Product Brochure 2016 - Life Insurance | Invest | Insure

2016

Product Brochure

You can’t put a priceon experience…

With a proudly South African heritage spanning over 33 years, Bonitas has an intimate understanding of how the healthcare industry works. Our aim is to make quality healthcare accessible to all South Africans and add value to their lives.

Affordable and generous, our benefits are designed to give our members more value for money. We have a wide range of products that are simple to understand so you know exactly what you’re covered for. They’re also easy to use, ensuring you get the support you need when you need it.

Our members know that when things get tough, we’re there to support them and take care of the little details so that they can receive the best of care and focus on getting better.

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Please note: The information contained in this brochure is subject to approval by the Council for Medical Schemes. Terms, conditions and Scheme rules apply. Version CMS2.

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Index

Introduction to Bonitas Page 08Why choose Bonitas Page 10 Standard Page 12Standard Select Page 18Primary Page 24BonComprehensive Page 30BonClassic Page 36BonSave Page 42BonFit Page 48BonEssential Page 52Benefit and Process Guides Page 56YourHealth Portal Page 56Maternity Page 57Prescribed Minimum Benefits Page 57Managed Care Page 59Medicine Management Page 60 Pharmacy Advised Therapy (PAT) Page 60 Chronic Medicine Page 60 Pharmacy Direct Page 61

Hospital Management Page 62Networks Page 64 GP Network Page 64 Specialist Referrals Page 64 Specialist Network Page 64 The Standard Select and BonFit Hospital Network Page 64Dental Benefits Page 64Optical Benefits Page 66Diabetic Program Page 67Hip and Knee Replacement Program Page 68HIV/Aids Management Page 68Emergency Medical Services Page 69Exclusion List Page 70Termination of Bonitas Membership Page 72How-To Guide Page 76

INDEX

Introduction to Bonitas

Page 8

A customer-centric approach

Bonitas brings you more

More experience: 33 years of experience in the healthcare industry = an intimate understanding of the needs of South Africans.

More support for customers – your every claim & query is met with superior support & advice.

More payouts than any other open medical scheme.

At Bonitas, we are committed to making quality healthcare accessible to all South Africans.

It is this focus that drives our development of affordable, generous and easy-to-understand benefits that offer excellent value for money.

We strive to give members the best advice when it comes to choosing the right product to suit their specific needs and pride ourselves on superior member support to ensure that every Bonitas experience is a great one.

That’s why we’re the second largest open medical scheme in the country.

Visit our website at www.bonitas.co.za to learn more about our products.

93%

Free flu vaccines & HIV tests on all options.

The only medical scheme to pay for dental benefits from risk.

The largest GP network in SA.

More & more members trust us to look after their healthcare needs.

More Added Value

What more reason do you need?

Why choose Bonitas

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Why choose Bonitas?Consider these factors when choosing the right

medical aid plan to suit your specifi c needs.

Assessment of your healthcare needs:How often do you and your family visit the doctor?

• Do you and your family often require medication?• Do you or your dependants need to visit a specialist?• Do you or anyone in your family need extra cover for cancer, HIVAIDS or any

other chronic condition?

Broker assistance:• A fi nancial advisor or broker can advise on which

plan best suits your needs and your budget.

Cover requirement history:

Adult Dependant: Any dependant on your medical aid who is 21 years of age or older.

Child Dependant: Any dependant on your medical aid who is under the age of 21 years. If your child is a student and is registered on your medical aid, child ates will apply up to and including the last day of the month, in which they turn 24 years of age. You will need to send us valid proof of registation from a recognised tetiay institution for this to apply.

Special Dependant: These include other members of your family that are currently fi nancially dependent on you for care and suppot, such as gandchildren, parents-in-law and siblings. Your application might be subject to undewriting.

Underwriting: Your membership may be subject to undewriting which include late joiner penalties, condition specifi c or geneal waiting periods. Undewriting aff ects your benefi t date.

Pro-Ration: If you join Bonitas during the year, benefi ts will automatically be pro-ated. This means that you will only have access to a percentage of your benefi ts based on the month you join us until the next benefi t year begins. For example, if you join in June, you will have access to six months’ woth of benefi ts, which is 50% of the total benefi ts.

Bonitas rates vs. Private rates All claims will be paid at the Bonitas Rate. This will vay between 100% and 300%, depending on the option chosen. Some sevice providers might charge you private ates for sevices. This means you will have to pay the diff erence yourself. Please check which ate your provider is charging before you receive treatment.

For more information, contact us on 0860 002 108.

If you haven’t claimed at all or have had few medical expenses and are unlikely to claim unless a major medical emergency, you will probably require a low level of coverage. If you have had a large amount of medical expenses, it is likely that you require a higher level of cover.

Some plans require that you use a specifi c GP and hospital network or a selection of preferred providers in order to claim your expenses. This helps to keep your costs as low as possible. If you would prefer to have freedom to use any provider, you may need to opt for a more expensive plan.

Decision to use network

Standard

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If you are single or married with children and wanting peace of mind that your family’s general medical needs are covered, without having to break the bank then this product is perfect for you.

Overall annual limit (OAL) - Unlimited

MONTHLY CONTRIBUTIONS

IN-HOSPITAL BENEFITS

These benefits include major medical events.

GP consultations Unlimited, at 100% of the Bonitas Rate

Specialist consultations Network Specialists:Unlimited, covered in full

Non-network Specialists:

Unlimited, covered at 100% of the Bonitas Rate

Pathology Unlimited, at 100% of the Bonitas Rate

General radiology Unlimited, at 100% of the Bonitas Rate

Specialised radiology Unlimited, subject to pre-authorisation

Paramedical services (Allied medical professions) - speech therapy, occupational therapy, dietetics

Unlimited, at 100% of the Bonitas Rate

Prosthesis internal and external R37 900 per family, per year

ICPS is the **DSP for hip and knee replacements a R5 000 co-payment is payable when not using the DSP.

Internal nerve stimulators R142 000 per family, per year

Cochlear implants R250 000 per family, per year

Mental health hospitalisation R34 800 per family, per year

Take home medication (TTO) R400 per beneficiary, per admission

Physical rehabilitation R42 500 per family, per year

Alternatives to hospitalisation R14 200 per family, per year

Oncology R295 400 per family, per year

Organ transplants Unlimited, subject to treatment protocols

Renal dialysis Unlimited, subject to treatment protocols

OUT-OF-HOSPITAL BENEFITS

Out-of-hospital claims excluding Network GP consultations will be paid from current available savings first. Once savings are depleted, claims will be paid from the day-to-day benefit .

DAY-TO-DAY BENEFITS

The day-to-day benefit covers out-of-hospital general radiology, pathology, paramedical services (such as audiology, physiotherapy, occupational therapy and more) and specialist consultations, if referred by your family doctor.

Main member only R4 020

Main member + 1 dependant R6 140

Main member + 2 dependants R6 590


Main member + 4 or more dependants R7 600

GP consultations In-network Out-of-network(Sub-limit to In-network)

Main member only R3 580 R1 160

Main member + 1 dependant R5 260 R1 790

Main member + 2 dependants R5 790 R1 950


Main member + 4 or more dependants R6 630 R2 210

*Specialist consultations Paid from available savings, then covered from day-to-day benefits

Acute medication Paid from available savings, then covered from day-to-day benefits

General radiology Paid from available savings, then covered from day-to-day benefits

Pharmacy Advice Therapy (PAT) Paid from available savings

Pathology Paid from available savings, then covered from day-to-day benefits

Main member

Adult dependant

Child dependant

R2 683 R2 321 R784

Your fourth and subsequent children will be covered free of charge.

Main member

Adult dependant

Child dependant

Savings R1 212 R1 056 R360

Standard

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Mental health consultations R13 600 per family, per year (sub-limit to mental health hospitalisation, in and out of hospital consultations)

Paramedical services Paid from available savings, then covered from day-to-day benefits

Specialised radiology R22 400 per family, per year (subject to pre-authorisation)

General medical appliances R6 900 per family, per year

Stoma care products General medical appliances limit may be exceeded by R5 600 per year

Hearing aids R13 700 per family, per two year cycle (10% co-payment)

Foot orthotics R3 900 per beneficiary, per year (10% co-payment)

Appliances - wheelchairs, CPAP machines, etc.

Included in general medical appliances limit

HIV/Aids R27 800 per beneficiary, per year (if registered on Aid for Aids program)

Optometry R5 270 per family, per two year cycle

Vision examination (Iso-Leso members) R490 per beneficiary, per two year cycle

Vision examination (Non Iso-Leso members)

R350 per beneficiary, per two year cycle

Single vision lenses (glass/plastic) R160 per beneficiary, per lens, per two year cycle

Bifocal lenses (glass/plastic) R350 per beneficiary, per lens, per two year cycle

Multifocal lenses (glass/plastic) R700 per beneficiary, per lens, per two year cycle

Frames R800 per beneficiary, per two year cycle

Contact lens materials R1 750 per beneficiary, per two year cycle

Basic dentistry Covered at the Bonitas Dental Tariff (BDT)

Consultations 2 x annual check-ups per beneficiary (once in 6 months)

X-rays: Intra-oral Benefit is subject to managed care protocols

X-rays: Extra-oral 1 x per beneficiary, per three year cycle

Additional benefit may be considered where specialised dental treatment is required

Oral hygiene 2 x annual scale and polish treatments per beneficiary (once in 6 months)

Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age

Benefit for fluoride is limited to beneficiaries between ages 5 & 16 years

Fillings Benefit for fillings are granted once per tooth in 365 days

Benefit for re-treatment of a tooth is subject to managed care protocols

A treatment plan and x-rays may be required for multiple fillings

Root canal therapy and extractions Benefit is subject to managed care protocols

Plastic dentures and associated laboratory costs

1 x set of plastic dentures (an upper and a lower) per beneficiary, per four year cycle

Specialised dentistry Covered at the Bonitas Dental Tariff (BDT)

Partial metal frame dentures and associated laboratory costs

1 x partial frame (an upper or a lower) per beneficiary, per five year cycle

Benefit is subject to managed care protocols

Crown and bridge and associated laboratory costs

Subject to a DENIS Designated Service Provider Network

Pre-authorisation is required

1 x crown per family, per year

Benefits for crowns will be granted once per tooth, per five year cycle

A treatment plan and x-rays may be requested

Implants and associated laboratory costs No benefit

Orthodontics and associated laboratory costs



Orthodontic treatment is granted once per beneficiary, per lifetime

Stan

dard

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On pre-authorisation cases will be clinically assessed by using an orthodontic needs analysis. Benefit allocation is subject to the outcome of the needs analysis and funding can be granted up to 80% of BDT

Benefit for Orthodontic treatment will be granted where function is impaired

Benefit will not be granted where Orthodontic treatment is required for cosmetic reasons

Only one family member may commence Orthodontic treatment in a calendar year

Benefit for fixed comprehensive treatment is limited to individuals between ages 9 & 18 years

Periodontics Pre-authorisation is required Benefit is subject to managed care

protocols Benefit is limited to conservative, non-

surgical therapy only and will only be applied to members who are registered on the Periodontal Program

Maxillo-facial surgery and oral pathologySurgery in the dental chair Benefit is subject to managed care

protocolsHospitalisation (general anaesthetic) Pre-authorisation is required

A co-payment of R2 000 per hospital admission applies

Admission protocols apply General anaesthetic benefits are available

for children under the age of 5 years for extensive dental treatment

General anaesthetic benefits are available for the removal of impacted teeth. Benefit is subject to managed care protocols

Laughing gas in dental rooms Benefit is subject to managed care protocols

IV conscious sedation in rooms Pre-authorisation is required Benefit is subject to managed care

protocols Benefit is limited to extensive dental

treatmentScheme exclusions Please refer to the last section herein for

exclusions and www.bonitas.co.za for Scheme rules & exclusions

* Subject to the specialist network.**Designated Service Provider

CHRONIC BENEFITS

These offer cover for conditions that require medicine on an ongoing basis.

