD-10codeforregistrationontotheChronicMedicineBenefitandonthesubsequentclaimthatissentthroughtoTopMed.LegislationdictatesthatfailurebytheserviceprovidertosubmitavalidICD-10codewillresultinthenon-paymentoftheclaimbyanymedicalscheme.

Prescriptions are valid for six (6) months only - The telephonic authorisationdoesnot replacetheofficialdocumentofascript.Ascriptisstillrequiredtobewrittenbyyourprescribingserviceprovidereverysix(6)months.Itisimportanttonotethatyourauthorisationmayextendbeyondthevalidityofthescriptthatyourdoctorgivesyou.Whenyourrepeatscriptexpires,youwillneedtoobtain a newone fromyourdoctor to give to yourpharmacist/DSP to ensure that youmaycontinuetoreceiveyourmedication.

Clinical/Payment Rules -Thepaymentofyourmedicineissubjecttoanumberofclinical/paymentrulesincludingbutnotlimitedto:

-Drugtodruginteractions -Gender/Agechecks -Earlyrefilllimitations(1scriptper24days) -Quantity/Dosagechecks -Genericsubstitutions -MediscorReferencePrice(MRP) -Formularies

TopMedMedicalSchemeusesUtilisationManagementRulestoenableearlydetectionofchronicdiseasesandenhancediseasemanagementformembers. The following Utilisation Management Rules apply:

Aero-chambersandspacers(foradmissionofinhalantmedication):Restrictedto1deviceperbeneficiaryperyear.

Medicationfortreatmentofpain:Restrictedto150tablets/capsulesperbeneficiaryperyear. Anti-asthmaticinhalers:Restrictedto3prescriptionsperyearfromacutebenefit,thereafterpre-

authorisationisrequired. Medicinesfortreatmentofdepression:Requirepre-authorisationfromChroniLine. Medicinesfortreatmentofpsychosis:Requirepre-authorisationfromChroniLine. Medicinesfortreatmentofanxiety:Limittoamaximumquantityof30permonthand3

prescriptionsperyearfromtheacutebenefit. Sedativemedicines:Restrictedto3prescriptionsperyearperbeneficiaryfromtheacutebenefit. Contraceptives:Limitedto1prescriptionpermonthforfemalesonly. Earpreparations:Restrictedto1bottle/tubepermonthwithamaximumof4prescriptionsper

beneficiaryperyear. Eyepreparations(exceptforthetreatmentofglaucoma):Restrictedto1bottle/tubepermonth

withamaximumof4prescriptionsperbeneficiaryperyear. Estring:Restrictedto1deviceand4prescriptionsperyearforfemalesonly.

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Fluvaccines:Restrictedto1vaccineperbeneficiaryperyearwithamaximumofR78. Glucocorticosteroidnasalsprays:limitedtoaquantitypermonthaccordingtomaximumregistered

dosage HumanPapillomaVirus(HPV)vaccines.eg.GardasilandCervarix:Willpayfromacutebenefit

withageandlifetimelimitsapplied. HypnoticMedicines:Restrictedtoaquantityof30permonthperbeneficiaryand3prescriptions

peryearfromtheacutebenefit. Productstotreatliceinfestations:Limitto2prescriptionsperbeneficiaryperyearfromtheacute

benefit. Malariaprophylactictreatment:Restrictedto2prescriptionsperbeneficiaryperyear. Medicatedshampoos:Limitedto2prescriptionsperbeneficiaryperyearfromtheacutebenefit. Topicalpreparationsformuscleaches:Limitedto2prescriptionsperbeneficiaryperyearfromthe

acutebenefit. Anti-inflammatoryMedicines:Restrictedtoayearlyquantityof150perbeneficiary. Medicationforthetreatmentofosteoporosis:Requirespre-authorisationfromChroniLineforthe

optionswherebenefitsareavailable. Prenatalvitamins:Frommaternitybenefitfor9prescriptionsandforfemalesonly. Roaccutaneandgenericequivalents:Payfromacuteandmaybeprescribedbyanymedicaldoctor. Stomaappliances:PayfromStomabenefit.ChroniLinecanauthorizestomaappliancesfrom

chronicbenefitwhereapplicable. Topicalacnepreparations:Limitedto4prescriptionsperbeneficiaryperyearfromtheacutebene-

fit. Topicalnasalpreparations:Restrictedto1bottle/tubepermonthandtoannualprescriptionsof4

perbeneficiary. Topicalsteroidpreparations:Limitedto4prescriptionsperbeneficiaryperyearfromtheacute

benefit.

NOTE:Utilisationmanagementrulesdonotapplytoproductsifpre-authorised. What is MRP?Mediscor Reference Price (MRP) sets amaximum reimbursable price for a list of generically similarproductswithacostlowerthanthatoftheoriginalmedicine.ItisthemaximumpricethatTopMedispreparedtopayforamedicinewithgenericalternatives.Thismeansthatifyouopttousetheoriginalproduct,andagenericalternativeisavailable,youwillhavetopaythedifferencebetweenthepriceofthechosenoriginalmedicineandthatofMRP.

What is generic medicine?Genericsaremedicines that containexactly the sameactive ingredientsasbrandedproducts. Thesemedicinesaremanufacturedbythesameoranothercompanyoncethepatentonthebrandedproducthasexpired.Asaresult,thepriceofgenericmedicineisusuallyconsiderablylower.

What are patented or branded medicines?Pharmaceuticalcompaniesincurhighresearchanddevelopment(R&D)costsbeforeaproductisfinallymanufacturedandreleasedontothemarket.Thepharmaceuticalcompanyisthereforegiventhepatentrighttobetheonlymanufacturerofthatspecificmedicine(brand)foranumberofyears,inordertorecoverR&Dcosts.

21

What are patented or branded medicines?Pharmaceuticalcompaniesincurhighresearchanddevelopment(R&D)costsbeforeaproductisfinallymanufacturedandreleasedontothemarket.Thepharmaceuticalcompanyisthereforegiventhepatentrighttobetheonlymanufacturerofthatspecificmedicine(brand)foranumberofyears,inordertorecoverR&Dcosts.

Why use a generic medicine? Genericsaremorecost-effective,whichmeansyougainoptimumusage in respectofyourmedicinebenefitlimit.Asaresultofcheapergenericalternatives,leviespayableperprescriptionarereduced.Theuseofgenericmedicinesthereforehelpstolimittotalmedicineexpenditure,whichinturnlimitsannualcontributionincreases.

How do I ensure that I use a quality generic medicine?InSouthAfrica,genericmedicinesaresubjecttothesamestringentqualitycontrolmeasuresasallothermedicines.

What happens if my Chronic Limit is exhausted and I have a Prescribed Minimum Benefit (PMB) Chronic Disease (CDL) condition? Intheeventthateitheryouoryourdependantsareregisteredforoneormoreofthe26PMBCDLconditions(seelistofchronicconditionsonpage23fordetails)andyourChronicLimit(whereapplicable)isexhausted,TopMedwillcontinuetoprovidea100%benefitprovidedyouobtainyourmedicinewithintheformularyandfromtheDSP.

