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					Products   Administered by
Manual
2011
Contents
Hospital Plan                             2
Foundation Plan                           5
Progressive Select Plan                   9
Progressive Flex and Prestige Plan       13




                                     1
HOSPITAL PLAN BENEFIT GUIDELINES
THE HOSPITAL PLAN DOCTOR NETWORKS

•   There are no out-of-hospital benefits for doctors on the hospital plan
•   However, PMB’s will be funded in an out-of-hospital environment according to management protocols as applicable. This includes
    consultations, treatment and medication limited to the criteria contained in the PMB regulations.
•   On-going management of PMB’s will be limited to GP’s unless suitable justification for specialists is pre-authorised
•   These benefits will be limited to the Preferred Provider networks of GP’s and specialists. Outside these networks co-payments
    may be applicable
•   The list of general practitioner and specialist doctors in the Preferred Provider networks is available at www.resomed.co.za or from
    Client Services.

CASUALTY BENEFIT

•   The casualty benefit covers the ‘facility fee’ for all treatment and medication given and dispensed at the time of the visit to the limit
    of R1,115 for the year
•   Medication is limited to the Hospital plan acute formulary
•   Radiology and pathology is limited to PMB confirmed conditions
•   The doctor’s fees are separate to the casualty benefit and also PMB dependent.

DENTAL AND OPTICAL BENEFITS

•   Dental benefits are limited to justifiably necessary hospitalisation. Benefits only cover the hospital and anaesthetist accounts.
    Dentist and Maxillofacial accounts are not funded
•   Pre-authorisation is required
•   There are no benefits for routine dentistry on the hospital plan
•   There are no optical benefits on the hospital plan.

NOMINATION OF ADDITIONAL NETWORK PROVIDERS BY MEMBERS

•   Members may nominate their current or an alternative GP, specialist, or dentist who is not yet a preferred or network provider to
    be included in the networks in future. Members need to provide their Resolution membership number and contact details and the
    nominated provider’s name, address, telephone number and practice (‘PR’) number to us at:

    •       Resolution Client Services at 0861 796 6400 or email clientservices@resomed.co.za
    •       Agility Global Health Solutions at 012 673 8600 or email info@agilityghs.com
    •       Via their broker

•   The provider will be approached to become a preferred network provider and the member will be informed accordingly of the
    providers decision. This process will take about 3 working days. Note if this is unsuccessful, the member will have to choose
    another provider within the network to avoid co-payments.

ACUTE MEDICATION

•   There is no benefit for acute medication except for PMB conditions.
•   Acute medication is limited to the Hospital plan acute formulary. There are no additional medication benefits outside this
    formulary.
•   Members may be liable for co-payments outside the Resolution Health Pharmacy Network listed at www.resomed.co.za

CHRONIC MEDICATION

•   The chronic conditions under this benefit are limited to the 25 CDL (chronic disease list) PMB conditions
•   A member’s chronic condition(s) need to be registered by the GP with MediKredit, for which certain clinical or pathology information
    may be required.
•   Chronic condition management is subject to consultation, pathology and treatment protocols
•   Medication is limited to the Hospital plan chronic formulary. Reference and MMAP pricing may apply
•   Medication can be obtained from Resolution Health Pharmacy Network pharmacies (www.resomed.co.za), or Optipharm courier
    pharmacies (needs to be organised by the doctor through MediKredit). Optipharm will contact members after their first script with
    the SMS number for requesting re-fills in future. Optipharm will deliver medication monthly to a physical address. Co-payments
    may be applicable from other pharmacy providers
•   Chronic medication from a specialist must be subsequently followed-up by a member’s GP unless there are justifiable reasons for
    continuing with the specialist, for which pre-authorisation is required.
•   On-going chronic medication also requires certain clinical and pathology information to be submitted on www.resomed.co.za.

PATHOLOGY

•   The chronic conditions under this benefit are limited to the 25 CDL (chronic disease list) PMB conditions
•   A member’s chronic condition(s) need to be registered by the GP with MediKredit, for which certain clinical or pathology information
    may be required.