The Standard option offers cover for all of the following 44 chronic conditions.

Cover is limited to R8 250 per beneficiary and R16 500 per family, per year on the Comprehensive Formulary. This is subject to pre-authorisation. A 40% co-payment will be required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is the **DSP for chronic medication.

Once this amount is depleted, you will still be covered for the 27 Prescribed Minimum Benefits, highlighted below, subject to the use of in-formulary medicine.

1. Acne 16. Crohn’s Disease 31. Hypertension

2. Addison’s Disease 17. Depression 32. Hypothyroidism

3. Allergic Rhinitis 18. Dermatitis 33. Multiple Sclerosis

4. Ankylosing Spondylitis

19. Diabetes Insipidus 34. Narcolepsy

5. Asthma 20. Diabetes Type 1 35. Obsessive Compulsive Disorder

6. Attention Deficit Disorder (5-18 Year Olds)

21. Diabetes Type 2 36. Panic Disorder

7. Barrett’s Oesophagus 22. Dysrhythmias 37. Parkinson’s Disease

8. Behcet’s Disease 23. Eczema 38. Post-Traumatic Stress Syndrome

9. Bipolar Mood Disorder

24. Epilepsy 39. Rheumatoid Arthritis

10. Bronchiectasis 25. Gastro-Oesophageal Reflux Disorder

40. Schizophrenia

11. Cardiac Failure 26. Glaucoma 41. Systemic Lupus Erythematosus

12. Cardiomyopathy 27. Gout 42. Tourette’s Syndrome

13. Chronic Obstructive Pulmonary Disease

28. Haemophilia 43. Ulcerative Colitis

14. Chronic Renal Disease 29. Hyperlipidaemia 44. Zollinger-Ellison Syndrome

15. Coronary Artery Disease

30. HIV/Aids

Standard

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SUPPLEMENTARY BENEFITS

At Bonitas we believe in giving you more. These additional benefits provide cover in or out-of-hospital and payable from OAL .

Maternity care

Per event 12 x ante-natal consultations

2 x 2D scans

4 x post-natal consultations with a midwife

R1 100 for ante-natal classes

1 x amniocentesis

Infant paediatric benefit

2 x consultations per beneficiary under 1 year of age

2 x consultations per beneficiary between ages 1 and 2 years

Childhood illness benefit

2 x GP consultations per beneficiary between ages 2 and 12 years

Preventative care Subject to DSP

Women's health 1 x mammogram - female members between ages 50 & 74 years, per two year cycle

1 x pap smear - female members between ages 21 & 65 years, per three year cycle

General health 1 x annual HIV test per beneficiary, per year

1 x annual Flu vaccine per beneficiary, per year

Cardiac health 1 x full Lipogram - members 20+ years of age, per five year cycle

Elderly health 1 x lifetime Pneumococcal vaccine - members 65+years of age

1 x annual Faecal Occult blood test - members between ages 50 & 75 years

Wellness screening benefit 1 x assessment per beneficiary, per year at a **DSP

Limited to:

Blood pressure test

Glucose test

Cholesterol test

Body mass index

Waist to hip ratio assessment

Wellness extender R1 400 per family per year

Subject to registration and completion of health risk assessment per beneficiary

Beneficiary may then choose from the following:

GP consultation

Biokineticist consultation

Dietician consultation

Physiotherapy consultation

Wearable devices (subject to approval)

Smoking cessation program (subject to approval)

Stan

dard

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Notes

Standard

Standard Select

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If you are married or single with children and looking for an affordable medical aid product that offers a wide range of benefits, the Standard Select is perfect for you. This option makes use of our extensive, high-quality Designated Service Provider network of medical professionals.




These benefits include major medical events and are unlimited subject to network hospitals. Non-network hospital admissions will attract a 30% co-payment.

GP consultations Unlimited, at 100% of the Bonitas RateSpecialist consultations Network Specialists:

Unlimited, covered in full



Pathology Unlimited, at 100% of the Bonitas RateGeneral radiology Unlimited, at 100% of the Bonitas RateSpecialised radiology Unlimited, subject to pre-authorisationParamedical services (Allied medical professions) - speech therapy, occupational therapy, dietetics


Prosthesis internal and external R37 900 per family, per yearInternal nerve stimulators R142 000 per family, per yearCochlear implants R250 000 per family, per yearMental health hospitalisation R34 800 per family, per yearTake home medication (TTO) R400 per beneficiary, per admissionPhysical rehabilitation R42 500 per family, per yearAlternatives to hospitalisation R14 200 per family, per yearOncology R295 400 per family, per yearOrgan transplants Unlimited, subject to treatment protocolsRenal dialysis Unlimited, subject to treatment protocols


Out of hospital claims excluding Nominated GP consultations will be paid from current available savings first. Once savings are depleted, claims will be paid from the day-to-day benefit.

The GP consultation benefit is subject to nomination of a GP for each beneficiary from the Bonitas GP network.

DAY-TO-DAY BENEFITS







GP consultations Nominated GP Non-Nominated GP(Sub-limit to Nominated GP)

Main member only R3 580 R1 160





Please note: Each beneficiary must have a nominated GP

*Specialist consultations Paid from available savings, then covered from day-to-day benefits

Acute medication Paid from available savings, then covered from day-to-day benefits

General radiology Paid from available savings, then covered from day-to-day benefits

Pharmacy Advice Therapy (PAT) Paid from available savings

Main member

Adult dependant

Child dependant

R2 321 R2 007 R678


Main member

Adult dependant

Child dependant

Savings R1 056 R900 R300

Standard Select

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Pathology Paid from available savings, then covered from day-to-day benefits

Mental health consultations R13 600 per family, per year (sub-limit to Mental health hospitalisation)

Paramedical services Paid from available savings, then covered from day-to-day benefits

Specialised radiology R22 400 per family, per year (subject to pre-authorisation)

















Basic dentistry Covered at the Bonitas Dental Tariff (BDT)







Benefit for fluoride is limited to beneficiaries between ages 5 and 16 years









1 x partial frame (an upper or a lower) per beneficiary, per five year cycle



Subject to a DENIS Designated Service Provider Network


1 x crown per family, per year

Benefits for crowns will be granted once per tooth, per five year cycle






Orthodontic treatment is granted once per beneficiary, per lifetime

Stan

dard

Sel

ect

Page 20

All pre-authorisation cases will be clinically assessed by using an orthodontic needs analysis. Benefit allocation is subject to the outcome of the needs analysis and funding can be granted up to 80% of BDT





Periodontics Pre-authorisation is required


Benefit is limited to conservative, non-surgical therapy only and will only be applied to members who are registered on the Periodontal Program

Maxillo-facial surgery and oral pathology

Surgery in the dental chair Benefit is subject to managed care protocols

Hospitalisation (general anaesthetic) Subject to Bonitas hospital network (Pre-authorisation is required)


Admission protocols apply

General anaesthetic benefits are available for children under the age of 5 years for extensive dental treatment



IV conscious sedation in rooms Pre-authorisation is required


Benefit is limited to extensive dental treatment

Scheme exclusions Please refer to the last section herein for exclusions and www.bonitas.co.za for Scheme rules & exclusions

* Subject to the specialist network and specialist referral from the Nominated GP.

CHRONIC BENEFITS


The Standard Select option offers cover for all of the following 44 chronic conditions.

Cover is limited to R8 250 per beneficiary and R16 500 per family, per year on the Comprehensive Formulary. This is subject to pre-authorisation. A 40% co-payment will be required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is the **DSP for chronic medication.


1. Acne 16. Crohn’s Disease 31. Hypertension2. Addison’s Disease 17. Depression 32. Hypothyroidism3. Allergic Rhinitis 18. Dermatitis 33. Multiple Sclerosis4. Ankylosing Spondylitis 19. Diabetes Insipidus 34. Narcolepsy5. Asthma 20. Diabetes Type 1 35. Obsessive Compulsive

Disorder6. Attention Deficit Disorder (5-18 Yr Olds)

21. Diabetes Type 2 36. Panic Disorder

7. Barrett’s Oesophagus 22. Dysrhythmias 37. Parkinson’s Disease8. Behcet’s Disease 23. Eczema 38. Post-Traumatic Stress

Syndrome


24. Epilepsy 39. Rheumatoid Arthritis

10. Bronchiectasis 25. Gastro-Oesophageal Reflux Disorder

40. Schizophrenia

11. Cardiac Failure 26. Glaucoma 41. Systemic Lupus Erythematosus

12. Cardiomyopathy 27. Gout 42. Tourette’s Syndrome13. Chronic Obstructive Pulmonary Disease


14. Chronic Renal Disease 29. Hyperlipidaemia 44. Zollinger-Ellison Syndrome


30. HIV/Aids

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At Bonitas we believe in giving you more. These additional benefits provide cover in or out-of-hospital, and payable from OAL.

Maternity care


2 x 2D scans

4 x post-natal consultations with

a midwife


1 x amniocentesis


2 x consultations per beneficiary under

1 year of age

2 x consultations per beneficiary between

ages 1 and 2 years


2 x GP consultations per beneficiary

between ages 2 and 12 years

Preventative car Subject to DSP

Women's health 1 x mammogram - female members

between ages 50 & 74 years, per two

year cycle

1 x pap smear - female members between

ages 21 & 65 years, per three year cycle

General health 1 x annual HIV test per beneficiary, per

year

1 x annual Flu vaccine per beneficiary,

per year

Cardiac health 1 x full Lipogram - members 20+ years of

age, per five year cycle

Elderly health 1 x lifetime Pneumococcal vaccine -

members 65+years of age

1 x annual Faecal Occult blood test -

members between ages 50 & 75 years

Wellness screening benefit 1 x assessment per beneficiary,

per year at **DSP

Limited to:

Blood pressure test

Glucose test

Cholesterol test

Body mass index



Subject to registration and completion of

health risk assessment per beneficiary

Beneficiary may then choose from the

following:

GP consultation





Smoking cessation program

(subject to approval)

Standard Select

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Notes Notes

Standard Select

Primary

Page 24

Primary

If you’re looking for a simple medical aid plan that offers affordable healthcare for you and your loved ones when you need it, then this product is perfect for you.











Specialised radiology R11 150 per family, per year (in & out-of-hospital)

Subject to pre-authorisation

Paramedical services (Allied medical professions) - speech therapy, occupational therapy, audiology, dietetics


Prosthesis internal and external PMB only






Organ transplants PMB only

Renal dialysis PMB only

A co-payment will apply to the following procedures in hospital.

R1 050 Co-Payment R2 650 Co-Payment R5 250 Co-Payment

1. Colonoscopy

1. Arthroscopy 1. Back surgery including spinal fusion

2. Conservative back treatment

2. Diagnostic laparoscopy 2. Joint replacements for example Hip and knee replacements (except PMBs)

3. Cystoscopy 3. Hysterectomy (except cancer and PMBs)

3. Laparoscopic pyeloplasty

4. Facet joint injections

4. Laparoscopic appendectomy

4. Laparoscopic radical prostatectomy

5. Flexible sigmoidoscopy

5. Percutaneous rhizotomies

5. Nissen fundoplication (reflux surgery)

6. Functional nasal surgery

7. Gastroscopy

8. Hysteroscopy (not endometrial ablation)

9. Myringotomy

10. Tonsillectomy and adenoidectomy (except PMBs)

11. Umbilical hernia repair

12. Varicose vein surgery

Main member

Adult dependant

Child dependant

R1 719 R1 345 R548Your fourth and subsequent children will be covered free of charge.

Page 25

Prim

ary


These benefits cover your day-to-day medical expenses, such as GP and specialist consultations, dentistry, optometry and more.

