SUMMARY OF BENEFITS LIMIT CHANGES FOR 2017 GOMOMO CARE OPTION 6.5% Average Increase GOMOMO CARE OPTION Plan Option Service Type 2016 Limit L2017 Limit Gomomo Care -Out Advanced radiology limited to a combined in and out benefit 6 360 6 770 Over the counter medication 265 280 Chronic medication 7 000 7 450 Optical (M) -subject to 24-month cycle 1 010 1 070 Optical (M + 1) -subject to 24-month cycle 1 160 1 230 Optical (M + 2) -subject to 24-month cycle 1 290 1 370 Optical (M + 3) -subject to 24-month cycle 1 850 1 970 Dentistry (M) 2 470 2 630 Dentistry (M+1) 2 840 3 020 Dentistry (M+2) 3 090 3 290 Dentistry (M+3) 3 340 3 560 Dentistry (M+4) 3 580 3 810 Dentistry (M+5) 3 820 4 070 Dentistry (M+6) 4 200 4 470 Other services (Includes physiotherapists, speech therapists, clinical psychologists, podiatrists, equipment and external prostheses) per family subject to PMBs 2 250 2 400 Gomomo Care Option -In-hospital Overall Prosthesis benefit sub-limit- per beneficiary per annum. 25 000 26 625 1
SAVINGS CARE OPTION SAVINGS CARE OPTION Savings Care Option - Out of Hospital Savings Care Option - In-Hospital Specialised Radiology (Combined limit in and out per family per annum) 22 500 23 960 Private nursing (per family per annum) 5 400 5 750 Appliances (Memb without a dependant) 1 160 1 230 Appliances (Memb with one or more dependant) 2 030 2 160 Prosthesis (per family per annum) 33 760 35 950 Mental Health (per family per annum) 6 750 7 190 Preventative care 1 802 1 920 Preauthorisation required) 286 300 Blood transfusions and blood replacement products 70 750 75 350 Prosthesis (Surgical and non-surgical prosthesis) 33 760 35 950 Oncology 114 480 121 920 Specialised Radiology (MRI/CAT scan/angiogram) subject to an overall combined in and 22 500 23 960 out limit Organ Transplant and Renal Dialysis (per family per annum) 178 800 190 420 2
PRIMARY CARE OPTION PRIMARY CARE OPTION Primary Care Option - Specialised Radiology (MRI/CAT scan/angiogram) subject to an overall combined in and 16 630 17 710 Out out limit) per family per annum Private nursing (per family per annum) 4 050 4 310 Auxiliary services ( Member without dependant ) 900 960 Auxiliary services ( Member with 1 or more dependant ) 1 460 1 550 Acute meds ( M) 1 680 1 680 Acute meds meds (M+1) 3 030 3 030 Acute meds (M+2) 3 370 3 370 Acute meds ( M+3) 3 820 3 820 Acute meds ( M+4) 3 930 3 930 Acute meds ( M+5) 4 150 4 150 Acute meds(m+6 and more) 4 490 4 490 Appliances(Member with one or more dependant ) 900 960 Mental Health ( per family per annum) 1 460 1 560 Preauthorisation required) 240 255 Other screening tests (Mamogram, pap smear, PSA (Limited to one test per beneficiary 1 800 1 920 per annum) subject to family limit as stated here 2 360 2 490 Hearing Aids ( per family ) every 4 years 4 610 5 500 Non-motorised wheelchairs (Member with or without dependants) 1 680 1 790 Primary Care Inhospital Prosthesis (per family within hospital limit as stipulated) 22 790 24 270 Specialised Radiology ((MRI/CAT scan/angiogram) per family per annum, preauthorisation 16 630 17 710 Oncology 100 000 106 500 3