        2
•   Chronic condition management is subject to consultation, pathology and treatment protocols
•   Medication is limited to the Hospital plan chronic formulary. Reference and MMAP pricing may apply
•   Medication can be obtained from Resolution Health Pharmacy Network pharmacies (www.resomed.co.za), or Optipharm courier
    pharmacies (needs to be organised by the doctor through MediKredit). Optipharm will contact members after their first script with
    the SMS number for requesting re-fills in future. Optipharm will deliver medication monthly to a physical address. Co-payments
    may be applicable from other pharmacy providers
•   Chronic medication from a specialist must be subsequently followed-up by a member’s GP unless there are justifiable reasons for
    continuing with the specialist, for which pre-authorisation is required.
•   On-going chronic medication also requires certain clinical and pathology information to be submitted on www.resomed.co.za.

RADIOLOGY

•   There are no out-of-hospital radiology benefits on the hospital plan except for confirmed PMB conditions
•   ‘Specialised Radiology’ e.g. CT and MRI scans, require pre-authorisation and are subject to the specialised radiology benefit
•   There is no radiology provider network

KIDNEY DIALYSIS

•   National Renal Care (NRC) is the designated dialysis provider for Resolution members. The list of their facilities is available at
    www.resomed.co.za
•   All dialysis requires pre-authorisation
•   Members using dialysis networks outside National Renal Care may be liable for large co-payments.
•   Dialysis is usually monitored by specialists – confirm they use National Renal Care as their provider for their dialysis patients
    otherwise members may be liable for co-payments

ONCOLOGY BENEFITS

•   Hospital plan oncology benefits are provided by the ICON network of doctors and protocols.
•   The list of ICON oncologists is available at www.resomed.co.za
•   All oncology treatment e.g. chemotherapy and radiotherapy requires pre-authorisation

HOSPITALISATION

•   Hospitalisation is subject to pre-authorisation.
•   Cover on the hospital plan is subject to clinical necessity for hospitalisation. Although members have benefits for all hospital-
    requiring conditions, authorisation will not be granted for those that would ordinarily be managed in an out-of-hospital setting.
•   PMB treatment will be approved out-of-hospital as the clinical state permits
•   The following hospital networks are available for Hospital plan members:

    •   NHN
    •   Netcare
    •   Clinix
    •   Lifehealthcare
    •   Medi-Clinic

•   Members should confirm their specialist is based in one of these network hospitals to avoid co-payments.
•   In-hospital professional fees are limited to 100% of the Scheme rate. Co-payments may be applicable outside the Preferred
    Provider network.
•   The list of hospitals within each network is available at www.resomed.co.za
•   Out-of-hospital benefits may be granted in lieu of hospitalisation for procedures which may also be performed out-of-hospital. Co-
    payments may be applicable for such in-hospital procedures

MATERNITY BENEFITS

•   Antenatal GP, specialist or midwife visits are limited to 2 consults in total per pregnancy
•   Any Specialist (obstetrician) needs to be in the specialist preferred provider network to avoid co-payments
•   Confinements require pre-authorisation
•   Hospitalisation for maternity benefits is limited to the hospital networks
•   Home deliveries are also funded from the maternity benefit

GUARDIAN BENEFIT

•   The Guardian Benefit is limited to a total R2,750 per family for the year, with sub limits according to the benefit schedule
•   Blood pressure, sugar and cholesterol and BMI checks are only available at the Allegra group of pharmacies (www.resomed.
    co.za)
•   The HIV test will be a rapid test if performed at a contracted pharmacy or doctor’s clinic and a formal HIV test if performed through
    a pathologist. Voluntary counselling and testing (VCT) is also available at all Allegra Pharmacies excepting the MediRite group
    (www.resomed.co.za)
•   Mammograms are only available at radiology practices, usually located in a hospital
•   The pap smear and PSA benefits cover the pathology specimen tests, and exclude any consultation