DAY-TO-DAY BENEFITS







GP consultations In-network Out-of-network(Sub-limit to In-network)

Main member only R1 700 R560





*Specialist consultations Covered from day-to-day benefit

Acute medication Covered from day-to-day benefit

General radiology Covered from day-to-day benefit

Pathology Covered from day-to-day benefit

Mental health consultations R8 200 per family, per year (sub-limit to Mental health hospitalisation, in and out of hospital consultations)

Paramedical services Covered from day-to-day benefit


















Basic dentistry Covered at the Bonitas Dental Tariff (BDT)Subject to a DENIS Designated Service Provider Network




Oral hygiene 2 annual scale and polish treatments per beneficiary (once in 6 months)







Page 26

Primary

Benefit for root canal includes all teeth except primary teeth and permanent molars





No benefit


No benefit


Orthodontics and associated laboratory costs No benefit

Periodontics No benefit



Hospitalisation (general anaesthetic) Pre-authorisation is required




General anaesthetic benefits are available for the removal of impacted teeth






Scheme exclusions Please refer to last section herein for exclusions and to www.bonitas.co.za for Scheme rules & exclusions

* Subject to the specialist network.

CHRONIC BENEFITS


The Primary option ensures that you are covered for the following 27 Prescribed Minimum Benefits, subject to the use of in-formulary medicine. A 40% co-payment will be required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is the **DSP for chronic medication.

1. Addison’s Disease 11. Diabetes Insipidus 21. Hypothyroidism

2. Asthma 12. Diabetes Type 1 22. Multiple Sclerosis

3. Bipolar Mood Disorder 13. Diabetes Type 2 23. Parkinson’s Disease

4. Bronchiectasis 14. Dysrhythmias 24. Rheumatoid Arthritis

5. Cardiac Failure 15. Epilepsy 25. Schizophrenia

6. Cardiomyopathy 16. Glaucoma 26. Systemic Lupus Erythematosus



8. Chronic Renal Disease 18. HIV/Aids

9. Coronary Artery Disease 19. Hyperlipidaemia

10. Crohn’s Disease 20. Hypertension



Maternity care


2 x 2D scans


1 x amniocentesis


1 x Peadiatric consultations per beneficiary under 1 year of age


Page 27

Prim

ary




Women's health 1 x pap smear - female members between ages 21 & 65 years, per three year cycle





Wellness screening benefit 1 x assessment per beneficiary, per year at a DSP

Limited to :

Blood pressure test

Glucose test

Cholesterol test

Body mass index


Wellness extender R1 000 per family, per year



GP consultation






Page 28

Primary

Notes

BonComprehensive

Page 30

BonComprehensive

Our premium product, BonComprehensive, is designed to meet the most arduous healthcare needs. It features extensive and exclusive benefits that cater for young and old alike. This elite option is perfect for those who appreciate high-quality and superior benefits.

Overall annual limit (OAL) – Unlimited





Specialist consultations Unlimited, at 300% of the Bonitas Rate






Prosthesis internal R47 250 per family, per year

Prosthesis external R47 250 per family, per year

Internal nerve stimulator R142 000 per family, per year

Cochlear implants R250 000 per family, per year






Biological drugs R210 400 per family, per year

Biological drugs (non-oncology) R168 300 per family, per year

Organ transplants Unlimited, subject to pre-authorisation

Renal dialysis Unlimited, subject to pre-authorisation



*Not all claims accumulate to the threshold level

GP consultations Subject to available savings and threshold

Specialist consultations Subject to available savings and threshold

Acute medication Subject to available savings and threshold

General radiology Subject to available savings and threshold

Specialised radiology R26 850 per family, per year


Pathology Subject to available savings and threshold

Mental health consultations R13 600 per family, per year (sub-limit to mental health hospitalisation, for in and out-of-hospital consultations.)

Physical therapy Subject to available savings and threshold







HIV/Aids Unlimited (if registered on Aid for Aids program)

Paramedical services - speech therapy, occupational therapy, audiology, dietetics

Subject to available savings and threshold

Main member

Adult dependant

Child dependant

R4 696 R4 428 R956


Main member

Adult dependant

Child dependant

Savings R10 632 R10 020 R2 172

Self-payment gap R3 428 R2 840 R1 308

*Threshold level R14 060 R12 860 R3 480

Above threshold benefit

Unlimited Unlimited Unlimited

Page 31

BonC

ompr

ehen

sive

Optometry Limited to R2 740 and subject to available savings and threshold

Basic dentistry Paid from available savings and/or threshold benefit

Consultations 1 x consultation per beneficiary every 6 months




Oral hygiene 1 x treatment every 6 months per beneficiary









Specialised dentistry Paid from available savings and/or threshold benefit


2 x partial frames (an upper and a lower) per beneficiary, per five year cycle


Crown, bridge and associated laboratory costs

Pre-authorisation is required3 x crowns per family, per year Benefit is subject to managed care protocols Benefits for crowns will be granted once per tooth, per five year cycle


Implants and associated laboratory costs Pre-authorisation is required

2 x implants per beneficiary, per five year cycle


Cost of implant components is limited to R2 205 per implant


Pre-authorisation is requiredBenefit is subject to managed care protocols

Orthodontic treatment is granted once per beneficiary per lifetime

All pre-authorisation cases will be clinically assessed by using an orthodontic needs analysis. Benefit allocation is subject to the outcome of the needs analysis and funding can be granted up to 100% of BDT





Periodontics Pre-authorisation is required






Page 32

BonComprehensive








CHRONIC BENEFITS


The BonComprehensive option offers generous and extensive cover for all of the 60 chronic conditions listed below.

This is limited to R11 850 per beneficiary and R23 600 per family, per year on the Comprehensive Formulary. This is subject to pre-authorisation.

Once this amount is depleted, you will still be covered for the 27 Prescribed Minimum Benefits, highlighted below.

1. Acne 21. Dermatomyositosis 41. Myasthenia Gravis

2. Addison’s Disease 22. Dermatitis 42. Narcolepsy

3. Allergic Rhinitis 23. Diabetes Insipidus 43. Neuropathies

4. Ankylosing Spondylitis 24. Diabetes Type 1 44. Obsessive Compulsive Disorder

5. Attention Deficit Disorder (5-18 year olds)

25. Diabetes Type 2 45. Osteoporosis

6. Alzheimer Disease (early onset)

26. Dysrhythmias 46. Paget’s Disease

7. Asthma 27. Eczema 47. Panic Disorder

8. Barrett’s Oesophagus 28. Epilepsy 48. Parkinson’s Disease

9. Behcet’s Disease 29. Gastro- Oesophageal Reflux Disorder

49. Pemphigus


30. Generalised Anxiety Disorder

50. Polyarteritis Nordosa

11. Bronchiectasis 31. Glaucoma 51. Post-Traumatic Stress Syndrome

12. Cardiac Failure 32. Gout 52. Psoriatic Arthritis

13. Cardiomyopathy 33. Haemophilia 53. Pulmonary Interstitial Fibrosis


34. HIV/Aids 54. Rheumatoid Arthritis

15. Chronic Renal Disease 35. Huntington’s Disease 55. Schizophrenia


36. Hyperlipidaemia 56. Systemic Lupus Erythematosus

17. Crohn’s Disease 37. Hypertension 57. Systemic Sclerosis

18. Cystic Fibrosis 38. Hypoparathyroidism 58. Tourette’s Syndrome

19. Depression 39. Hypothyroidism 59. Ulcerative Colitis

20. Deep Vein Thrombosis

40. Multiple Sclerosis 60. Zollinger-Ellison Syndrome

Page 33

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At Bonitas we believe in giving you more. These additional benefits provide cover in or out-of-hospital payable from OAL.

Maternity care


2 x 2D scans



1 x amniocentesis




Men's health PSA test - between ages 55 & 69 years, who are considered to be at high risk

Children's health 1 x TSH test for infants below 1 month

Childhood immunisations according to the EPI schedule


1 x annual flu vaccine per beneficiary, per year



1 x annual faecal occult blood test - members between ages 50 & 75 years

1 x lifetime bone density screening - female members 65+ years of age


Limited to :

Blood pressure test

Glucose test

Cholesterol test

Body mass index





GP consultation






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BonComprehensive

Notes

BonClassic

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If you have a family with children or perhaps your children are already all grown up and have moved out of your home, this option offers a comprehensive medical plan with a wide range of medical benefits for you and your loved ones.




These benefits include major medical events such as hospitalisation, oncology treatment and more.

GP consultations Unlimited, at 100% of the Bonitas RateSpecialist consultations Network Specialists:

Unlimited, covered in full

Non-network Specialists: Unlimited, covered at 100% of the

Bonitas RatePathology Unlimited, at 100% of the Bonitas RateGeneral radiology Unlimited, at 100% of the Bonitas RateSpecialised radiology R24 850 per family, per year

(in & out-of-hospital)Subject to pre-authorisation

Paramedical services (Allied medical professions) - speech therapy, physiotherapy, occupational therapy, audiology, dietetics


Prosthesis internal and external R46 800 per family, per yearICPS is the **DSP for hip and knee replacements, a R5 000 co-payment is payable when not using the DSP

Mental health hospitalisation R35 350 per family, per yearTake home medication (TTO) R400 per beneficiary, per admissionPhysical rehabilitation R42 500 per family, per yearAlternatives to hospitalisation R14 200 per family, per year

Oncology R351 900 per family, per year at the Preferred Provider

Biological Drugs (non-oncology) R105 200 per family, per year (10% co-payment and protocols apply)

Organ transplants Unlimited, at 100% of the Bonitas RateRenal dialysis Unlimited, at 100% of the Bonitas Rate


These benefits cover your day-to-day medical expenses, such as GP and specialist consultations.

GP consultations Subject to available savings

*Specialist consultations Subject to available savings

Acute medication Subject to available savings

General radiology R2 680 per beneficiary, per year

R4 130 per family, per year



Pathology R2 680 per beneficiary, per year


Mental health consultations R13 600 per family, per year (sub-limit to mental health hospitalisation limit and for in and out of hospital consultations)

Physical therapy R1 320 per beneficiary, per year



Stoma care products Included in general medical appliances limit

Hearing aids R14 500 per family, per three year cycle (10% co-payment)


BonClassic

Main member

Adult dependant

Child dependant

R3 260 R2 799 R805


Main member

Adult dependant

Child dependant

Savings R5 532 R4 752 R1 368

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HIV/Aids Unlimited, at 100% of the Bonitas Rate (If registered on Aid for Aids program)

Paramedical services - speech therapy, occupational therapy, audiology, dietetics

Main member only R2 550 per year

Main member + 1 dependant R3 900 per year

Main member + 2 dependants R4 500 per year

Main member + 3 dependants R4 800 per year

Main member + 4 dependants or more R5 150 per year










Basic dentistry R4 000 per family, per year. Covered at the Bonitas Dental Tariff (BDT)






Benefit for fluoride treatment is limited to beneficiaries between ages 5 & 16 years








Specialised dentistry R4 800 per family, per year. Covered at the Bonitas Dental Tariff (BDT)


2 x partial frames (an upper and a lower) per beneficiary, per five year cycle

Crown; bridge and associated laboratory costs

Subject to DENIS Designated Service Provider Network

(A bridge comprises 2 or more crown units. Each crown is payable from the available crown and bridge benefit)

Pre-authorisation is required1 x crown per family, per yearBenefit is subject to managed care protocols Benefits for crowns will be granted once per tooth, per five year cycle A treatment plan and x-rays may be requested



Pre-authorisation is required Benefit is subject to managed care protocols Orthodontic treatment is granted once per beneficiary, per lifetime Cases will be clinically assessed by using an orthodontic needs analysis. Benefit allocation is subject to the outcome of the needs analysis and funding can be granted up to 100% of BDT Benefit for Orthodontic treatment will be granted where function is impairedBenefit will not be granted where Orthodontic treatment is required for cosmetic reasons

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Only one family member may commence orthodontic treatment in a calendar year


Periodontics Pre-authorisation is required Benefit is subject to managed care

protocolsMaxillo-facial surgery Surgery in the dental chair Benefit is subject to managed care

protocolsHospitalisation (general anaesthetic) Pre-authorisation is required


Admission protocols apply General anaesthetic benefits are available

for children under the age of 5 years for extensive dental treatment



IV conscious sedation in rooms Pre-authorisation is required Benefit is subject to managed care

protocols Benefit is limited to extensive dental

treatmentScheme exclusions Please refer to the last section herein for

exclusions and www.bonitas.co.za for Scheme rules & exclusions

* Subject to the specialist network.**Designated Service Provider

CHRONIC BENEFITS

These offer cover for conditions that require medication on an ongoing basis.