Medical Management of your PMB CDL Chronic ConditionInadditiontothebenefitsprovidedforyourchronicmedicines,youmaybeeligibleforthetreatmentofyourPMBcondition,subjecttoTopMedsTreatmentAlgorithms(Plans),toincludecertainconsultations,pathologytestsetc.ToqualifyforthesebenefitsyouwillberequiredtoregisterforthemwhenregisteringforyourPMBcondition.Please Note: Consultations for non PMB chronic conditions are covered from your available day to day benefit. Toobtaina100%benefityouwillberequiredtoobtaintheaboveservicesfromthePublicHealthcareSectororfromaCareCrossNetworkGP/Specialist.Shouldyouuseyourownserviceprovider,TopMedwillonlypay100%oftheTopMedTariff.PleasenotethatitisveryimportantforyourserviceproviderstosubmittheseclaimswiththecorrectICD-10codetoensurethatyourclaimsmatchtothecorrectbenefit.IfyourproviderssubmitthegeneralICD-10code,whilstvalid,TopMedwillonlypayfromyourday-to-daybenefitsandnotfromthebenefitsprovidedbyyourtreatmentplan.Inaddition,thesebenefitsarenotunlimited,andareprovidedinaccordancewithgeneralindustryguidelinesandinconsultationwithclinicalexpertsinthevariousdisciplines.Additionalbenefitsmaybegranteduponmotivationfromyourserviceprovider.

Non-prescribed medicine (Pharmacist Advised Therapy - PAT)Mostcommonailmentscanbetreatedeffectivelybymedicinesavailableatapharmacywithoutadoctorsprescription. ThesemedicinesmaybeclaimedfromyourPATbenefit.(RefertotheSummaryofBenefitsforyouroption).

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7. CHRONIC CONDITIONS

Prescribed Minimum Benefit - Chronic Condition Disease List

Applicable to all options AddisonsDisease Asthma Bronchiectasis Cardiomyopathy ChronicRenalFailure CardiacFailure ChronicObstructivePulmonaryDisorder(COPD) - Emphysema CoronaryArteryDisease - IschaemicHeartDisease CrohnsDisease DiabetesInsipidus DiabetesMellitus(TypeIandII) Dysrhythmias - VentricularTachycardia - ArterialFibrilationFlutter Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypothyroidism Hypertension MultipleSclerosis ParkinsonsDisease PsychiatricDisorders - BipolarMoodDisorder - Schizophrenia RheumatoidArthritis SystemicLupusErythematosisUlcerativeColitis 23

Extended Chronic ConditionsInadditiontotheconditionslistedinpage 23,thefollowingconditionsarealsoavailable.(Please note that these are only applicable whilst your Chronic Medicine Benefit Limits are available).

Option Extended Chronic ConditionsTopMed Rainbow Comprehensive Unlimited

TopMed Professional AlzheimersDisease AnkylosingSpondylitis AttentionDeficitDisorder BarrettsOesophagus BenignProstaticHyperplasia Cancer ConnsSyndrome ChronicBronchitis CushingsSyndrome CysticFibrosis DeepVeinThrombosis Dermatomyositis Gout Hypoparathyroidism Menopause(HormoneReplacementTherapy) MotorNeuronDisease MuscularDystrophy MyastheniaGravis OrganTransplants(maintenancetherapy) Osteoporosis PagetsDiseaseofBone PancreaticDisease Paraplegia/Quadriplegia(associatedmedicine) Pemphigus PolyarteritisNodosa PsychiatricDisorders - AnorexiaNervosa - BulimiaNervosa - MajorDepression - Narcolepsy - Obsessive-compulsiveDisorder - PanicDisorder - Post-traumaticStressSyndrome - TourettesSyndrome - UnipolarMoodDisorder PulmonaryInterstitialFibrosis Scleroderma Stroke ThromboangiitisObliterans ThrombocytopaenicPurpuraZollinger-EllisonSyndrome

24

TopMed Paladin Comprehensive Osteoporosis Osteopaenia AttentionDeficitDisorder(ADD)/AttentionDeficitHyperactivityDisorder(ADHD) Gout DepressionotherthanprovidedforinPMBs AllergicRhinitisprevention(childrenonly) Psoriasis Osteoarthritis

25

8. MANAGED HEALTHCAREManagedHealthcareisdefinedasanyefforttopromotetherational,cost-effectiveandappropriateuseofhealthcareresources.ThephilosophyofTopMedistoworkwithmembersandserviceprovidersin achieving these aims. TopMeds Managed Healthcare Provider uses clinical funding guidelinesandevidence-basedmedicine in respectof certain servicesandsupplies forwhichTopMed allowsbenefits. Beneficiarieswill only qualify for benefits in respect of those services and supplies if theclinicalguidelinesandprotocolshavebeencompliedwith.

PartofTopMedsManagedCareapproachistoensurethatmembershaveaccesstohealthcarebenefitswhichwillenablethemtolivehealthier,moreactivelifestyles.TopMedsManagementProgrammesareavailabletomemberswithchronicconditions(e.g.highbloodpressure,cholesterol)and/ordegenerativeconditions(e.g.backandjointpain)whererehabilitationsuchasphysiotherapy,biokinetics,prescribeddietsandexercisecanbeeffectiveinreducingrelianceonchronicmedicinesorprevent/delayanoperation.

Eachmemberhasdifferentneedsandconditionsandaprogrammeisindividuallytailoredforthemembersmedicalneeds,inconsultationwithyourdoctorwherenecessary.MemberswhomaybenefitfromtheseManagementProgrammeswouldbecontactedbyoneofourDiseaseManagementNursesORmemberscanalsocontactusdirectinordertoapplyforregistrationononeoftheprogrammes.

Inordertodetermineamemberssuitabilityfortheseprogrammes,wewillasksomequestionsaboutthemembersmedicalhistoryandwherenecessaryariskassessmentwillberequiredfromthetreatingdoctor.Wewouldalsogathersomebaselinemedicalindicatorslikebloodpressure,bloodsugar,weightandheight.

Oncethisstepiscompleted,anappointmentwillbescheduledwitharelevantprovidertodoadetailedassessmentandtreatmentplan.Oncewereceivethisassessment,adetailedmanagementplanisagreedwiththeSchemeandcoveredaspartofthemembersmanagedcareprogrammeorasanalternativetohospitalization.

ThememberwillbeadvisedofthebenefitsthatwillbecoveredbytheSchemeandwillbeaskedtocommittoaregularfollowupprogrammewithaDedicatedProfessionalNurse,whichincludesgatheringresultsoftestsandprogressreportsinordertoevaluatewhetherthememberisbenefitingfromtheprogramme.Theseprogrammewouldtypicallyrunovera6monthperiodwithextensiontoayearifitisagreedwiththedoctorandprovidersthatthememberwillcontinuetobenefit.

26

Disease ManagementDiseaseManagementisaholisticapproachthatfocusesonthepatientsdiseaseorcondition,usingall the cost elements involved. The intervention takes place by means of patient counselling andeducation, behaviour modification, therapeutic guidelines, incentives and case management. If abeneficiary,however,doesnotco-operatewiththeprogramme,TopMedmayrefusetoallowfurtherbenefitsinsofarasitisrelatedtothespecificdisease/condition.Oralternatively,TopMedmaydecidetoonlyallowbenefits fora lower levelofservice.Formore information,contactTopMedsDiseaseManagement Department on 0860 00 21 58.

