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The Dynamix Option
Overview
The Dynamix option is an attractive new generation
plan, which offers comprehensive private hospital
cover, a savings account and traditional risk benefits
with above threshold benefits for day-to-day
healthcare expenses.
YOU CAN LOOK FORWARD TO EXCELLENT VALUE AND ATTRACTIVE BENEFITS FROM DYNAMIX IN
2012
- You receive day-to-day benefits of up to R25
191 per family per annum
- You can select
a medical service provider of your choice, without being locked into a restricted
network
- Above threshold benefits when you need additional day-to-day healthcare
cover
- You receive unlimited general practitioner consultations
- You receive unlimited
basic dentistry, with competitive specialised dentistry benefits
- We cover chronic
medicine cover for 62 chronic conditions
- We offer unlimited oncology benefits for
peace of mind
- We provide cover for professional sportsmen and
women, for injuries relating to participation in
professional sport
- We offer a benefit for oral contraceptives from risk
- You now have a basket of wellness benefits including
preventative screening for blood pressure, glucose,
cholesterol, BMI and waist circumference, certain baby
immunisations, flu vaccinations, HPV (cervical cancer)
vaccination, adult pneumococcal vaccination, pap smears,
prostate specific antigen test, VCT test, baby wellness
visits and malaria prophylaxis paid from risk, subject
to protocols
- You pay only for the first
three child dependants – the rest are free!
Day-to-Day Benefits
Day-to-day claims are paid at 100% of the Agreed Tariff (AT) from the
annual Medical Savings Account (MSA) - 15% of annual contributions.
Once the savings have been depleted, claims are payable from the
Annual Flexi Benefit (AFB) - 5% of annual contributions, whereafter the
member is liable for the Self Payment Gap (SPG). During this period
claims will accumulate to the threshold level at the Agreed Tariff,
without the member being refunded. Once the threshold level is
reached, the member will qualify for an above threshold benefit of
R4 240 p/b, and R8 480 p/f, with specified sub-limits.
Total annual Medical Savings Account and Annual Flexi Benefit
P – Principal member A – Adult dependant
C – Child dependant
| DYNAMIX |
Annual Flexi Benefit |
| P |
R6 367 |
| P + A |
R11 341 |
| P + A + C |
R13 131 |
| P + A + 2C |
R14 921 |
| P + A + 3C |
R16 711 |
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Medical Savings
Account |
Annual Flexi Benefit |
Total Day-to-Day Benefit |
|
Member |
R4 776 |
R1 591 |
R6 367 |
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Adult Dependant |
R3 720 |
R1 242 |
R4 962 |
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Child Dependant |
R1 344 |
R446 |
R1 790 |
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Day-to-day services payable from the MSA, AFB, SPG and above threshold benefit where applicable*
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Benefits
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Limits
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Above Threshold Benefit
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GP consultations
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Initially paid from MSA, AFB and SPG
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Unlimited (not subject to the above threshold benefit) |
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Specialist consultations
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Initially paid from MSA, AFB and SPG
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*R2
750 p/f
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Acute medicine (25% co-payment on all medicine without a generic equivalent –
member has the option to have this paid from available medical savings account
without accumulation to the threshold) |
Subject to formulary and MRP Initially paid from MSA, AFB and SPG |
*R2 120 p/f |
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Basic Radiology and Pathology
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Initially paid from MSA, AFB and SPG
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*R2 120 p/f (combined limit for radiology and pathology) |
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Basic dentistry
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Initially paid from MSA, AFB and SPG
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Unlimited (not subject to the above threshold benefit) |
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Auxiliary services
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Paid from MSA, AFB and SPG Collective limit of R3 700 p/f |
*R1 375 p/f for physiotherapy and bio kinetics |
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* BENEFITS (accumulates to the threshold level, unless otherwise
specified)
Day-to-day services paid from
the MSA and AFB*
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Benefits
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Limits
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Over the counter medicine (including schedule 0,1 and 2 medicines) and
homeopathic medicines |
Paid from MSA and AFB, subject to formulary and MRP, limited to R650 p/b and
R950 p/f (limited to one script per day and a maximum of R150 per event) Does
not accumulate to the above threshold level |
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Specialised dentistry |
Paid from MSA and AFB, limited to R8 000 p/b and R11 130 p/f, subject to
protocols |
Optometry
Visits
Lenses,
frames and contact lenses
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Paid from MSA and AFB
2 visits p/b per annum
Limited to R2 550 p/b per annum (subject
to protocols)
Frame sub-limit included in lens limit R1 060 p/b per annum |
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Clinical psychologist |
Paid from MSA and AFB, limited to R1 600 p/f, (subject to protocols) |
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Psychiatry |
Paid from MSA and AFB, limited to R6 900 p/f, (subject to protocols) |
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Home oxygen ventilation |
Paid from MSA and AFB, subject to pre-authorisation, PMBs and protocols |
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Private nursing at home |
Paid from MSA and AFB, limited to 40 days, subject to protocols and
pre-authorisation |
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Ante-natal classes |
Paid from MSA and AFB, limited to R850, subject to protocols |
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Hospital emergency room/casualty emergency visits (not requiring admissions
excluding facility fees) |
Paid from MSA and AFB |
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* BENEFITS (accumulates to the threshold level, unless otherwise
specified)
Day-to-day services not subject to the MSA and AFB,
paid from risk
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Benefits
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Limits
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Surgical & medical appliances
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100% of cost, limited to R14 840 p/f, sub-limits apply –
click here for details |
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Emergency road-side assistance and ambulance transportation
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Unlimited, preferred provider
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Wellness, lifestyle and preventative care
benefits paid from risk
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Benefits
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Limits
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Women's Health |
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Cervical Cancer Vaccine |
1 course (3 doses per registered schedule), once-off for female beneficiaries
between the ages of 12 and 18 years |
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Pap smear |
1 test per year per female beneficiary over the age of 18 years |
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Oral contraceptives |
Limited to R100 p/b per month |
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Men’s health |
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Prostate specific antigen |
1 test annually per male beneficiary over the age of 40 years |
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Children’s health |
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Baby wellness visits |
2 visits per annum for children between 4 weeks and 18 months at DSP |
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Vaccinations |
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Flu vaccine |
1 p/b per year, limited to R70 |
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Tetanus diphtheria injection |
As required |
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Pneumococcal vaccine |
As required, p/b over 60 years of age and high risk members, subject to
pre-authorisation |
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Prophylaxis (malaria) |
As required |
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Lifestyle |
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Universal 360° check including cholesterol, glucose, blood pressure, BMI, waist
circumference, exercise plan and meal plan |
1 per year p/b over the age of 18 years, limited to R100 p/b at DSPP |
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Smoking cessation programme |
Once a lifetime p/b Limited to R2 500 Conditions apply |
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VCT and HIV |
Once a year p/b |
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Cover for Chronic Conditions
The Dynamix option offers extensive cover for 62 chronic conditions, including the 26 Chronic Disease List (CDL) conditions and additional
36 non-CDL conditions.