BonClassic offers generous and extensive cover for the below 49 chronic conditions.

Cover is limited to R9 700 per beneficiary and R20 100 per family, per year on the Restrictive Formulary. This is subject to pre-authorisation. A 40% co-payment will be required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is the **DSP for chronic medication.


1. Addison’s Disease 18. Diabetes Insipidus 34. Multiple Sclerosis

2. Alzheimer’s Disease 19. Diabetes Type 1 35. Obsessive Compulsive Disorder

3. Ankylosing Spondylitis 20. Diabetes Type 2 36. Osteoporosis

4. Asthma 21. Dysrhythmias 37. Paget’s Disease

5. Attention Deficit Disorder (In 5-18 Year Olds)

22. Eczema 38. Panic Disorder

6. Barrett’s Oesophagus 23. Epilepsy 39. Parkinson’s Disease

7. Benign Prostatic Hypertrophy

24. Gastro-Oesophageal Reflux Disorder

40. Polyarteritis Nodosa

8. Bipolar Mood Disorder 25. Generalised Anxiety Disorder

41. Post-Traumatic Stress Syndrome

9. Bronchiectasis 26. Glaucoma 42. Pulmonary Interstitial Fibrosis

10. Behcet’s Disease 27. Gout 43. Rheumatoid Arthritis

11. Cardiac Failure 28. Haemophilia 44. Schizophrenia

12. Cardiomyopathy 29. HIV/Aids 45. Scleroderma


30. Hyperlipidaemia 46. Systemic Lupus Erythematosus

14. Chronic Renal Disease 31. Hypertension 47. Tourette’s Syndrome


32. Hypoparathyroidism 48. Ulcerative Colitis

16. Crohn’s Disease 33. Hypothyroidism 49. Zollinger-Ellison

17. Depression

BonClassic

Page 39


At Bonitas, we believe in giving you more. These additional benefits provide cover in or out of hospital

Maternity care

Per event: 12 x ante-natal consultations

2 x 2D scans



1 x amniocentesis

Preventative care Subject to **DSP







1 x Faecal Occult blood test - members between ages 50 & 75 years, per beneficiary, per year

1 x lifetime Bone Density screening - female members 65+ years of age


Limited to :

Blood pressure test

Glucose test

Cholesterol test

Body mass index



Subject to registration and completion of a health risk assessment per beneficiary


GP consultation






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BonClassic

Notes

BonSave

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Take total control of your benefits with BonSave - the flexible option that lets you decide how to use your savings. Designed to offer you cover when you need it most, while allowing you to customise your cover according to your needs, BonSave offers extensive hospital cover.






Specialist consultations Unlimited, at 150% of the Bonitas Rate















R1 050 Co-payment R2 650 Co-payment R5 250 Co-payment

1. Colonoscopy 1. Arthroscopy 1. Back surgery including spinal fusion



3. Cystoscopy 3. Laparoscopic Hysterectomy (except cancer and PMBs)


4. Facet joint injections 4. Laparoscopic appendectomy


5. Flexible sigmoidoscopy 5. Percutaneous rhizotomies



7. Gastroscopy


9. Myringotomy




Main member

Adult dependant

Child dependant

R1 908 R1 478 R572


BonSave

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These benefits cover your day-to-day medical expenses, such as GP and specialist consultations, optometry and more.

With BonSave, Dental is covered from risk and therefore doesn’t have any impact on your savings. If you use all your savings for the year, your family will still get a maximum of 6 consultations to use (limited to 3 per person), if illness strikes. We’ll cover these at no extra cost to you.

GP Consultations Subject to available savings



General radiology Subject to available savings

Pathology Subject to available savings

Paramedical services Subject to available savings

Specialised radiology R20 000 per family, per year (subject to authorisation)



Hearing aids No benefit


Appliances - wheelchairs, CPAP machines, etc. Included in general medical appliances limit


Optometry Subject to available savings

Basic Dentistry Covered at the Bonitas Dental Tariff (BDT)




Additional benefit may be considered where specialised dental treatment is required.








Benefit for root canal includes all teeth except primary teeth and permanent molars



Specialised Dentistry Covered at the Bonitas Dental Tariff (BDT)


No benefit

Crown, bridge and associated laboratory costs

No benefit



No benefit

Periodontics No benefit







BonS

ave

Main member

Adultdependant

Child dependant

Savings R3 672 R2 844 R1 104

Page 44








CHRONIC BENEFITS


The BonSave option ensures that you are covered for the following 27 Prescribed Minimum Benefits, subject to the use of in-formulary medicine A 40% co-payment will be required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is the **DSP for chronic medication.













At Bonitas, we believe in giving you more. These additional benefits provide cover in or out-of-hospital.

Maternity care


2 x 2D scans


1 x amniocentesis

Antenatal classes limited to R1 050 per pregnancy




Childhood illness benefit Subject to DSP


Preventative care

Women's health 1 x pap smear - female members between ages 21 & 65 years, per three years cycle


1 x annual flu vaccine, per beneficiary, per year

Elderly health 1 x lifetime Pneumococcal vaccine - members 65+ years of age

1 x annual faecal occult blood test - members between ages 50 & 75 years

Wellness screening benefit 1 x assessment per beneficiary, per year at DSP

Limited to:

Blood pressure test

Glucose test

Cholesterol test

Body mass index


BonSave

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BonS

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GP consultation






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BonSave

Notes

BonFit

Page 48

If you are young and healthy and just looking for peace of mind knowing that you and your family are covered for major medical events, as well as having access to savings for essential day-to-day medical needs, this option is perfect for you.




These benefits include major medical events. Major medical expenses are unlimited subject to the use of network hospitals. Non-network hospital admissions will attract a 30% co-payment.

























4. Facet joint injections 4. Laparoscopic appendectomy





7. Gastroscopy


9. Myringotomy




Main member

Adult dependant

Child dependant

R1 598 R1 238 R479


Page 49



GP Consultations Subject to available savings



General radiology Subject to available savings

Pathology Subject to available savings

Paramedical services Subject to available savings

Specialised radiology Subject to available savings

General medical appliances Subject to available savings

Stoma care products Subject to available savings

Hearing aids No benefit

Foot orthotics Subject to available savings


Subject to available savings


Optometry Subject to available savings

Basic dentistry Subject to available savings and dental managed care protocols

Consultations Subject to available savings

X-rays: Intra-oral Subject to available savings

X-rays: Extra-oral Subject to available savings

Oral hygiene Subject to available savings

Fillings Subject to available savings

Root canal therapy and extractions Subject to available savings


Subject to available savings

Specialised dentistry No benefit

Hospitalisation (general anaesthetic) Subject to Bonitas hospital network (Pre-authorisation is required)











CHRONIC BENEFITS


The BonFit option ensures that you are covered for the following 27 Prescribed Minimum Benefits subject to the use of in-formulary medicine A 40% co-payment will be required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is the **DSP for chronic medication.












BonFit

Main member

Adult dependant

Child dependant

Savings R2 880 R2 232 R864

Page 50


At Bonitas, we believe in giving you more. These additional benefits provide cover in or out-of-hospital and payable from OAL.

Maternity care


2 x 2D scans


1 x amniocentesis



1 x consultation per beneficiary between ages 1 and 2 years


1 x GP consultation per beneficiary between ages 2 and 12 years

Preventative care

Women's health 1 x pap smear - female members between ages 21 & 65 years, per three year cycle


1 x annual flu vaccine per beneficiary, per year

Elderly health 1 x lifetime Pneumococcal vaccine - members 65+ years of age



Limited to :

Blood pressure test

Glucose test

Cholesterol test

Body mass index





GP consultation






BonFit

BonEssential

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BonEssential

BonEssential is the ideal plan for healthier families and individuals who only really need cover for major medical events. BonEssential offers top-quality hospital cover at affordable prices with added Prescribed Minimum Benefits when you really need them.



MAJOR MEDICAL BENEFITS

















Organ transplants Unlimited, subject to pre-authorisation

Renal dialysis PMB only at **DSP







2. Diagnostic Laparoscopy 2. Joint replacements for example Hip and knee replacements (except PMBs)



4. Facet joint injections 4. Laparoscopic Appendectomy

4. Laparoscopic Radical Prostatectomy


5. Nissen Fundoplication (Reflux Surgery)


7. Gastroscopy


9. Myringotomy

10. Tonsillectomy and adenoidectomy (Except Pmbs)



Main member

Adult dependant

Child dependant

R1 316 R1 007 R386


Page 53

BonE

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CHRONIC BENEFITS


The BonEssential option ensures that you are covered for the following 27 Prescribed Minimum Benefits subject to the use of in-formulary medicine. A 40% co-payment will be required if you decide to use a non-DSP to obtain your medication. Pharmacy Direct is the **DSP for chronic medication.














Maternity care


2 x 2D scans


1 x amniocentesis


1 x GP consultation per beneficiary between ages 2 and 12 years

Preventative care



Elderly health 1 x annual Faecal Occult blood test - members between ages 50 & 75 years


Limited to:

Blood pressure test

Glucose test

Cholesterol test

Body mass index


Wellness extender R700 per family per year



GP consultation






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BonEssential

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Benefits & Process Guides

All about our processes and partners• The YourHealth Portal• Maternity• Prescribed Minimum Benefits• Managed Care• Medicine Management

- Pharmacy Advised Therapy (PAT) - Chronic Medicine - Pharmacy Direct

• Hospital Management• Networks

- GP Network - Specialist Referrals - Specialist Network - The Standard Select and BonFit Hospital Network

• Dental Benefits• Optical Benefits • Diabetic Program• Hip and Knee Replacement Program• HIV/Aids Management• Emergency Medical Services• Exclusion List • Termination of Bonitas Membership

The YourHealth Portal

The YourHealth Portal is an exciting online educational web and mobile health portal that gives you as a beneficiary access to an abundance of resources in order to help you make better health choices and to be well informed. The portal includes e-tutorials and educational articles, tools and quizzes, and so much more, all housed in an easy to use online space.

Easily accessible through the secure member zone, you will have access to the following:

• E-tutorials - covering topics such as asthma, backache, healthy eating, depression, diabetes, hypertension, smoking cessation, stress, weight loss and work place health. Weekly step-by-step emails with practical advice, motivating case studies and a short questionnaire to

help you to assess your understanding• Wellness programs including fitness and nutrition programs - personalised interactive diet

and fitness programs with week-by-week dietary and exercise guidelines, based on a profile-setting questionnaire. Your performance is tracked and displayed

• Pregnancy program - regular electronic communication to assist moms and dads during this “journey through life”

• A to Z database of diseases and conditions• Condition Centres (provide disease related information and articles on a number of

important chronic conditions)• Databases of symptoms, medication, first aid and wellness• Self-assessment tools

What do I need to register?