                                                                                                                                  3
•   The vaccination benefit covers the cost of the vaccine, excluding any facility or consultation fees
•   The pharmacist benefit provides additional primary health care medications within a formulary and annual family limit, available
    at all pharmacies
•   Tests and medications are funded at 100% of the Scheme rate

HOME OXYGEN

•   Benefits for home oxygen are limited to PMB conditions
•   The designated service provider for oxygen concentrators and cylinders is VitalAire.
•   Pre-authorisation is required for all home oxygen. Clinical and laboratory information is required to confirm necessity and continued
    benefits

EXTERNAL MEDICAL APPLIANCES

•   There is no basic benefit for external medical appliances on the Hospital plan
•   Funding for PMB conditions based on necessity is subject to pre-authorisation and limited to minimum costs

REHABILITATION AND SUB-ACUTE FACILITIES

•   The following are the preferred providers for rehabilitation and sub-acute services:

    •   Clayton House
    •   Parkmed Neuro Clinic
    •   Visit the website: www.resomed.co.za for updated lists

•   Members may be liable for co-payments at other facilities.
•   All rehabilitation and sub-acute services requires pre-authorisation

DRUG AND ALCOHOL MANAGEMENT

•   All benefits for drug and alcohol abuse are limited to PMB regulations and strictly monitored.
•   Pre-authorisation is required for all in- and out-of-hospital benefits.
•   Network centres are:

    •   Elim Clinic
    •   Mkondo Rehab
    •   Sanca Aurora
    •   Sanca Durban Lulama Treatment
    •   Sanra Horison
    •   Sanca Park
    •   Sanca Pretoria
    •   Sanca West Rand
    •   Ramet Centre
    •   Serenity
    •   Stabilis
    •   Visit the website: www.resomed.co.za for updated lists




    4
FOUNDATION PLAN BENEFIT GUIDELINES
THE FOUNDATION PLAN DOCTOR NETWORKS

•   Cover for routine general practitioner consultations and treatment on the Foundation Plan is limited to the Foundation GP doctor
    networks.
•   The list of general practitioner and specialist doctors in the networks is available at www.resomed.co.za or from Client Services.
•   Excepting the 3 ‘out-of-town or out-of-network visits’ services provided by non-network doctors will not be funded by Resolution
    Health.

    1. GENERAL PRACTITIONERS (GPs)

    •    Foundation members have unlimited access to General Practitioners within the Foundation GP network.
    •    This benefit includes all consultations and a broad basket of procedures.
    •    The guidelines for accessing these GP benefits are below. Note additional guidelines for pathology, radiology and medication
         etc as noted further below also form part of this GP network basket of benefits

    2. OUT-OF-TOWN or OUT– OF-NETWORK GP VISITS

    •    Foundation members are allowed a maximum of three out-of-town or out-of-network General Practitioner emergency visits
         per family for the year. This benefit covers the consultation at 100% of the Scheme rate which the Scheme reimburses directly
         to the GP. Members are liable for any additional cost in excess of the Scheme rate.
    •    Note the ‘doctor portion’ of a casualty visit will also constitute one of the maximum 3 out-of-network visits allowed
    •    Medication from the doctor or pharmacy will need to be paid upfront and claimed back from the Scheme. Medication is limited
         to the Foundation acute formulary and the Resolution Health Pharmacy Network mark-up
    •    Radiology and pathology tests and acute medication are limited to the respective formularies (www.resomed.co.za) at 100%
         of the Scheme rate. Members will be liable for any costs outside these formularies unless pre-authorised.

    3. A MEMBER’S REGULAR GP

    •    Foundation members are required to have a regular network GP for their consultations. From 1 January 2011, the first
         network GP consulted will be allocated as that member’s provider.
    •    Although members may choose any GP within the network, subsequent changes must be pre-arranged through Client
         Services before any new visit and before the 1st day of that month. Members will need to provide the new GP’s name and
         practice (‘PR’) number.
    •    Any further ‘doctor-hopping’ will require justification from the member for further cover.
    •    Any consults with a GP who is not their regular GP and has not been pre-arranged as above will be allocated to one of their
         three out-of-town or out-of-network visits.