Oncology (Cancer Management) Itisimportantthatpriortocommencingactivetreatmentforcancer,youareregisteredontheOncologyDiseaseManagementProgramme(SeeSummaryofBenefitsforapplicablebenefitsandlimitsperyourchosenoption).

Who needs to register?Beneficiariesdiagnosedwithapositivemalignanthistologythatrequiressomeformofchemotherapy,radiotherapy,hormonaltherapyand/orsupportivetherapy.

How to register1. AfteryouhavebeendiagnosedwithcanceryourOncologistmustfaxatreatmentplanandthe

histologyresultstotheSchemesOncologyDepartmenton086 762 4050.2. OncereceivedbyTopMed,theoncologydiseasemanagerwillreviewtherequestinaccordance

withrecognisedtreatmentprotocolsandguidelinesforoncologytreatmentbasedonclinicalappropriateness,evidence-basedmedicineandthechosenbenefitoption.Ifappropriate,anauthorisationisgeneratedandaresponseisprovidedtothetreatingoncologist,whointurnwillnotifymember.

3. Additionalinformationmayberequiredfromtheoncologist,suchastestresults,inordertocompletetheregistrationprocess.

Intheeventofanychanges,renewalsandamendmentstoyourtreatmentplan,pleaseensurethateitheryouoryourtreatingdoctoradvisethecasemanagertoensurethatyourauthorisationisupdatedaccordinglysubjecttoapprovalandavailablelimits.

Overview of TopMeds Oncology BenefitsDependingonyourtreatmentplanthefollowingbenefitscouldbeincluded: Chemotherapy,radiotherapyandsupportivetreatment.ThisisreferredtoasanActiveTreatmentPlan. Materialsthatareusedintheadministrationofyouractivetreatment,forexampledripsand

needles,iscoveredwiththeActivetreatment. Technicalplanningscans. Hormonaltherapyrelatedtoyourcancerregardlessofrouteispaidat100%oftheTopMedTariff. Consultationswithyouroncologist. Feeschargedbyaccreditedfacilities. Pathologytestsrelatedtoyourconditionduringactivetreatmentandaftertreatmentforfollow-up

asrequired.

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Supportingmedication,pain,nauseaaswellasothermedicineusedtotreatthesideeffectsresultingfromthedisease,willbecovered. Note:MedicinetocounteractthesideeffectsofchemotherapyandradiotherapywillbepaidaccordingtotheTopMedsOncologyDiseaseManagementProgrammesguidelines.

Cancermedicinereceivedondischargefromhospitalwillbelimitedtosevendayssupplyandispaidfromrisk.

Externalbreastprostheses,specialbras,stomaproductsandoxygenarepaidfromyourappliancelimit. The fees chargedby yourdoctor for administeringmedication, regardless ofwhether it is done

intramuscularly,sub-cutaneouslyorintravenously,arepaidat100%oftheTopMedTariff,irrespectiveofwhetherornottreatmentformspartofhospitalisation.

Note: Medicine to counteract the side effects of chemotherapy and radiotherapy will be paidaccordingtotheTopMedsOncologyDiseaseManagementProgrammesguidelines.

Cancermedicine, chemotherapyand radiotherapy is subject toDiseaseManagementunder thecareofamedicalprofessional.Pleasenotethatbenefitsmaybeforfeitedifmembersdonotcomplywiththetreatmentplan.

Cancermedicinereceivedondischargefromhospitalwillbelimitedto7dayssupplyandissubjecttoavailableday-to-daybenefits.

Pathology,x-rays,doctorvisitsduringactivetreatment,materialsanditemsclaimedasmaterialswillalsobepaidfromthemembersmajormedicalbenefits.

Consultations,pathologyandradiology related tocancerwill continuetobepaidoneyearafteractivetreatmenthasbeencompleted.

Long-termchronicconditionsthatdevelopasaresultofchemotherapyandradiotherapyarenotcoveredunderthisbenefit.

Breast ReconstructionBenefitsareallowedinrespectofreconstructivesurgeryafteramastectomyduetoprovenbreastcancer.Benefitswillbepaidonceonlyforfullreconstructionbywhichevermethod,aswellasforreductionsurgeryontheunaffectedsideforsymmetrywhereindicatedaspermotivation.Onlycomplicationsofatruemedicalnaturewillbeconsideredforbenefitsandnotfailedcosmeticsurgery.

Theannualoncologybenefitslistedbelowarepaidat100%oftheTopMedTariffsubjecttothetreatmentformingpartoftheDiseaseManagementProgramme.

28

Rainbow Comprehensive, Professional , Paladin Comprehensive and Savings

Active Saver Hospital Network Limited

Pre-Authorisation and Treatment Plan

Yes

Cancer Treatment

Chemotherapy,radiotherapyandsupportivetreatment.Treatmentplansubjecttooncologylimit

Chemother-apy,radio-therapyandsupportivetreatment. Treatment

plan limitedtoPMB

Chemotherapy,radiotherapyandsupportive

treatment. Treatment

plansubjecttooncologylimit

PMBtreatment

RefertoBenefitSummary

Surgery for your cancer

Pre-authorisation-partofHospitalManagement

PMB/ Pre-authorisa-tion-Hospital Management

RefertoBenefitSummary

Bone marrow of stem cell transplantation

Benefitpaidat100%ofTTsubjecttooncologylimit

Benefitpaidat100%ofTTsubjecttolimitedtoPMB

Benefitpaidat100%ofTTsub-jecttooncology

limit

PMBbenefitsonly

RefertoBenefitSummary

Donor searches

Nobenefit NobenefitRefertoBenefitSummary

PET Scans

Oneperannumforstaging,thereafterclinicalappropriateness PMBRefertoBenefitSummary

Bone Density Scans

Oneperannumifonaromataseinhibitors PMBRefertoBenefitSummary

Overall Limit

No R1MillionR500000perincident

29

Breast ReconstructionBenefitsareallowedinrespectofreconstructivesurgeryafteramastectomyduetoprovenbreastcancer.Benefitswillbepaidonceonlyforfullreconstructionbywhichevermethod,aswellasforreductionsurgeryontheunaffectedsideforsymmetrywhereindicatedaspermotivation.Onlycomplicationsofatruemedicalnaturewillbeconsideredforbenefitsandnotfailedcosmeticsurgery.

Theannualoncologybenefitslistedbelowarepaidat100%oftheTopMedTariffsubjecttothetreatmentformingpartoftheDiseaseManagementProgramme.

HIV/AIDS ProgrammeAtTopMedwehavebeencoveringHIV/AIDSasabenefit(includingtheprovisionofanti-retroviraltreatmentand,ART)sincetheinceptionofART.TheTopMedHIV/AIDSProgrammegoesbeyondregisteringaconditionandallocatingbenefitsandisdesignedtoaddresstheneedsofpatientsandfamiliesaffectedbyHIVandAIDS.