If you suffer from one of the chronic conditions on the list, you need to
register with Mediscor in order to qualify for the chronic benefit.
Chronic medication is subject to the standard formulary and Mediscor
Reference Pricing. A 25% co-payment is payable for the voluntary use of
non-formulary or non-generic medicines.
All CDL chronic medication is unlimited. Non-CDL chronic medication is
paid from the MSA, AFB and Self Payment Gap, limited to R6 360 p/b and
R10 600 p/f. An above threshold benefit of R2 120 p/f is available, only if
the limit mentioned above has not been exceeded, subject to the overall
above threshold limit.
Insulin dependent members may join the diabetes programme with our
preferred provider, Centre for Diabetes and Endocrinology (CDE).
In-hospital Benefits
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Benefits
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Limits
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Overall Annual Limit
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Unlimited, subject to pre-authorisation Co-payments are payable for certain
elective procedures Co-payments may be paid from the MSA with no accumulation to
the threshold |
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TTO medication (take home medication)
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Limited to 7 days supply
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GP and specialist cost
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100% of AT, unlimited
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Surgical prosthesis and electronic nuclear devices
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Limits per category, sub-limits apply, subject to pre-authorisation and protocols
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Radiology and pathology
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100% of AT, unlimited
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MRI, CT scans and PET scans (combined in-and-out-of-hospital benefit)
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100% of AT, unlimited First R2 000 paid from the MSA, (with accumulation to the
threshold), pre-authorisation required |
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Physiotherapy in hospital
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100% of AT, unlimited
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Organ transplants, renal dialysis (includes transportation of the organ, surgically
related procedures, professional fees and services, as well as immunosuppressant
drugs)
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100% of AT, PMBs only, subject to pre-authorisation, protocols and DSP
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Sport injuries
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100% of AT, including professional sport
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Emergency room/casualty
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100% of AT for emergency medical treatment for injuries resulting from accidents
or trauma
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Alternatives to Hospitalisation
The Dynamix option offers cover for step down nursing facilities, Hospice and rehabilitation.
Cover is subject to pre-authorisation, protocols and case management.
Prescribed Minimum Benefits (PMB)
- Subject to Scheme protocols
- Hospitalisation – 100% of cost at DSP, unlimited
- Medication – CDL conditions are unlimited subject to a formulary and dispensed by a DSP
- Medical management in and out of hospital
– 100% AT, subject to protocols and treatment by DSP
- HIV/AIDS – subject to registration
on HIV/AIDS programme, subject to protocols, failing which a R3 000 limit will apply
Co-Payments for in-hospital procedures
Gastroscopy, colonoscopy, cystoscopy, nasal/sinus endoscopy, functional
nasal surgery (septoplasty), hysteroscopy, flexible sigmoidoscopy, arthroscopy,
diagnostic laparoscopy, dental, joint replacements (arthroplasty), conservative
back and neck treatment (spinal cord injections), laminectomy and spinal
fusion, Nissen fundoplication (reflux surgery), hysterectomy (except
for cancer)
The following treatment requires a R1 000 co-payment:
Excision lesion (benign & malignant)
Contributions Table
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Principal
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Adult |
child |
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Mecical
Savings
Account
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R398 |
R310 |
R112 |
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Risk
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R2 254 |
R1 760 |
R6322 |
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Total Contribution
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R2 652 |
R2 070 |
R744 |
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Annual day-to-day benefits before threshold
(MSA and AFB)
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R6 367 |
R4 974 |
R1 790 |
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Annual Self Payment Gap |
R2 721 |
R2 117 |
R754 |
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Threshold
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R9 088 |
R7 091 |
R2 544 |
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Glossary
- PMB - Prescribed Minimum Benefit
- P/F - Per Family
- MSA - Medical Savings Account
- AT - Agreed Tariff
- SPG - Self Payment Gap
- MRP - Mediscor Reference Pricing
- CDL - Chronic Disease
List
- CDE - Centre for Diabetes and Endocrinology
- P/B - Per Beneficiary
- AFB - Annual Flexi Benefit
- TTO - To Take Out i.e. Medicines taken out of hospital when discharged
- DSP - Designated Service Provider
- GWR - General Ward Rate
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