    4. SPECIALIST DOCTOR NETWORK

    •    The list of Foundation Specialist network doctors is available at www.resomed.co.za or through Client Services
    •    Consultations with specialist doctors need to be arranged through Pre-authorisation. This requires a referral from a Foundation
         network GP with their referral form or they can request authorisation via the Pre-Authorisation link at www.resomed.co.za. An
         authorisation number (‘NEO....’) needs to be supplied by Pre-authorisation to confirm cover for the visit.
    •    Members must confirm the network GP is referring to a specialist in the Resolution network. There will be no cover for any
         costs incurred outside the specialist network
    •    Subsequent follow-up and management is routinely through a member’s regular GP. Any further follow-up with the specialist
         will require pre-authorisation.
    •    Within the specialist network, members will have no co-payments or up-front fees for consultations, but benefits are limited to
         4 visits per family, and/or to a total of R1,000 for the year
    •    Radiology and pathology investigations listed in the Foundation approved investigations at www.resomed.co.za are
         automatically funded and claimed by the provider. Any additional investigations from a specialist need pre-authorisation.
         Without approval, they will be for the member’s account
    •    Specialist medication is limited to the acute and chronic formularies as noted below. Any medication outside these formularies
         requires pre-authorisation and may be subject to co-payments
    •    Acute medication from specialists can be obtained at a Resolution Health Pharmacy Network (www.resomed.co.za)
         pharmacy.
    •    Chronic medication from specialists can be obtained from a Resolution Health Pharmacy Network (www.resomed.co.za)
         pharmacy or Optipharm courier pharmacies.
    •    Note members consulting a specialist for procedures (eg surgery, scopes etc) need to confirm that specialist practices within
         a network hospital (see ‘Hospitalisation’). Co-payments are applicable for certain procedures performed in hospital rather
         than as rooms’ procedures

CASUALTY BENEFIT

•   The casualty benefit covers the ‘facility fee’ for all treatment and medication given and dispensed at the time of the visit to the limit
    of R1,115 for the year
•   Any medication scripts for a pharmacy will need to be paid by the member and claimed back from Resolution
•   Medication is limited to the Foundation acute formulary
•   Radiology and pathology is limited to the Foundation radiology and pathology formularies (www.resomed.co.za). Members will be
                                                                                                                                     5
    liable for tests outside these formularies unless pre-authorisation is arranged
•   The fees for the casualty doctor will be included as one of the ‘out-of-network’ GP visits, limited to 100% of the Scheme rate.

DENTAL AND OPTICAL BENEFITS

•   Foundation members may consult any dentists in the Foundation Dental Network and opticians in the Foundation Optical network.
    Benefits are limited to the Foundation plan treatment protocols.
•   Services obtained outside the networks may be subject to co-payments
•   Details of the Scheme dental and optical networks are available at www.resomed.co.za or from Client Services.
•   Benefit limits are provided in the schedule of the Member’s Handbook.

NOMINATION OF ADDITIONAL NETWORK PROVIDERS BY MEMBERS

•   Members may nominate their current or an alternative GP, specialist, dentist or optometrist who is not yet a network provider to
    be included in the network in future. Members need to provide their Resolution membership number and contact details and the
    nominated provider’s name, address, telephone number and practice (‘PR’) number to us at:

    •   Resolution Client Services at 0861 796 6400 or email clientservices@resomed.co.za
    •   Agility Global Health Solutions at 012 673 8600 or email info@agilityghs.com
    •   EMC contact centre at 0860 362 362 or via www.emconline.co.za
    •   Via their broke

•   The provider will be approached to become a preferred network provider and the member will be informed accordingly of the
    providers decision. This process will take about 3 working days. Note if this is unsuccessful, the member will have to choose
    another provider within the network to avoid co-payments.