• Membership number• ID number• Email address• A username and Password

How to register on Member Zone to access the YourHealth Portal

• Visit the Bonitas website at www.bonitas.co.za• Go to the top right hand corner of the page and click on “Login/Registration”• This will take you to the “Account Login Page” where you can either sign in or create a new

account

If you are already registered to log into the secure area where you can view personal information:

• Fill in your username and password and click on “Sign in” to access your account• Click on “YourHealth Portal”

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If you are not registered to log into the secure area where you can view personal information:

• Click on “Register”• Click on “Members”• Fill in your membership number and click “Validate Code”• Confirm or choose from the list of members/dependants to indicate your status and name

and click “Select”• Enter your chosen Username and validate with your email address• Create a password and confirm your password• Read through the terms and conditions and then click “Create Account” to complete the

process• Click on “YourHealth Portal”

Maternity

At Bonitas we strive to create the best experience for you and your loved ones during your pregnancy by providing you and your unborn child with the necessary health information and support.

The Scheme will supply every pregnant member with a mother and baby gift pack when registered on the maternity program.

How do I register?

Register by either logging on to the Bonitas website or contacting the call centre. - Go to www.bonitas.co.za in order to login onto the member zone. - Call 0860 002 108 between 8:30am and 4:00pm Monday to Friday to register for

your mother and baby gift pack. This number is not available on public holidays or weekends

What information do I need when I apply for the mother and baby gift pack?

• Membership number• Name and surname• Contact details• Delivery address• Alternative delivery address• Date of expected delivery

Please note: In order to ensure that you receive your mother and baby gift pack, the courier company will be in contact with you to arrange a suitable date and time for delivery.

Prescribed Minimum Benefits (PMB)

By law, all medical aids are required to fund the diagnosis, treatment and care of any emergency medical condition and a list of 270 groups of conditions known as Diagnosis and Treatment Pairs, which includes 27 common chronic conditions known as Prescribed Minimum Benefit conditions.

Which PMB conditions are covered by Bonitas?

Emergency medical conditions

An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not provided, the emergency could result in damage to bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

Diagnosis and Treatment Pairs (270 medical conditions)

The Regulations of the Medical Schemes Act provide a long list of conditions identified as Prescribed Minimum Benefit conditions. The list is in the form of Diagnosis and Treatment Pairs (DTPs). A DTP links a specific diagnosis to a treatment and indicates how these PMB conditions should be treated.

Please note: It is not always possible to diagnose a condition before admitting a patient for treatment. However, if doctors suspect that the patient suffers from a condition that is a PMB condition, the medical fund will need to approve treatment in order for it to be paid correctly. Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time.

The 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:

• Brain and nervous systems• Eye• Ear, nose, mouth and throat• Respiratory system• Heart and blood vessels

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• Gastrointestinal• Liver, pancreas and spleen• Musculoskeletal• Skin and breast• Endocrine, metabolic and nutritional• Urinary and male genital system• Female reproductive system• Pregnancy and childbirth• Haematological, infectious and miscellaneous systemic conditions• Mental illness

Chronic conditions

The following 27 conditions must be covered:

• Addison’s Disease• Asthma• Bipolar Mood Disorder• Bronchiectasis• Cardiac Failure• Cardiomyopathy• Chronic Obstructive Pulmonary Disorder• Chronic Renal Disease • Coronary Artery Disease• Crohn’s Disease • Diabetes Insipidus• Diabetes Mellitus Type 1• Diabetes Mellitus Type 2• Dysrhythmias • Epilepsy• Glaucoma • Hemophilia• HIV/Aids• Hyperlipidemia• Hypertension• Hypothyroidism• Multiple Sclerosis• Parkinson’s Disease• Rheumatoid Arthritis

• Schizophrenia• Systemic Lupus Erythematosus• Ulcerative Colitis

Did you know? PMB diagnoses may not legally have Scheme Specific Exclusions applied to them. For example, if you contract septicaemia after cosmetic surgery, Bonitas has to provide healthcare cover for the treatment of the septicaemia because it is a PMB condition. The cost of the cosmetic surgery would however, remain uncovered, as this is on the Exclusion List.

Do I need to apply for Prescribed Minimum Benefits?

Although the process is mostly automated and these conditions are identified through the ICD-10 (diagnosis) codes reflected on your claims, you can apply for Prescribed Minimum Benefits by calling the call centre or by logging into www.bonitas.co.za

How will PMB’s be covered?

As per legislation, you will be provided with at least the minimum treatment needed for you PMB condition. Your Fund will pay costs in full for PMB treatment only received from our DSP’s. This will be paid from your available benefit limits first, then your treatment will be covered from risk. For example, radiology services will be paid from your Radiology annual sub-limit. Once your benefit limits are reached, further services clinically appropriate for your PMB condition will continue to be paid from a risk pool.

If further treatment is needed for your condition, your treating doctor will need to submit clinical motivation for assessment and approval.

How can I avoid rejected PMB claims?

Check that your doctor (or any other medical service provider) has placed the correct ICD-10 code on your invoice. ICD-10 codes provide accurate information on your diagnosis and help the Scheme to decide what benefits you are entitled to and how these benefits should be paid.

ICD-10 codes must also be provided on medicine prescriptions and referral notes to other healthcare providers (e.g. pathologists and radiologists) who are not able to make a diagnosis, therefore they require the diagnosis information from your referring doctor in order for their claims to be paid correctly by the Scheme.

Did you know? Medical Schemes are obliged by law to treat information about members’ conditions as confidential.


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What do I do if my PMB claim is rejected?

In the event of your PMB claim being rejected, you can contact the Bonitas call centre to query the rejection. Once diagnosed, please keep all your supporting documents on file as the consultant may ask for this information when advising on your claim.

Managed Care

What is managed care?

The term “managed care” describes a range of techniques that aim to reduce instances of high cost treatment and hospitalisation that are caused by a medical condition, sometimes due to complications or deterioration, which could have been avoided or improved through quality care and support. By looking at both the type of treatment you are receiving from your doctor and the cost thereof, we aim to improve the quality of care while managing your benefits more effectively. Each Managed Care program has specific criteria and protocols which are followed. The aim of these programs is to ensure that you get good quality medical care while managing your benefits carefully, thereby also minimising the clinical and financial risk to the Scheme.

In some cases, we have agreements with doctors, hospitals and healthcare professionals to provide you with a range of services at a reduced cost. With your consent, we work closely with your doctors to help your benefits stretch further and make sure that you are supported more than adequately.

Our Managed Care programs put you on the path to wellness by supporting you through your treatment. They cover everything from chronic medicine, to the long-term treatment of a condition like diabetes and emergency hospitalisation.

Which Managed Care programs do Bonitas offer?

We offer a variety of programs that coordinate care for everything from back ailments to oncology.

Chronic Medicine Management

This program ensures that you are covered for the treatment of a list of chronic diseases and provides you with quick and easy methods to update your medicine. It also ensure you aren’t paying too much for your medicine by working together with the pharmaceutical industry to regulate medicine prices, to keep track of new products and generics and negotiate dispensing fees.

Hospital Benefit Management

This program will help you to pre-authorise your hospital stay and support you through the process to make sure that you know what to expect when you’re admitted and discharged. It will ensure that your benefits are managed effectively.

Oncology Benefit Management

This program offers you emotional support through social workers and clinical staff and manages your oncology benefits, on your behalf, by liaising with your treating doctor regarding your treatment plan and, where possible, matching it to your available benefits.

Bonitas has partnered with The Independent Clinical Oncology Network (ICON) of dedicated specialist oncologists who subscribe to the ICON culture of patient-centric and ethical cancer care. The network represent 80% of the private practising oncologists with a national geographic footprint. The partnership with Bonitas focuses on the enhancement of every aspect of quality of care including patient-centeredness, clinical outcomes and affordability of care.

Disease Management through Integrated Care

This program supports you through your prescribed treatment to ensure you are getting the best care and doing what you can to get better. A team of health coaches help you to identify the areas you need to improve on, offer you advice on your condition and work together with your treating doctor to give you the best support possible.

The Bonitas Back Rehabilitation Program

If you are diagnosed with certain back and neck conditions, you will be provided with advice on the most appropriate care, as well as have access to physiotherapists and doctors, where clinically appropriate, that will help you to manage and improve your condition.

Contact details:

Chronic Medicine Management• Call: 0860 002 108• Email: [email protected]

Hospital Authorisations• Call: 0860 002 108• Email: [email protected]

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Oncology Management• Call: 0860 100 572• Email: [email protected]

Medicine Management

Pharmacy Advised Therapy (PAT)

What is PAT?

You don’t always have to go to a doctor to get medicine. Your pharmacist can recommend and dispense certain medicines without a doctor’s prescription.

When is it useful?

If you have a mild sore throat, cold, a mild cough or anything similar, ask your pharmacist to dispense appropriate medicine and to clearly write “PAT” on your claim.

Why do it?

The cost of this claim is deducted from your normal day-to-day benefit or savings accounts. You don’t have to pay for this out of your pocket and you save on the cost of a consultation with your doctor (subject to benefit limit).

Chronic medicine

Chronic medicine is medication used on an ongoing basis to treat certain chronic health conditions.

Did you know? Common chronic conditions include heart disease, diabetes, hypertension, arthritis, asthma and osteoporosis.

How do I apply for the chronic medicine benefit?

You, your doctor or pharmacist may apply for chronic registration. You will need to have the following information on hand:

• Your membership number• The beneficiary’s date of birth

• The ICD 10 code• The doctor’s practice number• The medicine details

Some chronic medication may require additional clinical information.

Apply via telephone

Call 0860 002 108 and follow the voice prompts. Once you select the appropriate option your call will be routed through to a consultant who will guide you through the process.

Apply online

• Go to www.bonitas.co.za and log in as a member.• Go to “Clinical Information” and click on “Online Chronic Application”.• Follow the prompts on the system and once all information has been captured click on

“View Summary”. You can print this screen for your records.• Click on “Submit” and a reference number will be provided for follow up on the progress of

the application.

What happens after I register on the program?

• Once registered and your application has been approved, you will receive a Medicine Access Card listing the medicines to be paid from your Chronic Medicine benefit.

• If the medicine authorised differs from the medicine requested, a letter of explanation will be attached to your access card and a copy will be sent to the prescribing doctor.

• ou will need a repeat script from your doctor for the medicines listed on the card.

Please note: The access card is not a prescription and cannot be used to have medicines dispensed. Your doctor determines the number of repeats and will advise you how often he needs to see you to monitor your condition. Whenever you need to have your medicine dispensed, produce a valid doctor’s prescription together with the access card. The duration of authorisation varies from medicine to medicine. Some medicines may be authorised ongoing, whilst others may only be authorised for a limited period.


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Types of formularies

There are two types of formularies:

• Restrictive Formulary

- Restrictive formularies provides access to a restrictive range of medicines to treat your chronic condition.

- You will not have a co-payment for medicines on this formulary if they are authorised and obtained from the Designated Service Provider.

• Comprehensive Formulary

- Provides access to a wider range of medicines to treat your chronic conditions.

If you choose to use a medicine that is not on the formulary allowed by your option, you may have to pay a co-payment upfront. Your co-payment may be substantial if the cost of your medicine is higher than listed on the Medicine Pricing List. A co-payment may also apply if you are required to use a Designated Service Provider and choose not to. Both formularies include alternative products that will not require a co-payment to be made, so if you do not wish to incur any co-payments, discuss alternative therapies with your treating doctor and ensure that you obtain your medicine through a Designated Service Provider.

Disease Authorisation

When you apply for chronic medicine, you are approved for treatment of your chronic condition and not a specific medicine only. This means that when you need to change or add a new medicine for your condition, you can do this quickly and easily at your pharmacy with your new prescription without having to contact us. Each condition is allocated a basket of medicine for its treatment. The quantity of each medicine in the basket is limited to the most commonly prescribed monthly dose.

You do need to contact us on 0860 002 108 if:

• You have a medicine that is not in your condition’s basket • If you are diagnosed with a new condition• You require higher quantities than those in the basket

You do not need to update us with your new medicine if:

• Your medicine is in the basket• You change to another medicine in the basket • You need a quantity or dosage of a medicine that is listed in the basket.