ManagedbyourDedicatedProfessionalNurses,togetherwithadedicatedHIV/AIDSProgrammeCoordinator,theTopMedprogrammeisafullyconfidentialprogrammethatcoversissuessuchas:

Pre-testingandpre-treatmentcounsellingandplanning Helpinchoosingthetreatmentthatsuitsyourneeds Educationregardingthepreventionoftransmissionaswellashealthcareandnutritional

guidance Monitoringofsideeffectsandresponsetotreatmenttomakesureyourmedicationisworking

foryou Encouragementofadherenceandcompliancewiththeprogrammeandmedication Liaisonwithyourmedicalproviderwhennecessaryandatyourrequest Medicationbenefitsincludinganti-retroviraldrugs Consultationanddiagnosticbenefits Preventionofmothertochildtransmission OccupationinjuryandexposuretoHIVpositivebloode.g.sexualassault Managementofopportunisticinfections

IfyouoranyofyourbeneficiariesareaffectedbyHIV/AIDS,pleasecontacttheHIVProgrammeCoordinatorwhoisinthebestpositiontoassistyouwiththeregistrationprocessandongoingmanagement.

0860 448 2273 (0860 HIV CARE). This is a fully confidential line.

Please note that anti-retroviral drugs may only be obtained once registration has occurred and cannot be authorised through the chronic medication process with Mediscor Chroniline. HIV/AIDS benefits are authorised by TopMed HIV/AIDS Programme only.

SEE DOCTOR

BLOOD TEST

CONTACT TopMed0860 448 2273

(HIV Care)

PLEASE NOTE: ThisbenefitisapplicabletoalloptionsexcepttheNetworkOption.NetworkmembersarerequiredtoregisterthroughCareWorks(seepage13).

(RefertotheSummaryofBenefitsformoreinformation)

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Disease Management ProgrammesManagedCareProgrammesmanagespecificchronicdiseasessuchasdiabetesandcardiovasculardiseases.Theseimprovecontroloftheconditions,preventillnessprogressionandimproveyourhealth.

Diabetes Management

Althoughdiabetescannotbecured,itcanbemanaged.Propermanagementleadstodramatichealthimprovements.AtTopMed,ourcomprehensivediabetesdiseaseandcasemanagementprogrammeisdesignedtosignificantlyimprovethetreatmentandcomplianceofourdiabeticmembers.

Our programme: Identifiespatientswithdiabetesandtheirco-morbidities. Enrollspatientsontotheprogrammeforprimaryandsecondaryprevention. RiskStratification:Stratifiesmembersintolow,moderateandhighriskgroupsfortargetedintervention. Ongoingmonitoringevaluationsandautomaticreminders. Comprehensivereportingonqualityimprovementswithpositivehealthandfinancialoutcomesonan

on-going basis.

Benefits of the programme: Bymeansofourongoingassessmentandgatheringofpertinentinformationweareabletoassess

severitiesandotherco-morbidities. Weareabletopickuptrendsinapatientshealthprofileandintervenetoavoidexpensivehospitalcare. Discreetpackagesofcareareallocatedwhereclinicallyappropriate. Encouragehealthylivingbymeansofourinterventions.

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Organ Transplants and Dialysis

BenefitsinrespectoforgantransplantsanddialysisaresubjecttotreatmentformingpartofaCaseManagement Programme. Benefits are allowed in respectof kidneydialysis and the followingorgan transplants: heart, lung,heart-and-lung,bonemarrow,andrenaldialysis.

PleaserefertotheBenefitSummaryformoreinformationaboutthebenefitsthatyouroptionoffers.Toobtainauthorisationforthisbenefitcall0860 00 21 58.

Mental Wellness

Doyouexperiencesomeorallofthesesymptomsonadailybasis?

Feelings of helplessness and hopelessness. A bleak outlooknothingwill ever get better andtheresnothingyoucandotoimproveyoursituation.

Lossofinterestindailyactivities.Nointerestinformerhobbies,pastimes,socialactivities,orsex.Youvelostyourabilitytofeeljoyandpleasure.

Appetiteorweightchanges.Significantweightlossorweightgainachangeofmorethan5%ofbodyweightinamonth.

Sleep changes. Either insomnia, especially waking in the early hours of the morning, oroversleeping(alsoknownashypersomnia).

Angeror irritability.Feelingagitated,restless,orevenviolent.Yourtolerance level is low,yourtempershort,andeverythingandeveryonegetsonyournerves.

Lossofenergy.Feelingfatigued,sluggish,andphysicallydrained.Yourwholebodymayfeelheavy,andevensmalltasksareexhaustingortakelongertocomplete.

Self-loathing.Strongfeelingsofworthlessnessorguilt.Youharshlycriticizeyourselfforperceivedfaultsandmistakes.

Recklessbehavior.Youengageinescapistbehaviorsuchassubstanceabuse,compulsivegambling,recklessdriving,ordangeroussports.

Concentrationproblems.Troublefocusing,makingdecisions,orrememberingthings. Unexplainedachesandpains.Anincreaseinphysicalcomplaintssuchasheadaches,backpain,

achingmuscles,andstomachpain.

ThiscouldbeasignthatyouaresufferingfromDepression,propermanagementleadstodramatichealthimprovements.AtTopMedourcomprehensiveMentalWellnessprogrammeisrunbyqualifiedPsychiatricNursingSisters,andisdesignedtosignificantlyimprovethetreatmentandcomplianceofour members.

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Benefits of the programme:TelephonicconfidentialsupportfromqualifiednursesDetailedassessmentofyourpersonalriskfactorsandassistancewithregisteringforbenefitstohelpyou to manage your symptomsReferraltospecialistsifnecessaryReducedadmissionstohospitalandbetteroutofhospitaltreatment

How do you register?Contactuson0860002158Askyourdoctortocontactus

Ifyouhavehadanadmissiontohospitaloraretakingmedicinesfordepression,oneofournursesmayalsocontactyoutoinviteyoutojoin.Youwillneedtogiveyourdoctorpermissiontoshareinformationwithusasthebenefitsaresubjecttospecificclinicalcriteria.Thisistomakesurethatwearehelpingmemberswhoneeditthemost.

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Ambulance Services ER24ER24 provides TopMedMedical Schememembers with EmergencyMedical Services throughoutSouthAfricaaswellasinLesothoandSwaziland.ER24hasapproximately250rapidresponsevehiclesandambulances stationedat bases around the country and this national network includesBasic,Intermediate and Advanced Life Support Emergency Services. Together with additional quality-controlledcontractedserviceproviders,ER24snational footprintensurespromptresponseof themostappropriateteamofparamedicsatalltimes.

Inordertoensureefficientandeffectivecall-takingandcall-handling,ER24usesonenationalnumber 084 124operatedthroughahigh-techemergencyContactCentre,24hoursaday.ER24sclinicalstaffareallhighlyspecialisedinemergencycareandincludefriendlyandhelpfulprofessionalnursesandparamedicswhoaresupportedbytheER24ChiefMedicalOfficer.Dailytransferofschemedataallowsproviderstoconfirmmemberstatusafter-hours.

Why should I call ER24?ER24isTopMedsPreferredProviderforanyambulanceservices.Ifservicesarenotrenderedby(orthroughtheinterventionof)ER24,benefitswillbelimitedtoaspecifiedmaximum(pleaserefertotheSummaryofBenefitsfordetails).

What to do in the event of a medical emergency: Alwayscall084124. Ifsomeoneiscallingonyourbehalf,tellthemtocall084124.