ACUTE MEDICATION

•   Acute medication is limited to the Foundation acute formulary. There are no additional medication benefits outside this
    formulary.
•   GP Network doctors will either provide the medication from their rooms (dispending doctors) or issue a script for members to
    collect medication at a pharmacy.
•   Foundation members are limited to Resolution Health Pharmacy Network pharmacies listed at www.resomed.co.za. Outside this
    network, members will have to pay upfront and claim back from Resolution. Note such claims will be limited to the acute formulary
    and network pharmacy mark-ups.
•   Acute medication is unlimited within the formulary through GP network doctors.
•   Acute medication from specialists can be obtained from Resolution Health Pharmacy Network pharmacies. This is limited to the
    acute formulary.

CHRONIC MEDICATION

•   The chronic conditions under this benefit are limited to the 25 CDL (chronic disease list) PMB conditions
•   A member’s chronic condition(s) need to be registered by the network GP with MediKredit, for which certain clinical or pathology
    information may be required.
•   Medication is limited to the Foundation chronic formulary (www.resomed.co.za)
•   Medication can be obtained from Resolution Health Pharmacy Network pharmacies (www.resomed.co.za). Optipharm courier
    pharmacies will also courier chronic medication monthly to a member’s physical address – this needs to be organised by the
    network doctor.
•   Following the first Optipharm script, members will be contacted by Optipharm with the SMS number members need to use in
    future to request re-fills
•   Members will have to pay upfront for any chronic medication outside these sources and claim back from Resolution, which will be
    restricted to the Foundation chronic formulary and network mark-ups
•   Chronic medication from a specialist must be subsequently followed-up by a member’s network GP unless there are justifiable
    reasons for continuing with the specialist, for which pre-authorisation is required.
•   Ongoing chronic medication also requires certain clinical and pathology information to be submitted on www.resomed.co.za

PATHOLOGY

•   The list of Foundation and Progressive Select pathology (eg laboratory) approved tests applicable to GP’s and specialist’s is
    available at www.resomed.co.za
•   Any additional tests outside this list require pre-authorisation or members will be required to pay up front. These will be limited to
    PMB conditions
•   The following laboratories are the Scheme’s Preferred Providers for pathology:

    •   Ampath Laboratories
    •   Lancet Laboratories
    •   PathCare
    •   Vermaak & Partners Pathologists

•   Services outside the Preferred Provider network may have co-payments.


    6
RADIOLOGY

•   The list of Foundation and Progressive Select radiology approved tests applicable to GP’s and specialists is available at www.
    resomed.co.za. This list covers basic X-rays and sonars
•   ‘Specialised Radiology’ eg CT and MRI scans, requires pre-authorisation
•   Any additional tests outside this basic radiology list require pre-authorisation or members will be required to pay up front. These
    will be limited to PMB conditions.
•   There is no radiology provider network and Foundation members may consult any radiologist

KIDNEY DIALYSIS

•   National Renal Care (NRC) is the designated dialysis provider for Resolution members. The list of their facilities is available at
    www.resomed.co.za
•   All dialysis requires pre-authorisation
•   Members using dialysis networks outside National Renal Care may be liable for large co-payments.
•   Dialysis is usually monitored by specialists – confirm they use National Renal Care as their provider for their dialysis patients
    otherwise members may be liable for co-payments

ONCOLOGY BENEFITS

•   Foundation oncology benefits are provided by the ICON network of doctors and protocols.
•   The list of ICON oncologists is available at www.resomed.co.za
•   All oncology treatment eg chemotherapy and radiotherapy requires pre-authorisation

HOSPITALISATION

•   The following hospital networks are available for Foundation members:

    •   NHN
    •   Netcare
    •   Clinix
    •   Lifehealthcare
    •   Medi-Clinic

•   Members should confirm their specialist is based in one of these network hospitals to avoid co-payments.
•   The list of hospitals within each network is available at www.resomed.co.za
•   All hospitalisation requires pre-authorisation and subject to Foundation Scheme protocols.
•   Co-payments may be applicable for in-hospital procedures which may also be performed out-of-hospital
•   Doctors are limited to the Foundation network doctors.