Please note: Pre-approved medicine in the basket will still be subject to the Medicine Pricing List and formulary co-payments.

Pharmacy Direct

Pharmacy Direct is the Designated Service Provider (DSP) for chronic medication. Medicine is delivered to your home, place of work or to the nearest Post Office, depending on your choice. A large number of our patients are based in rural areas where there are no other pharmaceutical services available. Pharmacy Direct has the capability to deliver medication to members and dependants residing at different addresses. Patients are advised by SMS, telephone or email of delivery.

Members are required to register with Pharmacy Direct in addition to applying for chronic medication.

Contact details:

Practice number: 0126225Fax: 086 611 4000/1/2/3Queries: 0860 027 800Aid for AIDS: 0860 103 810Email: [email protected]: www.pharmacydirect.co.za

How do I register with Pharmacy Direct?

• Ensure you’ve applied for chronic medicine.• Visit www.pharmacydirect.co.za to download the application form, complete all relevant

sections and fax it to 086 611 4000/1/2 or email it through to [email protected].• Alternatively, you can call Pharmacy Direct on 086 002 7800 to register an online

application.• Please fax a copy of the original repeat prescription for all medication required to 086 611

4000/1 or email to [email protected]. If you do not have the prescription, please contact your doctor.

Please note: An electronic copy of all documentation is acceptable. However, you are required to send your original prescription for schedule 5 and 6 medicine to Pharmacy Direct.

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How do I order medication?

Please fax a copy of the original repeat prescription for all medication required to 086 611 4000/1/2 or

E-mail to [email protected]. If you do not have a valid, repeat prescription, please contact your doctor.

Please note: By law, medication can only be dispensed once a pharmacy is in possession of a valid prescription. It remains the responsibility of the patient to obtain his/her prescription from the prescribing doctor and to forward this to Pharmacy Direct and to Chronic Medicine Management for chronic authorisation.An electronic copy of documentation is acceptable. However, by law you are required to send your original prescription for any schedule 5 and 6 medicine to be obtained from Pharmacy Direct.

How soon can I expect delivery of my medication?

Please note: Before medication can be sent, to new or existing Pharmacy Direct users, Pharmacy Direct would engage in certain interventions to ensure good pharmacy practice.

Case Dispatch Time Note Delivery Time

First time delivery of urgent/life-threatening medication

24-48 hours until dispatch

Dependant on whether chronic authorisation is already in place

24-72 hours, depending on location

First time delivery of other chronic medication

3-5 working days until dispatch



Delivery of medication where a new, valid prescription has been received

3-5 working days until dispatch, or as per automated existing dispense dates



Medication is automatically dispensed on a 28-day cycle. Pharmacy Direct uses an advanced scheduling and planning system to deliver medication to patients on a monthly basis.

Did you know? By law, prescriptions are only valid for six months. Therefore, patients don’t need to re-order medication each month, but rather, update their prescription every six months.

Pharmacy Direct contact details:

Fax: 086 611 4000/1/2/3Queries: 0860 027 800Email: [email protected] Website: www.pharmacydirect.co.za

Hospital Management

Pre-authorisation for hospital admission

All hospital stays must be pre-authorised (including emergencies). It is best to do this at least two days before you go to hospital.

No account will be paid unless pre-authorisation is obtained. In cases of emergency, pre-authorisation can be obtained 48 hours after the emergency.

On the Standard Select and BonFit options, a 30% co-payment will apply to all non-network and non-authorised hospital admissions, except in the case of an emergency.

How do I apply for pre-authorisation?

You can apply for pre-authorisation in one of these ways:

• Online Log in to www.bonitas.co.za and click on the pre-authorisation button. Follow the prompts.

• Email Email all the relevant information to [email protected].

• Telephone Call 0860 002 108 between 8:30am and 4:00pm Monday to Friday to pre-authorise your hospital stay. This number is not available on public holidays or weekends.


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What information do I need when I apply for pre-authorisation?

• Membership number• Beneficiary name and date of birth• Date of admission and the proposed date for the operation• Name of the doctor and their telephone and practice numbers• Name of the hospital with their telephone and practice numbers• All the relevant procedure codes• All the relevant associated medical diagnosis codes

Are there any other treatments/procedures that I need pre-authorisation for?

You will also need pre-authorisation for the following:

• Renal clinic admissions for dialysis• Procedures in doctor’s rooms instead of hospitalisation• Physical rehabilitation care in rehabilitation facilities• Drug and alcohol rehabilitation care in specific facilities• Hospice admissions• Oxygen therapy at home• All specialised radiology

What happens in the case of an emergency treatment/admission to hospital over a weekend, public holiday or at night?

In this case, you must contact the pre-authorisation call centre on the first working day after the incident.

Failure to obtain pre-authorisation for a planned event or authorisation on the first working day after an emergency event will mean that you are liable for the full account according to the rules of the Scheme.

Will I receive any communication about my pre-authorisation?

You will receive a letter confirming your pre-authorisation by email or post. This letter contains a number of disclaimers printed at the end. Please make sure you take note of these disclaimers as they reflect the Scheme rules. If you are unclear, please discuss the disclaimers with your treating doctor.

You will also need to keep note of:

• The unique pre-authorisation number• The initial approved length of stay• The status of all the codes

What happens if I have to stay in hospital for longer than the initial approved length of stay?

Ensure that your doctor, the hospital case manager or a family member emails [email protected] to inform the case management department of the extended length of stay. If there is a clinical reason for the stay, your Fund will approve the extra days. If not, you will be liable for the costs of the non-approved days and treatment.

Do co-payments still apply on procedures performed in-hospital?

Any procedure that is stipulated in the Scheme rules as attracting a co-payment will still attract a co-payment whilst in-hospital. Your diagnosis or treatment plan will not change this.

Why are some requests for pre-authorisation declined?

Some of the pre-authorisation requests may be declined if:

• The planned procedure is not covered by your benefit option as specified in the Scheme rules.

• The planned procedure is not in line with the acceptable treatment standards for a particular medical condition.

• The appropriate clinical information has not been received.• The membership is inactive or similar issues with membership status.

Case Management

While you are in hospital, case managers ensure that appropriate care is provided at all times and that appropriate discharge planning takes place where clinically indicated and where benefits are available. This takes place according to the Scheme rules, clinical protocols and funding guidelines.

When extended length of stay or level of care is requested, the case manager will request supporting information to be able to make an informed clinical decision. If there is any doubt at all, a medical advisor will assist and motivation might be requested from your treating provider, if needed. All changes in initial approvals are communicated to the hospital and treating provider. With long-term cases, your family members may also be involved.

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Networks GP (General Practitioners) Network

Bonitas offers the largest GP network in South Africa, providing you with access to over 7 000 GPs countrywide. We’ve negotiated special rates with these GPs to ensure that you won’t have any co-payments and that your benefits last longer. Members on the Standard and Primary options are advised to use the Bonitas GP Network for all their GP visits.

Members on the Standard Select option will be required to nominate their GP per beneficiary from our network on the application form or contact the call centre.

How do I find a doctor on the Bonitas GP Network

• Call us on 0861 002 108 or use the ‘Find a doctor’ tool on our website - www.bonitas.co.za or use the SMS locator facility.

Specialist referrals

Your GP should be the first person to advise you about your healthcare needs. Not only does your GP understand your illness, but he/she also knows which type of specialist is best for you to see. The GP will assist you in consulting with the right specialist should you need to, saving you both time and money.

Please remind your GP to call the call centre to obtain an automated specialist referral authorisation number, via the IVR (Interactive Voice Response) system. On BonClassic, Standard, Standard Select, Primary and BonFit, female members may visit the gynaecologist once a year without referral. Members may also visit the ophthalmologist and oncologist without referral.

Specialist Network

At Bonitas, we constantly strive to give you access to affordable, quality healthcare. That’s why we’ve partnered with various healthcare professionals to create the Bonitas Specialist Network, which gives you access to over 2 000 specialists nationally.

If you are a member on the Standard, Standard Select, Primary, BonSave, BonClassic, BonFit and BonEssential Options, the Specialist Network will provide you with access to specialist services at a negotiated tariff for both in and out-of-hospital costs. The benefit of this initiative will result in your claim being paid in full without you being responsible for any shortfall.

If you have a Prescribed Minimum Benefit condition and your day-to-day benefit limits have been exhausted, you can continue to consult with a specialist within the Bonitas Specialist Network without incurring any co-payments. Services for these conditions will be subject to the guidelines as contained within the Medical Schemes Act.

How do I find a specialist on the Bonitas Specialist Network?

Visit www.bonitas.co.za and use the provider locator tool. Alternatively, call us on 0860 002 108 or email us at [email protected].

The Standard Select and BonFit Hospital Network

The Standard Select and BonFit options offers members access to the best quality private hospitals on the extensive hospital network list. Visit www.bonitas.co.za and use the hospital locator tool. Alternatively, call us on 0860 002 108 or email us at [email protected].

Dental Benefits

DENIS is a fully accredited managed care organisation that manages your dental benefits. There is a pre-defined benefit per procedure, which is paid at the published Bonitas Dental Rate (see www.denis.co.za for the list of dental rates).

Your dentist will also be able to provide information regarding your benefits, as DENIS supplies all dentists with a Chair side & Benefit Guide, which illustrate the dental benefit management methodology and benefits. Benefits for dentistry are paid on a fee for service basis. This means that for every procedure done by a dentist, there is a fee that is charged. These fees may differ from dentist to dentist. Your fund pays a benefit for each procedure, which may differ from the fee charged by your dentist. It is your right to negotiate this difference with your dentist.

Dental benefits are paid at the Bonitas Dental Tariff (BDT) and are dependent on the plan you’re on.

Hospitalisation and certain specialised dentistry procedures and treatment must be pre-authorised.


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Please note: • Procedures and treatment not pre-authorised will not attract a benefit, with the exception

of crown and bridge procedures where a 20% penalty will apply if authorisation is applied for after the treatment has been done.

• A co-payment of R2 000 is applicable on all hospital admissions for dentistry on the Standard, Standard Select, BonSave, Primary, Bonfit and BonEssential options.

• Failure to pre-authorise orthodontic treatment will result in payment only from the date of authorisation for the remaining months of treatment, provided that the treatment is clinically indicated.

• Penalties do not apply to emergency hospital admissions. • Co-payments for Orthodontics are levied on the Standard and Standard Select Option. • A benefit for Crown & Bridgework on the Standard & BonClassic Options is subject to a

DENIS Designated Service Provider Network. • All conservative, out-of-hospital services on the BonCap Option are subject to a DENIS

Designated Service Provider Network.• Dental benefits are subject to managed care protocols and interventions, which may

include the requirement of treatment plans and/or radiographs prior to benefit application.

Dental Wellness Program

As a Bonitas member, you are automatically a member of the Dental Wellness Program. You will receive various treatment-related information leaflets and oral screenings, advice and dental products will be provided at your company’s wellness days. Visit www.denis.co.za for more information.

How do I find a DENIS Network Provider?

Visit www.denis.co.za and use the “find a dentist” tool.

How do I submit claims to DENIS?

Post the original copies of your dental claims to Private Bag X 1 Century City 7446, Cape Town or email [email protected]

Please ensure the following details are clearly visible:

• Your membership number• The dentist’s details and practice registration number• The correct dependant name and code (see your membership card)

• The treatment date• The relevant procedure codes• The tooth numbers (if applicable)• The relevant ICD-10 codes Which specialised dental benefits need to be pre-authorised?

• Crown and bridge procedures• Orthodontics• Implants• Hospitalisation • Intravenous Conscious Sedation• Periodontics

How do I get pre-authorisation for these specialised dental procedures?

To pre-authorise dental procedures in hospital or under IV Conscious Sedation, please call 0860 336 346.