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Medical Information and Assistance HotlineER24medicalpersonnel,includingparamedics,nursesanddoctors,willbeavailable24hoursadaytoprovidegeneralmedicalinformationandadvice.Thisisanadvisoryandinformationservice,asatelephonicconversationdoesnotpermitanaccuratediagnosis: Membersareencouragedtoutilisethis24hourcost-savingservice. Ourdoctorsandnursesusemedicaldatabasealgorithmsandprotocolstoadvisemembersonhealthcaresolutions. Memberscanfirstseekadviceasto:- Urgencyofattentionneeded-dispatchambulance,gotohospital,gotodoctor,gotopharmacyforOTCmeds,self-medicatefromhome.- DoctorandfacilityreferralforschemebenefitDSPse.g.networks,GPs,hospitalsandpharmacies.- Genericmedicationadvice.

Crisis Counselling and Referral HotlineInadditiontoourmedicalinformationandassistanceline,allTopMedMedicalSchememembershaveaccesstotelephonicTraumaCounsellingwheretrainedcounsellorswillprovideassistancewith,interalia,thefollowing: Poisonadvice Suicidehotline Substanceabuse Domesticandchildabuse RapecounsellingandreferraltoRapeCentres Bereavementcounselling Hijacking HIV/Aidsinformationandcounselling

Claims QueriesForanyclaimsenquiries,youcanphone0861 084 124 ore-mailclaims@er24.co.za

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Optical BenefitsTopMedhaspartneredwithPreferredProviderNegotiators(PPN)fortheadministrationoftheOpticalbenefitsonthefollowingoptions:

TopmedRainbowComprehensiveTopMedProfessionalTopmedPaladinComprehensive

PPNwillprovidethefollowingservicesformembersontheaboveoptions: Benefitconfirmations Claimsreceiptandprocessing Claimspaymenttomembersandproviders

PPN has 20 years experience in the field of optometry benefits management and has over 2500contractedproviders (90%ofall registeredoptometrist) thatwillaffordTopMedthebestpricing forclearspectaclelenses.ByconsultingataPPNprovider,memberscansaveupto70%onclearlenses.

ToensurethatyourproviderbelongstothePPNnetwork,eithervisitthePPNwebsitewww.ppn.co.zaorcallthePPNcallcenteron0860103529.

PLEASE NOTE:

ForTopMedsRainbowComprehensive,ProfessionalandPaladinComprehensiveOptionyouropticalclaimsMUSTbesenttoPPN.

Claimscaneitherbeemailedtoclaims@ppn.co.zaorfaxedto0415065750.

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Maternity ProgrammeTopMedoffersaMaternityProgrammeonalloptions(except the TopMed Network and TopMed Limited Options).Toenjoythisbenefityouarerequiredtoregisterontheprogrammewhenyouarebetween12and20weeksinyourpregnancy.

How to registerMembersmustphonetheTopMedMedicalSchemememberCallCentreon0860 00 21 58.

When you call to register, please have the following information ready: Acontactoremailaddress; yourGP,gynaecologistorregisteredmidwifesnameandsurname; yourGP,gynaecologistorregisteredmidwifespracticenumber; yourexpecteddateofdelivery; whetherornotyouvehadamiscarriagebefore;and whetherthisisyourfirstchild.

AspartoftheprogrammeoneofTopMedsin-housemidwiveswillcontactyouonaregularbasistoofferadvice,supportandencouragement,andyouwillbecontinuouslymonitoredthroughoutyourpregnancy.

MATERNITY PROGRAMME BENEFITS REGISTER BETWEEN 12 AND 20 WEEKS

Antenatal Consultations - Tariff Codes: 190-192 12consultationsfromMaternityProgramme

Antenatal Scans - Tariff Codes: 3615/3617/5107 2fromMaternityProgrammethereafterfromDay-to-DayBenefit

Antenatal Classes - Tariff Code 88407 PaysfromtheMaternityProgramme

Antenatal Vitamins and Iron Supplements PaidfromCore-BasketgeneratedonRegistration

Paediatrician Visit 2Consultationsfornewborns37

What information should be contained in a claim in order for it to be processed? Surnameandinitialsofthemember,membershipnumber,nameanddateofbirthofthepatient,

aswellasthedoctorspracticenumberandthenature,relevantICD-10code,servicedateandcostofeachservicerenderedoritemsupplied.

Medicineclaims:thename,quantity,dosage,thegrossamountoftheclaim,therelevantdiscountreceived by themember, and a receipt confirming the net amount payable by themember inrespectofthemedicinedispensed,therelevantnationalpharmaceuticalproductinterface(NAPPI)code,andtherelevant ICD-10code.Non-electronicaccountspayablebythemembermustalsobeaccompaniedbyacopyoftheoriginalprescriptionmadeoutbyapersonlegallyauthorisedtoprescribethemedicine(ifapplicable)andproofofpaymentmustbeattached.

Medicineprescriptionsthatarerepeated: inadditiontotheabove,anotationfromthemedicalpractitionerwhoprescribesthemedicine,specifyingthenumberofrepeats.

Dentalclaims:thenumberofeachtoothtreated.Pleaseincludethelaboratoryslipwhensubmittingyourclaims.

Surgicalclaims:thename,practicecodenumberandregistrationnumberissuedbytherelevantregisteringauthorityofeverymedicalpractitionerordentistwhoassistedintheperformanceofthatoperation.

* Please Note: Failure by your Service Provider to include the mandatory ICD-10 code on a claim will lead to the rejection of that claim and non-payment by TopMed.

What is the deadline for the submission and payment of a claim?Aclaimmustbesubmittedwithinfourmonthsfromtheendofthemonthinwhichtheservicewasprovided,orwithinfourmonthsfromtheendofthemonthinwhichitwasreturnedbyTopMedforanycorrections.Ifnotsubmittedwithinthisperiod,theaccountwillNOTbepaid.ThisdeadlinealsoappliestoclaimspaidfromyourMedicalSavingsAccount.

How will I know when my claim has been settled?Attheendofeachmonthyouwillbesentaclaimsadvice.Allclaimsprocessedduringthemonthwillbelisted.Shouldyouhaveanyqueriesonhowtoreadthisdocument,pleasecontactClientServiceson0860002158.YoucanalsoviewyourclaimsontheTopMedwebsitewww.topmed.co.zaForsecurityreasonsyouwillneedtoregisterausernameandpasswordbeforeyoucanlogintoviewclaims.Forassistancewithloggingin,pleasecallClientServicesasabove.

9. PAYMENT OF CLAIMS

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Claimstatementsincorporatethefollowinginformation: ThebenefitamountpaidbyTopMedandtheperson/serviceprovidertowhompaymenthasbeenmade ThemoneyowedtoyoubyTopMed(ifany) TheamountowedbyyoutoTopMedoranyprovider(doctor,hospitaletc)ifany

Inadditiontoyourmonthlyclaimsstatement,subjecttoTopMedhavingavalidemailaddressforyou,youwillalsoreceiveanemailnotificationaftereveryclaimspaymentruninwhichwehavepaidclaimssubmittedbyyouoryourproviderofservice.

Differentprovidershavedifferentmethodsofbillingtheirservices.SomeproviderswillsubmitdirectlytotheSchemewhileothersmayhavecashpracticesanddonotdealwiththeScheme.

Forexample,PharmaciesandHospitalswillusuallysendclaimselectronically.GeneralPractitionerswillusuallysubmitclaimsdirectlybutitisbesttocheckwithyourdoctor.