MATERNITY BENEFITS

•   Antenatal GP visits are unlimited at the GP network. There are no GP antenatal benefits outside the Foundation GP network.
•   Specialist and midwife visits are limited to 2 consults in total per pregnancy and require pre-authorisation
•   Any specialist (obstetrician) visits will be allocated from the 4 specialist visits/max R1,000 per year limit for specialists. The
    obstetrician needs to be in the specialist network to avoid co-payments
•   Confinements require pre-authorisation
•   Hospitalisation for maternity benefits is limited to the hospital networks
•   Home deliveries are also funded from the maternity benefit

GUARDIAN BENEFIT

•   The guardian benefit is limited to that provided inclusively in consultations at the GP network (flu and tetanus vaccines)

HOME OXYGEN

•   Benefits for home oxygen are limited to PMB conditions
•   The designated service provider for oxygen concentrators and cylinders is VitalAire.
•   Pre-authorisation is required for all home oxygen. Clinical and laboratory information is required to confirm necessity and continued
    benefits

EXTERNAL MEDICAL APPLIANCES

•   There is no basic benefit for external medical appliances on Foundation
•   Funding is subject to pre-authorisation and limited to minimum costs

REHABILITATION AND SUB-ACUTE FACILITIES

•   The following are the preferred providers for rehabilitation and sub-acute services:

    •   Clayton House
    •   Parkmed Neuro Clinic
                                                                                                                                  7
    •   Visit the website: www.resomed.co.za for updated lists

•   Members may be liable for co-payments at other facilities.
•   All rehabilitation and sub-acute services requires pre-authorisation

DRUG AND ALCOHOL MANAGEMENT

•   All benefits for drug and alcohol abuse are limited to PMB regulations and strictly monitored.
•   Pre-authorisation is required for all in- and out-of-hospital benefits.
•   Network centres are:

    •   Elim Clinic
    •   Mkondo Rehab
    •   Sanca Aurora
    •   Sanca Durban Lulama Treatment
    •   Sanra Horison
    •   Sanca Park
    •   Sanca Pretoria
    •   Sanca West Rand
    •   Ramet Centre
    •   Serenity
    •   Stabilis
    •   Visit the website: www.resomed.co.za for updated lists




    8
PROGRESSIVE SELECT PLAN BENEFIT GUIDELINES
PROGRESSIVE SELECT DOCTOR NETWORKS

•   Cover for doctor consultations and treatment on the Progressive Select Plan is limited to the Progressive Select doctor networks.
    The list of general practitioner and specialist doctors in the networks is available at www.resomed.co.za or from Client Services.
    Please note that services provided by non-network doctors may incur co-payments.

    1. GENERAL PRACTITIONERS (GPs)

    •    Progressive Select members have unlimited access to General Practitioners within the Progressive Select GP network (www.
         resomed.co.za)
    •    GP procedures are limited to the Approved GP network procedures for Progressive Select (www.resomed.co.za)
    •    The guidelines for accessing these GP benefits are below.

    2. OUT-OF-TOWN or OUT– OF-NETWORK GP VISITS

    •    Progressive Select members are allowed a maximum of three out-of-town or out-of-network General Practitioner emergency
         visits per family for the year. This benefit covers the consultation at 100% of the Scheme rate which the Scheme reimburses
         directly to the GP. Members are liable for any additional cost in excess of the Scheme rate.
    •    Note the ‘doctor portion’ of a casualty visit will also constitute one of the maximum 3 out-of-network visits allowed
    •    Radiology and pathology tests and acute medication are limited to the respective formularies (www.resomed.co.za) at 100%
         of the Scheme rate. Members will be liable for any costs outside these formularies unless pre-authorised.
    •    Medication is limited to the Progressive Select acute formulary and the Resolution Health Pharmacy Network (www.resomed.
         co.za) mark-up.