Please have the following information on hand:

• Hospital practice number• Anaesthetist practice number• Treating clinician• Hospital admission date• Procedure code(s) with ICD10 code(s) and where relevant the applicable tooth numbers• Main complaint as to why the procedure is needed• If applicable, medical report of special medical conditions• X-rays are needed if a 54 practice applies for the removal of impactions

To pre-authorise the following specialised dental benefits, please use the relevant email contact details:

• Crown and bridge procedures – Email [email protected]• Orthodontics – Email [email protected]• Implants – Email [email protected]

Alternatively, you can fax the details to 0866 770 336.

For more details on the pre-authorisation requirements for the above-mentioned specialised dental benefits, please visit www.denis.co.za

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The Periodontal Program

This benefit is only available to those members on the Standard, Standard Select, BonClassic and BonComprehensive Options.

How do I apply to the Periodontal Program?

Submit your CPITN score (supplied to you by your dental practitioner), together with your Periodontal treatment plan to [email protected], or alternatively, fax it to 0866 770 336.

Once authorisation has been obtained, cover for the treatment is subject to Scheme rules, exclusions and benefit protocols.

What happens if my procedure is not pre-authorised?

• Procedures and treatment not pre-authorised will not attract a benefit and thus not be paid by the Scheme, with the exception of crown and bridge procedures where a 20% penalty will apply if authorisation is applied for after the treatment has been done.

• Failure to pre-authorise orthodontic treatment will result in payment only from the date of authorisation for the remaining months of treatment, provided that the treatment is clinically indicated.

• Penalties do not apply to emergency hospital admissions. Co-payments for Orthodontics are levied on the Standard and Standard Select options.

Contact details:

Call: 0860 336 346Fax: 0866 770 336Email: [email protected]: [email protected] authorisations: [email protected] and implant authorisations: [email protected] and bridge authorisations: [email protected] authorisations: [email protected]

Optical Benefits Your optical benefits depend on the plan you have chosen.

Our preferred provider for optical benefits is Iso-Leso. Their respected national network of optometric practices has a reputation for delivering high quality service and products to its patients and members of medical Schemes. They offer medical aid members substantial savings on clear single vision, bifocal and multifocal quality spectacle lenses. Their mission is to ensure the viability and stability of the optometric environment for all role players.

The Iso-Leso philosophy is to encourage participation of all registered optometrists in the provision of optometric services. As the Iso-Leso provider base is diverse and includes private practitioners, group practices and optometric franchisees, we have a fair representation of the choices that Bonitas members face in seeking optometric care.

In addition, Iso-Leso has embarked on improving the quality of professional services with the Practitioner Enhancement Program. This initiative is designed to accredit optometrists who invest in their professional standards of practice.

This ultimately translates into a higher level of the quality of care for the Bonitas member.

Your available savings may be used for Optical benefits.

You can visit a non-network provider, however, your plan’s optical benefit is limited to the Iso-Leso tariff. This means you may have to make a co-payment.

How do I find an Iso-Leso Optical Provider?

If you have any questions regarding your nearest Iso-Leso Provider, you can contact Iso-Leso at the following contact details.

Contact details:

Call: 0860 10 30 50 / 60 Email: [email protected]


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Each beneficiary is entitled the following benefit over a 24-month cycle commencing on 1 January 2015:

Either:

• One consultation and, if the required prescription is not less than 0,50DS or 0,50DC or the required reading addition is greater than 0,75DS

• One pair single vision lenses or;• One pair flat top bifocal lenses or;• One pair multifocal lenses or;• A spectacle frame to the value of the specific benefit option

Or:

One consultation and contact lenses to the value of specific benefit option

Please note:• Services not covered by the matrix are for the members’ portion and should be paid directly

to the practice, or can be refunded from available savings.• Please note that claims older than 4 months from the date of service will not be accepted

for payment.• The practice is not entitled to collect the unpaid portion for the above products from the

patient unless they are: - Lens enhancements and add-ons (tints, ARC etc.) - The difference on the frame value over the specific plan maximum benefit - The difference on the contact lens value over the specific plan maximum benefit

• All tariffs are inclusive of VAT. • Mobile Practice claims will only be paid if confirmation of registration as a mobile practice

by HPCSA is supplied.• Spectacle lens prescriptions must be included in both paper and electronic claims. Please

contact your service provider for assistance in this regard.• Payment for materials will be declined under the following circumstances:

- Where no script is indicated - Where no ICD 10 codes are indicated - Where the script is less than 0.50 D sphere or 0.50 D cylinder (with no sphere) in both

eyes in the case of spectacles - Invoices that do not comply with VAT legislation requirements - Where the claim is older than 4 months from the date of service

Diabetic Program

Bonitas Medical Fund has partnered with the Centre for Diabetes and Endocrinology to provide excellent care to members with diabetes.

The CDE is a holistic, multi-specialist Diabetes Centre in Houghton, Johannesburg. The Centre manages diabetes by using a team approach that includes diabetes specialists, diabetes educators, a dietician, podiatrists, a clinical psychologist, as well as exercise specialists if necessary. In addition, the Centre trains healthcare professionals in the principles and practice of good diabetes care and acts as the central office for a nationwide network of over 240 affiliated “Centres for Diabetes”. These accredited centres are contracted to provide all the benefits of the diabetes management program, which is a complete diabetes management package.

The CDE has won numerous awards over the last 20 years for their excellence and they are acknowledged as world-class providers of diabetes care. Join now to optimise your diabetes health!

The CDE program includes:

• consultations with a doctor who has received further training in diabetes management (a minimum of two per year)

• diabetes education to supplement your knowledge in diabetes and to enable you to “self-manage” your diabetes more effectively

• annual consultations with a registered dietician• access to the best and most appropriate medicines for diabetes• a diabetes 24 hour emergency hotline• a diabetes specialist (endocrinologist) supporting your treating doctor regarding your

treatment as well as care support from a CDE case manager.

Eye screening (ophthalmologist), and foot screening (podiatrist) services are also important components – these are made available by Bonitas via their normal funding mechanisms.

Your diabetes medication is important. The CDE, in conjunction with your treating doctor and a CDE endocrinologist, will ensure that your diabetes prescription is optimized for your diabetes treatment. Importantly, you will have your diabetes medication sent directly to you by the Bonitas preferred provider, Pharmacy Direct. This valuable service makes it convenient for you and ensures you always receive what you need for your diabetes care in a timeous manner.

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If you wish to remain with the doctor who is currently treating your diabetes, ask him / her to contact the CDE central office in Houghton, Johannesburg. They will then provide information and the doctor will be trained and accredited as a “preferred provider” within the “Centre for Diabetes” network.

How do I join the CDE?

Members on all options who have diabetes can join the Centre for Diabetes and Endocrinology by:

• Calling them on 011 053 4400 to join the program.• Asking your doctor to refer you to the nearest CDE Centre where you can register on the

program.

How much does it cost?

There is no joining fee and no charge for your diabetes care services.

If your Bonitas GP Network doctor is not a CDE accredited doctor, they are still able to participate. This means that you should be able to stay with your current Bonitas GP network doctor if you wish. The CDE will facilitate this if required.

Contact details:

Tel: (011) 053 4400Fax: (011) 728 6661Email: [email protected]: www.cdediabetes.co.za

Hip and Knee Replacement Program

ICPS (Improved Clinical Pathway Services) is a group of orthopaedic surgeons that specialise in performing hip and knee replacements according to standardised clinical care pathways. These care pathways have been developed in accordance with evidence based outcomes to ensure that the quality of the hip and/or knee replacement is of highest standard and to ensure the best health outcomes.

ICPS uses a multidisciplinary team dedicated to assist with rapid and successful recovery and keeping the patient as comfortable as possible during the healing period.

How to access and orthopaedic surgeon on the ICPS program

Call the Bonitas call centre on 0860 00 2108 where you will be given the details of an ICPS orthopaedic surgeon closest to you.

Following your consultation with the ICPS orthopaedic surgeon and if the decision for surgery is made, an application for an authorisation number will be arranged on your behalf by the admin staff of the practice. This will allow you access to the ICPS program and ensure payment in full (subject to your prosthesis benefit) with no co-payment for the procedure. The ICPs surgeon will give you a booklet providing you with information on the ICPS program.

The program is applicable to all members on the Bonitas Standard, Standard Select and BonClassic options.

ICPS will assist with your hospital pre-authorisation should an operation be required. To alleviate the admin burden of submitting accounts, ICPS will submit one account to Bonitas for payment which will include:

• All hospital costs• Surgeons and anaesthetist fees• Prosthesis (subject to prosthesis benefit)• Physiotherapist (pre-, intra-, and post-operative)

Should you choose not to use an ICPS orthopaedic surgeon and are admitted for hip or knee surgery you will be liable for a R5 000 co-payment on admission to the hospital. If you are on the Standard Select option you are only allowed to use ICPS facilities.

The program has been established to assist you in taking an active part in planning your care and recovery for hip or knee surgery as well as ensuring financial peace of mind.

HIV/Aids Management

South Africa’s leader in HIV/Aids management and care, Aid for AIDS is a revolutionary, integrated approach to HIV/Aids management that has been delivering excellence since 1998. Our approach is to act as a care-coordinator between the funder, doctors, pathology labs, pharmacies and patients. Supported by a team of worldwide-respected clinicians in their field. Backed by a custom IT system that has become the gold standard in HIV/Aids disease management and we enable the optimal care of patients with an end-to-end solution.


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Our program is designed to meet the needs of patients and equip them with the treatment and tools to lead normal, fulfilled lives. We empower funders to guard against the financial risk posed by unmanaged HIV/Aids in their employee or member populations. Shaped over years of clinical research and expertise, our methods are considered as the industry standard by healthcare professionals globally.

It is very important to register on the program as soon as you know your status.

Your plan has a benefit amount specifically for HIV/Aids-related medication. This benefit amount is used to pay for:

• Antiretroviral therapy (ART)• Medication to protect you against illnesses such as TB and flu• Regular monitoring tests

Aid for AIDS offers a complete HIV/Aids disease management program to both members and beneficiaries:

• Medication to treat HIV (including drugs to prevent mother-to-child transmission and infection after sexual assault or needle-stick injury) at the most appropriate time

• Treatment to prevent opportunistic infections like certain serious pneumonias and TB• Regular monitoring of disease progression and response to therapy• Regular monitoring tests to detect possible side-effects of treatment• Ongoing patient support via a team of trained and experienced counsellors• Clinical guidelines and telephonic support for doctors• Help in finding a registered counsellor for face-to-face emotional support

Even if you do not need ART because it is still too early, it is important to register on the program in order to have access to all the other benefits that will assist in keeping you healthy.

Strict confidentiality

Every effort is made to keep members’ HIV status confidential. The staff members at our Aid for AIDS unit have all signed confidentiality agreements and work in a dedicated unit. They use separate telephone, fax, email and private mailbag facilities. Patients need to use these facilities to maintain confidentiality.

How do I register with Aid for AIDS?

If you are HIV-positive, you must register with Aid for AIDS as soon as possible in order to make use of this benefit.

• Call 0860 100 646 and ask for an application form. All calls are strictly confidential.• You may also pre-register yourself on the program where you will receive guidance on how

to continue on the program to receive the benefit.• You and your doctor must complete the application form and return it to Aid for AIDS by

using the confidential, toll-free fax-line number on the form or via email.

What happens after I have registered?

A highly qualified medical team will check your medical details and, if necessary, discuss cost-effective and appropriate treatment with your treating doctor. Once treatment has been agreed upon, you and your doctor will be sent a detailed treatment plan, which explains the approved medicine, as well as the regular tests that need to be done to ensure that the drugs are working correctly and safely.

Contact details:

Call: 0860 100 646Fax: 0800 600 773Email: [email protected]: www.aidforaids.co.zaMobi-site: www.aidforaids.mobiPlease call me: 083 410 9078

Emergency Medical Services

ER24 is the designated service provider for all emergency medical services for Bonitas members and their registered dependants.