AFFORDABLE CARE OPTION Affordable Care Specialised Radiology MRI/CAT scan/angiogram) subject to an overall combined in and 25 280 26 920 Option -Out out hospital limit Private nursing ( per family per annum) 6 040 6 430 Clinical & Medical technology services ( memb without a dependant ) 1 350 1 440 Clinical & Medical technology services ( memb with 1 or more a dependants ) 2 360 2 510 AFFORDABLE CARE OPTION Auxiliary services ( Member without dependant ) 1 350 1 440 Auxiliary services ( Member with 1 or more dependant ) 2 360 2 510 Non-PMB Chronic meds ( M)- (Subject to a maximum of R5 261 per beneficiary) 4 940 5 260 Non-PMB Chronic meds ( M+1) - (Subject to a maximum of R5 261 per beneficiary) 9 880 10 520 Non-PMB Chronic meds ( M+2) - (Subject to a maximum of R5 261 per beneficiary) 14 820 15 780 Non-PMB Chronic meds ( M+3) - (Subject to a maximum of R5 261 per beneficiary) 19 760 21 040 Non-PMB Chronic meds ( M+4) - (Subject to a maximum of R5 261 per beneficiary) 24 690 26 290 Non-PMB Chronic meds ( M+5) - (Subject to a maximum of R5 261 per beneficiary) 29 31 570 640 Non-PMB Chronic meds ( M+6 and more) - (Subject to a maximum of R5 261 per 34 36 830 beneficiary) 580 All Non-PMB meds are subject to a maximum of this amount per beneficiary 4 940 5 261 Appliances (Member without a dependant) 1 350 1 440 Appliances( Member with one or more dependant ) 2 360 2 510 Mental Health ( per family per annum) 7 640 8 140 Wellness screening - One consultation visit in doctors rooms (per beneficiary per annum at a Preferred Provider facility; Preauthorisation required) 240 255 Other screening tests (Mamogram, pap smear, PSA (Limited to one test per beneficiary 1 800 1 920 per annum) subject to family limit as stated here 2 360 2 490 Hearing Aids (per family) every 4 years 7 190 8 600 Non-motorised wheelchairs (Member with or without dependants) 2 810 2 990 Affordable Care Option -In-hospital Prosthesis (per family within hospital limit as stipulated) 37 980 40 450 Specialised Radiology ((MRI/CAT scan/angiogram) per family per annum, preauthorisation 25 280 26 920 Refractive surgery including Radial Keratotomy (per family per annum) 5 620 5 980 Oncology 250 000 266 250 4
FULL BENEFIT CARE OPTION FULL BENEFIT CARE OPTION Full Care Option -Out Specialised Radiology ( MRI/CAT scan/angiogram ) subject to an overall combined in and out 33 260 35 420 limit ) per family per annum Private nursing ( per family per annum) 8 090 8 620 Clinical & Medical technology services ( memb without a dependant ) 2 364 2 520 Clinical & Medical technology services ( memb with 1 or more a dependants ) 3 816 4 060 Auxiliary services ( Member without dependant ) 2 470 2 630 Auxiliary services ( Member with 1 or more dependant ) 4 150 4 420 Non-PMB Chronic meds ( M) 9 770 10 400 Non-PMB Chronic meds ( M+1) 19 550 20 820 Non-PMB Chronic meds ( M+2) 29 210 31 110 Non-PMB Chronic meds ( M+3) 38 990 41 520 Non-PMB Chronic meds ( M+4) 48 760 51 930 Non-PMB Chronic meds ( M+5) 58 540 62 340 Non-PMB Chronic meds ( M+6 and more) 68 310 72 750 All Non-PMB meds are subject to a maximum of this amount per beneficiary 9 770 10 400 Appliances (Member without a dependant) 2 360 2 510 Appliances( Member with one or more dependant ) 3 930 4 180 Mental Health ( per family per annum) 14 720 15 680 Preauthorisation required ) 240 255 Other screening tests( Mamogram, pap smear,psa (Limited to one test per beneficiary per 1 800 2 500 annum) subject to family limit as stated here 2 340 2 490 Hearing Aids ( per family ) every 4 years 9 770 12 700 Non-motorised wheelchairs (Member with or without dependants ) 3 920 4 170 Full Care Option -Out Prosthesis ( per family within hospital limit as stipulated ) 50 140 53 400 Specialised Radiology ((MRI/CAT scan/angiogram) per family per annum, pre-authorisation 33 260 35 420 Refractive surgery including Radial Keratotomy (per family per annum) 109 790 116 930 Oncology 300 000 319 500 5