SomeSpecialistruncashpracticesforconsultationsintheirconsultingroomsbutwillbilldirectlyforhospitalprocedures.ThisvariesbyproviderandisnotcontrolledbytheScheme.Wethereforerecommendthatyoudiscussthemethodofbillingwithyourdoctororthereceptionistatthedoctorsroomtoensurethatyouknowwhetheryouwillneedtosubmitaclaimyourselfornot.

TopMed Limited: Otherthanthehospitalaccount,membersmustfirstpayandthensubmitclaimsonaclaimform.

Note: If you received a discount on an account, you will only be entitled to the lower benefit amount after the discount was taken into consideration.

Tariff PayablePleasenotethatthepaymentofclaimsissubjecttotheNRPLGuidelineswhicharesubjecttocertainrulesasoutlinedinthetariffguide.Asanexample,whenmultipleproceduresareperformed,modifiersareused,asfollows,namely: Mainprocedure-100%oftheTTispayable2ndprocedure-75%oftheTTispayable3rdprocedure-50%oftheTTispayableetc.

Theserulesareanindustrystandardandwillapplywhereapplicable.

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10. RESOLVING PROBLEMS AND QUERIES

Thefollowingtableillustrateshowtologatelephonicoremailquery,problemorcomplaintinthemosteffectivemanner.

CallClientServices0860002158for:

ClaimspaymentandaccountsBenefitsContributionsNewcardsUnderwritingContactdetailsDesignatedServiceProviderFormularies

CallaDedicatedProfessionalNurses0860002158for:

HealthAdviceHIVMaternityProgrammeEx-GratiaMedicalQueriesProtocolforPMB,ChronicBenefit,Investigationand Procedures

ForEscalatedQueries

OperationsManager0860002158

or

AdministratorsChiefOperatingOfficer0860002158

DisputesandcomplaintsmayalsobepostedtoQueries/ComplaintsatTopMed,P.O.Box1462,Durban,4000orviaemailtoinfo@topmedms.co.za.Itisimportanttofollowtheprocessdepictedaboveasitwillprovideyouwitharesponseintheshortestpossibletime.

ShouldyoufeelthatyourconcernsarenotbeingaddressedyoumayalsocontactthePrincipalOfficeratprincipalofficer@topmed.co.za

Ifyourissuesarenotresolvedthroughtheaboveprocess,membersmayalsoappealviatheCouncilforMedicalSchemesoncomplaints@medicalschemes.co.za.

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11. CO-PAYMENTS AND DEDUCTIBLES A CO-PAYMENT isaspecificpercentage,randamountorthedifferenceyouwouldneedtopayfromyourownpocketifyourproviderchargesmorethantheTopMedTariffforyouroptionorthebenefitspecifiesaco-paymente.g.MRIandCTScans,ExtendedCoverandsomemedicines.

Aco-paymentcannotbepaidfromyourYearlyLimitifyouarememberoftheRainbowComprehen-siveorPaladinComprehensiveoptionsandyouneedtosettlethisdirectlywithyourprovider.IfyouareamemberofanoptionthatoffersaMedicalSavingsAccount(MSA)youmayrequesttohaveyourco-paymentsrefundedtoyoufromyourMSAprovidedthatyouhaveapositivebalance.

A DEDUCTIBLEisaspecificamountthatisdueforaspecificprocedureaspertheSchemeRules.TheDeductibleappliestothehospitalaccountandneedstobepaidbythemembertothehospital.IfthehospitalbillstheSchemethefullamount,theSchemewillpaytheclaimlesstheDeductiblewhichwillberecoveredfromthememberbythehospital.

CertainproceduresontheProfessional,PaladinComprehensive,ActiveSaverandNetworkoptionsattractadeductible.PleaserefertotheBenefitSchedulesformoredetails.

Co-PaymentsandDeductiblesdonotapplytoconfirmedPrescribedMinimumBenefitstreatedataDesignatedServiceProviderandaspertheSchemeprotocols.Medicalreportsmayberequiredtocon-firmthediagnosisandprotocolasbeingconsistentwiththePrescribedMinimumBenefitentitlement.

Avoiding a Tariff Co-Payment on your hospital accountHospitalbenefitsandcertainspecifiedproceduresperformedinhospitalarelimitedto100%-300%oftheTopMedTariffdependingonyouroption.TopMedhasnegotiatedwithcertainhospitalgroupstoprovideservicesformembersatthenegotiatedTopMedTariff.TheseprovidersareknownasPreferredProviders(PP).

Note:APreferredProviderdiffersfromaDesignatedServiceProvider(DSP)inthatTopMedhasne-gotiatedarateforallservicesataPreferredProviderwhereasaDSPisspecificallyforPMBservices.ServicesprovidedataPreferredProvidermaybelimitediftheyexceedsub-limitswhereasservicesataDSPareunlimitedforPMBconditions.

Youhavethefreedomofchoicetouseanyoneofhospitalgroups,dependingonyouroption,butmaybeliableforaco-paymentifyouareadmittedtoahospitalthatisNOToneofthePreferredProviders.ItisrecommendedthatyoucheckwithourClientServicespriortoadmissiontodeterminewhetherthehospitalyouwillbeusingisaPreferredProvider.

TopMedLimitedisatraditionaldesignoptionwithspecificbenefitlimitsreimbursedonan80%basisfordoctorsandhealthcareprovidersandaslidingscaleco-paymentforhospitalaccounts.* Co-payments applicable to TopMed LimitedMembersontheLimitedoptionhaveco-paymentsforallclaims.Non-hospitalclaimswillhaveaco-paymentof20%,exceptforMRI/CTscanswheretheco-paymentisR1000perscan.Privatehospitalclaimswillhaveaco-paymentof50%ofthefirstR4650perincident,thereafter10%oftheremainder,uptoamaximumco-paymentofR10000.*WithdueregardtoPMBs.

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The following are general exclusions, but may be claimed from the Medical Savings Account:

Substancedependency,unlesstreatmentformspartofaCaseManagementProgramme Bandages,cottonwool,plastersandotherhouseholdfirst-aiditems,unlessthesearesuppliedduring

astayinhospital Examinationsforpurposesofinsurance,employment,lawsuitsandsimilarpurposes Cosmeticandreconstructivesurgery,includingsurgeryforprotrudingears,eitherbythemembers

or dependants own choice, or where recommended for psychological reasons only - and anycomplicationsarisingfromsuchsurgery

WheremorethanoneclinicalprocedureordiagnosisrequiringaPARisperformedatthesametimeandaPARwasnotobtainedforall theprocedures,nobenefitswill be granted for complicationsarisingfromanyoftheprocedures

Beautytreatments,beautypreparationsandcosmetics Examinationsand/ortreatmentwherenorealordiagnosedillnessexistsandsuchexaminationor

treatmentwasrecommendedpurelyforpsychologicalreasons Examinationsand/ortreatmentforsterilityorerectiledysfunction Artificialinsemination Marriagecounselling Birthcontrol,exceptoralandinjectablecontraceptivesandIUDs Breathingexercises,antenatalandpost-natalexercises,groupexercisesandfitnesstests Treatmentofobesity Hyperbaricoxygentreatment Telephonicconsultations Servicesofsocialworkers,unlessformingpartofaCase/DiseaseManagementProgramme Feesformedicalreports AlldesensitisationtreatmentandALCATallergytests Sclerotherapytreatment,unlessavascularsurgeonisresponsibleforthetreatmentwhereitforms

partofthesurgicalremovalofvaricoseveins Treatmentofkeloids,exceptinthecaseofburnsrequiringaPAR Refractivesurgery Functionalreconstructionofpalateanduvula(uvulapalatopharyngoplasty) Acupuncture,ReflexologyandAromatherapy Injuriesduetoprofessionalsport(exceptonTopMedActiveSaver) Pet-scansunlessformingpartofaDiseaseManagementProgramme Haemapurebloodproducts TreatmentformingpartofaClinicalTrialorExperimentalDrugs AllassociatedcostsforElectiveKnee/HipReplacementsontheTopMedNetwork,ActiveSaverand

HospitalOptionsonly(Onlycoveredintheeventoftrauma) Biologicaldrugs/medicineunlessformingpartofaDiseaseManagementProgrammeandsubjectto

clinicalprotocols.

