The Symmetry Option

Overview

The Symmetry option provides unlimited cover in a private hospital of your choice and comprehensive day-to-day benefits comprising of a medical savings account and traditional risk cover for complete peace of mind.

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

• You receive day-to-day benefits in excess of R13 674 per family per annum
• You receive unlimited general practitioner consultations
• We provide unlimited cover for basic dentistry
• You can select a medical service provider of your choice, without being locked in to a restricted network
• You receive a separate chronic medicine benefit for 46 chronic conditions, which is paid from risk
• 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!

Annual Medical Savings and Annual Flexi Benefit for day-to-day medical expenses

P – Principal member A – Adult dependant C – Child dependant

Symmetry	Annual Flexi Benefit
P	R5 830
P + A	R9 540
P + A + C	R10 918
P + A + 2C	R12 296
P + A + 3C	R13 674

 

Day-to-Day Benefits

Day-to-day claims are paid at 100% of the Agreed Tariff (AT) from the Medical Savings Account (MSA) and the Annual Flexi Benefit (AFB). Once the MSA have been depleted, claims are payable from the AFB, where after certain benefits are unlimited for the remainder of the year, e.g. GP consultations and basic dentistry.

Day-to-Day Benefits

On All Income Categories	Medical Savings Account	Annual Flexi Benefit	Total Day-to-Day Benefit
Member	R2 916	R2 914	R5 830
Adult Dependant	R1 860	R1 850	R3 710
Child Dependant	R684	R694	R1 378

 

Day-to-day services are initially paid from the Medical Savings Account (MSA) and thereafter from the Annual Flexi Benefit (AFB)

Benefits	Limits
GP consultations	Initially paid from the MSA and AFB, thereafter unlimited
Specialist consultations	Paid from the MSA and AFB
Acute Medicine (25% co-payment on all medicine without a generic equivalent)	Paid from the MSA and AFB, subject to formulary and Mediscor Reference Pricing (MRP)
Over-the-counter medicine (including schedule 0,1 and 2 medicines) and homeopathic medicines	Paid from the MSA and AFB, subject to formulary and MRP.  Limited to R530 p/b and R850 p/f, (limited to one script per day and a maximum of R130 per event)
Basic Radiology and Pathology	Paid from the MSA and AFB
Basic dentistry	Initially paid from the MSA and AFB, thereafter unlimited
Specialised dentistry	Paid from the MSA and AFB, limited to R5 340 p/b (subject to protocols)
Optometry Visits Lenses Frames and contact lenses	Initially paid from the MSA and AFB, thereafter the balance of the limit is available 1 p/b per annum Limited to R1 430 p/b per annum (subject to protocols) Frame sub-limit included in lens limit R750 p/b per annum
Auxiliary services	Paid from the MSA and AFB, collective limit of R2 120 p/b
Clinical psychology	Paid from the MSA and AFB, limited to R1 375 p/f, subject to protocols
Psychiatry	Paid from the MSA and AFB, limited to R4 450 p/f, subject to protocols
Home Oxygen Ventilation	Paid from the MSA and AFB, subject to pre-authorisation, PMBs and protocols
Private nursing at home	100% GWR, paid from the MSA and AFB, limited to 20 days, subject to protocols and pre-authorisation
Ante-natal classes	Paid from the MSA and AFB, limited to R700
Hospital emergency room/casualty emergency visits (not requiring admissions excluding facility fees)	Paid from the MSA and AFB

Day-to-day services not subject to the MSA or AFB, Paid from Risk

Benefits	Limits
Surgical & medical appliances	100% of cost, limited to R11 130 p/f, sub-limits apply - click here for details
Emergency road-side assistance and ambulance transportation	Unlimited; Preferred provider

Wellness, lifestyle and preventative care benefits paid from risk

Benefits	Limits
Women's Health
Cervical Cancer Vaccine	1 course (3 doses per registered schedule), once-off for female beneficiaries between the ages of 12 and 18 years
Pap smear	1 test per year per female beneficiary over the age of 18 years
Oral contraceptives	Limited to R100 p/b per month
Men’s health
Prostate specific antigen	1 test annually per male beneficiary over the age of 40 years
Children’s health
Baby wellness visits	2 visits per annum for children between 4 weeks and 18 months at DSP
Vaccinations
Flu vaccine	1 p/b per year, limited to R70
Tetanus diphtheria injection	As required
Pneumococcal vaccine	As required, p/b over 60 years of age and high risk members, subject to pre-authorisation
Prophylaxis (malaria)	As required
Lifestyle
Universal 360° check including cholesterol, glucose, blood pressure, BMI, waist circumference, exercise plan, meal plan	1 per year p/b over the age of 18 years, limited to R100 p/b at DSP
Smoking cessation programme	Once a lifetime p/b Limited to R2 500 Conditions apply
VCT and HIV	Once a year p/b

Cover for Chronic Conditions

The Symmetry option offers extensive cover for 46 chronic conditions, including the 26 Chronic Disease List (CDL) conditions and additional 20 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 basic formulary and Mediscor Reference Pricing. A 25% co-payment is payable for the voluntary use of non-formulary or non-generic medicines.

All registered CDL chronic and non-CDL medication is limited to R3 180 p/b and R4 770 p/f, thereafter CDL chronic medication is unlimited.

In-hospital Benefits

Benefits	Limits
Overall Annual Limit	Unlimited, subject to pre-authorisation Co-payments are payable for certain elective procedures - Please click here
TTO medication (take home medication)	Limited to 7 days supply
GPs and specialists	100% of AT, unlimited
Surgical prosthesis and electronic/nuclear devices	Limits per category, sub-limits apply, subject to pre-authorisation and protocols
Basic Radiology	100% of AT, unlimited
Basic Pathology	100% of AT, limited to R21 200 p/f
MRI, CT and PET scans (Combined in-and-out-of hospital benefit)	100% of AT, limited to R12 720 p/f
Physiotherapy in hospital	100% of AT, limited to R5 300 p/f
Organ transplants, renal dialysis (includes transportation of the organ, surgically related procedures, professional fees and services, as well as immunosuppressant drugs)	100% of AT, PMBs only, subject to pre-authorisation, protocols, and DSP
Sport injuries	100% of AT, including professional sport
Emergency room/casualty	100% of AT for emergency medical treatment for injuries resulting from accidents or trauma

Alternatives to Hospitalisation

The Symmetry 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

Co-payments are payable on specified elective procedures (excluding PMBs) done in a hospital or a day facility. The following treatments require a R1500 co-payment:
Gastroscopy, colonoscopy, cystoscopy, nasal/sinus endoscopy, functional nasal surgery (septoplasty), hysteroscopy, flexible sigmoidoscopy, arthroscopy, diagnostic laparoscopy, dental, conservative back and neck treatment (spinal cord injections)

The following treatment requires a R1000 co-payment:
Excision lesion (benign & malignant)

The following treatments require a R4000 co-payment:
Joint replacements (arthroplasty), laminectomy and spinal fusion and Nissen fundoplication (reflux surgery)

The following treatment requires a R2000 co-payment:
Hysterectomy (except for cancer)

Contributions Table

Principal	Adult	Child
R2 106	R1 638	R594

Glossary

• PMB - Prescribed Minimum Benefit
• P/B - Per Beneficiary
• AFB - Annual Flexi Benefit
• P/F - Per Family
• CDL - Chronic Disease List
• AT - Agreed Tariff
• MSA - Medical Savings Amount
• DSP - Designated Service Provider
• GWR - /General Ward Rate