This benefit includes:

• Emergency medical response by road or air to the scene of the medical emergency• Transfer to the closest appropriate medical facility by road or air• Inter-hospital transfers (subject to authorisation) in accordance with Scheme rules• Medical information and assistance hotline• Trauma counseling and referral to appropriate healthcare professionals as required• Member/dependant validation• Medical information and assistance hotline where trained personnel provide trauma

counseling, medical advice in emergencies and HIV counseling

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What do I need to do in the case of a medical emergency?

• Call 084 124• Provide your name and the telephone number you are calling from• Provide a brief description of the incident and the severity thereof• Provide the address/location (road name, number and nearest crossroad)• Do not hang up until ER24 has all the details

Please note: When you join Bonitas, you will receive specially designed ER24 car stickers. Please ensure that these are attached to your vehicle as described in the letter sent with the stickers.

If you use another service provider, a 40% co-payment will apply. Ensure that ER24 is informed of this and that the account is submitted to [email protected] no later than 30 days after the date of service.

Exclusion List

Certain holistic procedures• Aromatherapy• Art therapy• Ayurvedics• Herbalists• Iridology• Reflexology• Sleep therapy• Therapeutic Massage Therapy

Appliances, devices and procedures not scientifically proven• Back rests and chair seats• Bandages and dressings (except medicated dressings)• Cardiac assist devices – e.g. Berlin Heart• Diagnostic kits, agents and appliances unless otherwise stated (except for diabetic

accessories)• Humidifiers, ionisers and air purifiers• Orthopaedic shoes and boots• Pain relieving machines, stethoscopes and blood pressure monitors• Oxygen hire or purchase, unless authorized• Portable oxygen cylinders and Portable oxygen concentrators

Specific reproductive technology and procedures• Medical and surgical treatment for infertility • 3D and 4D maternity scans• Anabolic steroids and immuno stimulants unless Prescribed Minimum Benefits• Contraceptives (including oral, parenteral, foams and IUCDs)• Erectile dysfunction and loss of libido treatment (medical or surgical)• Gender reassignment medical or surgical treatment

Cosmetic procedures and items• Breast augmentation• Breast reconstruction - unless mastectomy following cancer and pre-authorised• Cosmetic items such as moisturisers, sunscreen and shampoos, except for the treatment of lice,

scabies and other microbial infections and coal tar products for the treatment of psoriasis• Epilation• Electric toothbrushes• Cosmetic effect contact lenses• Contact lens accessories and solutions• Keloid surgery and revision of scars except for functional impairment• Optical devices which are not regarded by the relevant managed healthcare program, as clinically

essential or clinically desirable, except on BonSave and BonComprehensive Options• Rhinoplasties for cosmetic purposes• Sunglasses

Dentistry• Appointments not kept • Behavior management• Caries susceptibility and microbiological tests• Cost of Mineral Trioxide• Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments• Crown and bridge procedures for cosmetic reasons and associated laboratory costs• Crowns or crown retainers on wisdom teeth (3rd molars)• Dental bleaching• Dental testimony including Dento-legal fees• Diagnostic dentures and associated laboratory costs• Direct and indirect pulp capping procedures• Dolder bars and associated abutments on implants including the associated laboratory

costs• Electrognathographic recordings, pantographic recordings and other such electronic

analyses• Emergency crowns that are not placed for the immediate protection in tooth injury and

associated laboratory costs


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• Enamel micro abrasion• Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis • Fissure sealants on patients 16 years and older• Full mouth rehabilitations and associated laboratory costs• Gold foil restorations• High impact acrylic• Implants on wisdom teeth (3rd molars)• Intramuscular or subcutaneous injection• Invisible retainer material• Multiple hospital admissions• Nutritional and tobacco counseling• Oral hygiene evaluation and/or instructions• Orthodontic re-treatment and any related Laboratory costs• Orthognathic (jaw correction) and other orthodontic related surgery and any related

Hospital cost including associated Laboratory costs • Ozone therapy• Perio chip placement• Pontics on 2nd molars• Porcelain veneers and inlays and associated laboratory costs• Procedures that are defined as unusual circumstances and procedures that are defined as

unlisted procedures• Professionally applied fluoride for beneficiaries 16 years and older• Provisional crowns and associated laboratory costs• Provisional dentures and associated laboratory costs• Pulp tests• Resin bonding for restorations that are charged as a separate procedure to the restoration• Root canal therapy on primary (milk) teeth and on wisdom teeth (3rd molars)• Snoring appliances and associated laboratory costs• Special reports• Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue

grafting and the hemisection of a tooth• The cost of dental materials for procedures performed under general anaesthesia• The cost of gold, precious metal, semi-precious metal and platinum foil• The metal base to full dentures and associated laboratory costs • The polishing of restorations• Where the only reason for admission to hospital is dental fear and anxiety • Where the only reason for the admission request is for a sterile facility

Dietary and nutritional supplements• Food and nutritional supplements including baby food and special milk preparations unless

prescribed for life-threatening malabsorption disorders and if registered on the relevant managed healthcare program

• Slimming preparations for obesity• Smoking cessation and anti-smoking preparations, except for benefits paid from

wellness extender• Tonics, multi-vitamins, supplements and mineral combinations (except for registered

products that include haemotonics and those for use by infants and pregnant mothers)

Other procedures and treatments• All benefits for clinical trials unless pre-authorised by the relevant managed healthcare

program• Appointments which a beneficiary fails to keep• Autopsies• Balloon Sinuplasty on Primary, BonEssential, BonClassic and BonSave Options• Bilateral gynaecomastia• Bone densitometry performed by a GP or specialist not included in the Scheme credential list• Carmustine Wafers for the treatment of malignant Gliomas• Chiropractor benefits in hospital• Cryo-storage of fetal stem cells and sperm• CT colonography for screening• Genioplasties as an isolated procedure• Holidays for recuperative purposes• Hyperbaric oxygen therapy (except for anaerobic life-threatening infections, Diagnosis

Treatment Pairs 277S and specific conditions pre-authorised by the relevant managed healthcare program)

• MDCT Coronary Angiography for screening• Medicines used specifically to treat alcohol and drug addiction, unless it is a PMB• MRI scans ordered by a GP, unless there is no reasonable access to a relevant specialist• Organ and bone marrow donations to a person who is not a member or dependant on Bonitas• Otoplasties• Pectus excavatum / carinatum• Positron Emission Tomography, except on BonComprehensive and PET plus PET-CT for

screening on all options• Robotic assisted surgery• Screening that has not been pre-authorised or is not in accordance with the Scheme’s protocols• Specialised radiology procedures where pre-authorisation is not made or declined• Surgical treatment for obesity (excluding certain bariatric surgical procedures performed

for life threatening morbid obesity by a multidisciplinary team in accordance with an agreed protocol in a credentialed centre of excellence when pre- authorised, but not including post-operative plastic and reconstructive surgery)

• Uvulo-palatal pharyngoplasty (UPPP and LAUP)• X-rays performed by chiropractors

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Termination of Bonitas membership

Your membership will be terminated if you no longer pay your contributions. You may also leave Bonitas after giving one calendar month’s written notice.

If you leave Bonitas and join a Scheme with a savings account, the full amount available in your savings account will be transferred to that of your new Scheme. This will take place after a waiting period of five months. If you do not join another medical Scheme, or if the medical Scheme you are joining does not have a savings account, the full balance in your savings account will be paid to you.

Please note: Your refund is taxable and must be declared in your annual income tax return. If you leave Bonitas during the year, the savings amount due to you will be pro-rated according to the number of months you were a member of Bonitas. If claims at that stage exceed the pro-rated value, you will have to pay the shortfall.


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Notes

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How-To Guide

How

-To Guide

Use these helpful tips on how to get the most out of your Bonitas medical aid membership.

Do you have a question for us?

Contact the call centre on 0860 002 108 or email [email protected]. Please include your membership number in all correspondence with us.

How To:

Change your personal details

You must let us know if any of your details change within 30 days of the change. This includes changes to:

• Your marital status• Dependants on your medical aid• Your contact details

Simply contact the call centre on 0860 002 108 or email the changes through to [email protected]

Change your banking details

If your banking details change, please let us know immediately. If your medical aid is a deduction on your salary you will also need to inform your employer’s payroll department immediately. You will need to send us your latest bank statement and a copy of your ID to validate the change.

Submit claims in 4 easy steps

Submit your claims

You must send us your claims within four months of receiving treatment or they will not be paid. Submit claims quickly and easily by following these simple steps.

1. Ensure your bank details are correct

Claims refunds are only paid into a bank account via electronic transfers. Please contact the call centre on 0860 002 108 if you need to update your banking details.

2. Check your account and receipt

Make sure that your membership number is clearly indicated on both the account and the receipt.

Please ensure that your account shows the following:

• Your name and initials• Your medical aid number• The treatment date• The name of the patient as shown on your membership card• The amount charged• The tariff• The ICD-10 code

Please check that prescriptions for medicine show all your details. Also check that the correct amount of medicine dispensed is shown on the claim. If the pharmacy omits any of these details, we will not be able to process your claim.

3. Send us a copy of the account and receipt

Please post all claims to:

Bonitas Claims DepartmentPO Box 74Vereeniging, 1930

Or email:[email protected]

4. Check that your claim has been paid

We pay claims weekly. A statement will be sent to you, by post or email at the end of the month showing your claims. You can also log in to the website to view the status of your claims.

Report fraud

Fraudulent use of membership cards (I.e. letting other people use your membership card) is illegal. It results in increased costs that affect all members. Phone our toll-free fraud hotline on 0860 002 108 to report cases of fraud or abuse of Bonitas.

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Use the Bonitas website

If you have internet access, you will be able to log into a secure area to view your statements, claims history, monthly contribution, personal information and much more. You will also be able to view your benefits and update certain personal details. Visit www.bonitas.co.za and follow the steps to register.

How-To Guide

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How

-To Guide

Notes

CONTACT

Page 80Page 80Page 80

PretoriaGround Floor, Benstra Building,473B Church Street, Arcadia,Pretoria

Northam 180 Botha Street,Northam

Port Elizabeth Block 6, Greenacres Offi ce Park, 2nd Avenue, Newton Park, Port Elizabeth

Vereeniging 36 Merriman Avenue,Ground Floor, Vereeniging

BloemfonteinShop C7, 1st Floor, Middestad Centre,c/o Charles and West Burger Street, Bloemfontein

Roodepoort 37 Conrad Road,Florida North,Roodepoort

Secunda Grand Palace, Unit 82,2302 Heinis Street,Secunda

Rustenburg 141 Fatima Bhayat Street, Rustenburg

Lephalale Onverwacht Business,Mienie Building, Block C, Walter Sisulu Avenue,Lephalale

Kathu 6 Rietbok Street,Kathu, Northern Cape

Cape Town

The Icon Building, Ground Floor, Corner Lower Long Street and Hans Strydom Avenue, Cape Town

Polokwane Ground Floor, Bonitas House, 22 Hans van Rensburg Street,Polokwane

Durban 3rd Floor, 67 Old Fort Road, Durban

Visit one of our walk-in centresResolve queries; get a new membership card and so much more at our walk-in centres.

Call our customer service team on 0860 002 108Available between 08:30am and 4:00pm, Monday to Friday the Bonitas Call Centre is here to help you with everything you need.You can:

• Get hospital and specialised radiology authorisation• Authorise chronic medicine• Get a tax certifi cate• Resolve queries

Visit us onlineVisit our website to learn more about our products. You can also join us on Facebook and get health tips, benefi t information and much more. www.bonitas.co.za I www.facebook.co.za/BonitasMedicalFund

Page 1 Bonitas Medical Fund I 0860 002 108 I www.bonitas.co.za

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