12. GENERAL EXCLUSIONS

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The following are general exclusions and cannot be claimed from the Medical Savings Account

Eyeexaminationsorvisiontestingbyanyoneotherthananeyespecialistorregisteredoptometrist,andthecostofanyinstrumentotherthanspectaclesorcontactlenses

Travelexpenses-exceptforthetransportationofthepatienttoandfromhospital Applicators,toiletpreparationsandcosmetics Holidaysforrecuperativepurposes Accommodationinretirementhomes,frail-careunits,long-term-careunitsandsimilarinstitutions Non-prescriptionsunglasses Costs rejected by TopMed, due to them either being fraudulent or not clinically or medically

necessary,asindicatedbyTopMedsexternalauditingcompany ThedifferencebetweenMRPandthecostschargedformedicine. CostschargedbyaProviderforModifier0018.

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Exclusions applicable to Basic and Specialised DentistryThefollowingtreatmentisnotcovered.Thememberisliableforthetotalcostoftheseprocedures:

Ozonetherapy Orthognathic (jaw corrections) surgery and the related hospital cost (except on the TopMed

RainbowComprehensiveoption). Snoringappliances CostofMineralTrioxide Costofprescribedtoothpastes,mouthwashes(e.g.Corsodyl)andointments Oraland/orfacialimage(Digital/conventional) Microbiologicalstudies Cariessusceptibilitytest Pulptest Occlusionanalysismounted Pantographicrecording Electrognathographicrecordingwithout/withcomputeranalysis Polishingcompletedentition Removalofgrosscalculus Topicalapplicationoffluoride-adult NutritionalandTobaccocounselling Resincrownanterioranteriorprimarytooth(direct) GoldfoilclassI-V Inlays/Onlays Crowncastmetal/porcelain/ceramic Provisionalcrown Veneers Prefabricatedmetalorresincrown Re-burnishingandpolishingofrestorationscompletedentition. Carverestorationtoaccommodateexistingclasporrest Pedicleflappedgraft Costofboneregenerative/repairmaterial Interim,partialorcompletedenture Diagnosticdenture Locksandmilledrest Precisionattachment Metalbasetocompletedenture Remountcrownorbridgeforprosthetics Alteredcasttechnique Additivepartialdenture Connectorbarimplantsupported Implants Clasporreststainlesssteel Stressbreaker CopingMetal

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OrthoTx-fixedlingualorthodontics Therapeuticdruginjection Bleaching Specialreport Appointmentnotkept/30min Sedativefilling Enamelmicroabrasion Behaviourmanagement Implantsandallassociatedcosts(exceptontheTopMedRainbowComprehensiveoption). Generalanaestheticforbeneficiariesfrom7yearsofage

Exclusions applicable to optical benefits

Adjustmentofframes Fittingofcontactlenses Coloured/tintedcontactlenses Sunglassesortintedlenses Contactlenssolutions Hardcoatingandotherextras

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Exclusions applicable to Acute Medicine Patent,patentpreparationsandhouseholdremedies Patentfood-stuffs,includingbaby-foodandspecialformulae Tonics,nutritionalsupplements,multi-vitaminpreparationsandvitamincombinations,except

forprenatal,lactationandpediatricuse(exceptontheTopMedRainbowComprehensive,TopMedPaladinComprehensiveandTopMedActiveSaveroptions).

Slimmingpreparations Birthcontrolpreparations,exceptoral-andinjectablecontraceptivesandIUDs Anti-smokingpreparations SurgicalappliancesanddevicesunlessbasedonEBMprotocols Diagnosticagentsandappliances,exceptdiabeticaccessories Medicineusedspecificallytotreatalcoholism,exceptifusedaspartofaBeneficiarys

rehabilitationtreatmentatarecognisedfacility Thepurchaseofoxygendeliverysystems Aphrodisiacs Anabolicsteroids Sunscreensandtanningagentsincludingemollientsandmoisturisers Cosmeticpreparations,soaps,shampoosandothertopicalapplicationsmedicatedorotherwise

exceptforthetreatmentoflice,scabies,andotherparasiticandfungalinfections Singleorcombinedmineralpreparations,exceptforcalciumpreparationswith300mgormore

ofelementalcalciumusedforthepreventionandtreatmentofosteoporosisandpotassiumwhenusedinconjunctionwithadiuretic(exceptontheTopMedRainbowComprehensive,TopMedPaladinComprehensiveandTopMedActiveSaveroptions).

Contactlenspreparations Preparationsnoteasilyclassified Stimulantlaxatives Treatmentoferectiledysfunction,e.g.Sildenafiland/orsimilarremedies Productsusedforincontinence Immunoglobulinsunlessprotocoldriven Injectionmaterial,exceptdiabeticinjectionmaterial BiologicalDrugsunlesspartofaDiseaseManagementProgrammeandsubjecttoClinical

Protocols46

13. DEFINITIONSAct TheMedical Schemes Act, 1998, as amended or replaced from time to time, and the regulationspromulgatedthereunder

Acute MedicineMedicineusedfordiseasesorconditionsthathavearapidonset,severesymptoms,andthatrequireashortcourseofmedicinetreatment,aswellasmedicinesthatqualifyforbenefitsbuthavenotbeenclassifiedaschronicmedicinebyTopMed.

AdultAdependantwhois21yearsorolder.

Agreed TariffWhere agreements have been entered into with preferred providers, the tariff as specified intheagreements,asamended fromtimetotime,and/or formedicine thesingleexitpriceplus thenegotiateddispensingfeesubjecttoMMAP.

Annual ThresholdAThresholdisasetvaluetobereachedbeforeclaimsforday-to-daymedicalexpensesarecoveredfromMajorMedical.Allday-to-dayclaimspaidfromthemembersYearlyLimit/MSAorself-funded,accumulatetowardsreachingthisthreshold.Oncethisthresholdlimitisreached,furtherday-to-dayclaimswillbepaidbyTopMedsubjecttobenefitlimitsasstipulatedinthebenefitsummaryforeachoption.

Application DateThe date onwhich the application formembership of TopMed, or registration of a dependant, isactuallyreceivedbyTopMed.

BeneficiaryEachindividualmemberanddependant.

Case Management ProgrammeAprocesswhereby clinically indicated, appropriate and cost-effective healthcare, as an alternativetohospitalisation,orotherwise, isofferedtobeneficiarieswithspecifichealthcareneeds-whetherTopMedprescribesitorapprovesitonapplicationbyabeneficiary.

ChemotherapyMedication used in the cure and containment of cancer. This includes cytostatics and hormoneinhibitorsandexcludesmedicationforthesideeffectsofchemotherapy.

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Chronic MedicineMedicinethatmeetsallthefollowingrequirements:

prescribedbyamedicalpractitionerforanuninterruptedperiodofatleastthreemonths;and fora conditionappearingonTopMeds listofapprovedchronic conditionsasamended from

timetotime;and whichhasbeenappliedforinthemannerandatthefrequencyprescribedbyTopMedfromtime

totime,andwhichapplicationhasbeenacceptedbyTopMed.

Clinical ProcedureAprocedurecategorisedassuchbytheBoardofHealthcareFunders.

Dental ImplantsPlacementofmetalrodsintothejawboneintheplaceofamissingtoothtoprovideastructureuponwhichacrownordenturecanbeplaced.

DependantThefollowingpersonsforwhomthememberisliableforfamilycareandsupport,andwhoarenotmembersordependantsofmembersofanyothermedicalschemeand,ifapplicable,whoaredulyregisteredasdependantsbyTopMed: aspouse/partner;and/or achild-includinganadoptedchild,stepchildorfosterchild;and/or theprincipalmembersparents,sistersandbrothers;and/or anyotherpersonapprovedbyTopMed.

Designated Service Provider (DSP)TopMeds chosen service provider used to offer benefits in respect of the Prescribed MinimumBenefitconditions.

Disease ManagementAholisticapproachfocusingonthepatient,usingallthecostelementsofthediseasetoidentifythepatienteligibleforadiseasemanagementprogramme.Theinterventiontakesplacebymeansof:

Patientcounsellingandeducation Behaviourmodification Therapeuticguidelines(theapplicationof) Incentivesandpenalties;andCasemanagement.

Effective DateThedateonwhichabeneficiarybecomesentitledtobenefits.

Extended Cover / Above Threshold BenenfitCoverprovidedbytheSchemefordaytodayclaimsoncetheYearlyLimit/MSAisdepleted,andasetThresholdvalueisreached.Oncethisthresholdlimitisreached,furtherday-to-dayclaimswillbepaidbyTopMedsubjecttobenefitlimitsasstipulatedintheRules.

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EmergencyEmergency-aconditionmanifestingitselfbyacutesymptomsofsufficientseverity(includingseverepain),whereoftheabsenceofimmediatecarecouldreasonablybeexpectedtoresultin:placingthehealthofabeneficiaryorunbornchildinseriousjeopardyseriousimpairmentofbodilyfunctionsseriousdysfunctionofanybodilyorgan,limborsystem

FamilyAmemberandhis/herdependants.

FormularyAdefinedlistofmedicineusedinthetreatmentofvariousdiseases.

HospitalIncludesamentalhealthinstitution,registeredunattachedtheatreanddayclinic,butexcludesaninstitutionforrehabilitationforsubstanceabuse.

Inception DateThedateonwhichapersonbecomesamemberofTopMedoronwhichadependantsregistrationbecomeseffective.

Late JoinerAnapplicantortheadultdependantofanapplicantwho,ontheApplicationDate, is35yearsorolderbutexcludesanybeneficiarywhoenjoyedcoveragewithoneormoremedicalschemesasfromadatepreceding1April2001,withoutabreakincoverageexceedingthreeconsecutivemonthssince1April2001.

Major Medical BenefitsInsuredbenefitsforservicessuchashospitalisationandthetreatment/proceduresperformedwhilstabeneficiaryis hospitalised.

Maxillo-Facial SurgeryThetreatmentofcystsandtumoursofthejaw,aswellasconditionsofthesalivaglands;thetreatmentofabscessesofthejaw,excludingperiodontaltherapy;and/orthetreatmentofalltraumastotheboneandsofttissueoftheface;orthesurgicalremovalofteeth.

Medical Savings AccountAsavingsfacilitytowhichmemberscontributemonthly.Acreditequalto12xthemonthlysavingscontributionisavailableupfronttobeutilisedinrespectofalmostanymedicalservicesorsupplies;evensomeofthosethatareotherwiseexcludedfrombenefitsontheTopMedActiveSaver,SavingsandProfessionalOptions.

MedicineAsubstanceregisteredundertheMedicinesandRelatedSubstancesControlActof1965,asamendedorreplacedfromtimetotime.

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Mediscor Reference Price (MRP)ThemaximumpricethatTopMedispreparedtopayforamedicinewithgenericalternatives.MRPsetsareferencepriceforalistofgenericallysimilarproductsatwhichtheseproductsarereimbursed.

MemberApersonwhohasbeenregisteredasamemberbyTopMed.

MinorAdependantwhoisnotyet21yearsold.

NRPL List (National Reference Price List)Thetariffandapplicablerulesforspecificservicesorsuppliesprovided,basedonthe2006NRPListpublishedbytheCouncilforMedicalSchemes,withannualinflationaryincreases.

OrthodonticsBracesandremovableplateswhichrealigntheteethwithinthejawbone.

Periodontal surgeryAdvancedtreatmentofguminfectionwhichincludesdeepcleaningofrootswiththegumflappedopenandgraftingoforaltissue.

Pre-Authorisation Reference Number (PAR)AnumberallocatedbyTopMedsmanagedhealthcareagent,whichisrequiredbeforecertainservicesqualifyforbenefits.

Preferred ProviderAServiceProviderwithwhompreferentialrateswerenegotiatedbyoronbehalfofTopMed,orwhoispartofapreferredprovidernetworkcontractedfororonbehalfofTopMed.

Prescribed Minimum BenefitsTheminimumbenefitsthatTopMedisobligedtoprovideundertheAct.

RegistrarTheRegistrarofMedicalSchemesappointedintermsoftheMedicalSchemesAct.

Self-Payment Gap Aperiodduringwhichamemberwillberequiredtofundacertainportionofday-to-dayclaimsfromhis/herownpocketafterthePrivateFund(YearlyLimit)/MedicalSavingsAccountisdepleted.

Service DateIntheeventof: hospitalisation-thedateofeachdischargefroma hospital;orterminationofmembership,

whichevertakesplacefirst anyotherserviceorsupplies-thedateonwhichtheservicewasrenderedorthesupplies

obtained,whetherforthesameillnessornot.

Service ProviderAmedical practitioner, dentist, pharmacist, nurse,medical auxiliaryorhospital duly registeredorlicensedassuchwithastatutorycouncilorrelevantstatedepartmentorifpractisinginaterritoryoutsideSouthAfrica,registeredorlicensedassuchwithasimilarbodyinthatterritory.

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TopMed TariffTheratethatisapplicableforthepaymentofbenefits,includingtheNRPLRateoramendedrateaspublishedbyTopMedoritsagentfromtimetotime.

ThresholdAspecifiedamount,calculatedaccordingtofamilysize,towhichcertainday-to-dayclaimsaccumulatewhenpaidfromyourMedicalSavingsAccount,PrivateFundorfromyourownpocket.Oncethethresholdamountisreached,TopMedwillstart