    3. A MEMBER’S REGULAR GP

    •    Progressive Select members are required to have a regular network GP for their consultations. From 1 January 2011, the first
         GP consulted will be allocated as that member’s provider.
    •    Although members may choose any GP within the network, doctor hopping is strongly discouraged as it does not support
         continued care.
    •    ‘Doctor-hopping’ will require justification from the member for further cover.

    4. SPECIALIST DOCTOR NETWORK

    •    The list of Specialist doctor preferred providers is available at www.resomed.co.za or through Client Services
    •    The number of specialist visits allowed per year is family-size dependent, per the Primary Network Benefit in the Members
         Handbook.
    •    Costs outside the preferred provider network may incur co-payments
    •    Subsequent follow-up and management is routinely through a member’s regular GP. Any further follow-up with the specialist
         will require motivation.
    •    Radiology and pathology investigations out-of-hospital are limited to PMB conditions.
    •    Specialist medication is limited to the acute and chronic formularies as noted below. Any medication outside these formularies
         requires pre-authorisation and may be subject to co-payments
    •    Note members consulting a specialist for procedures (e.g. surgery, scopes etc.) need to confirm that specialist practices
         within a network hospital. Co-payments are applicable for certain procedures performed in hospital rather than as rooms’
         procedures

CASUALTY BENEFIT

•   The casualty benefit covers the ‘facility fee’ for all treatment and medication given and dispensed at the time of the visit to the limit
    of R1,115 for the year
•   Any medication scripts for a pharmacy will need to be paid by the member and claimed back from Resolution
•   Medication is limited to the Progressive Select acute formulary
•   Radiology and pathology is limited to the Progressive Select radiology and pathology formularies (www.resomed.co.za). Members
    will be liable for tests outside these formularies unless pre-authorisation is arranged
•   The fees for the casualty doctor will be included as one of the ‘out-of-network’ GP visits, limited to 100% of the Scheme rate.

DENTAL AND OPTICAL BENEFITS

•   Progressive Select members may consult any dentists in the Dental Preferred Provider Network and opticians in the Optical
    Preferred Provider Network. Benefits are limited to the Progressive Select plan treatment protocols.
•   Services from outside the networks may incur co-payments and will be limited to the specified benefits
•   Details of the dental and optical preferred provider networks are available at www.resomed.co.za or from Client Services.
•   Benefit limits are provided in the schedule of the Member’s Handbook.

NOMINATION OF ADDITIONAL NETWORK PROVIDERS BY MEMBERS

•   Members may nominate their current or an alternative GP, specialist, dentist or optometrist who is not yet a network provider to
    be included in the network in future. Members need to provide their Resolution membership number and contact details and the
                                                                                                                                     9
    nominated provider’s name, address, telephone number and practice (‘PR’) number to us at:

    •    Resolution Client Services at 0861 796 6400 or email clientservices@resomed.co.za
    •    Agility Global Health Solutions at 012 673 8600 or email info@agilityghs.com
    •    Via their broker

•   The provider will be approached to become a preferred network provider and the member will be informed accordingly of the
    providers decision. This process will take about 3 working days. Note if this is unsuccessful, the member will have to choose
    another provider within the network to avoid co-payments.

ACUTE MEDICATION

•   Acute medication is limited to the Progressive Select acute formulary. There are no additional medication benefits outside this
    formulary. Strict MMAP pricing applies.
•   GP Network doctors will either provide the medication from their rooms (dispending doctors) or issue a script for members to
    collect medication at a pharmacy.
•   Progressive Select members are limited to Resolution Health Pharmacy Network pharmacies www.resomed.co.za. Outside this
    network, members will have to pay upfront and claim back from Resolution. Note such claims will be limited to the acute formulary
    and network mark-ups.
•   Acute medication is unlimited within the formulary through GP network doctors.

CHRONIC MEDICATION

•   The chronic conditions under this benefit are limited to the 25 CDL (chronic disease list) PMB conditions
•   A member’s chronic condition(s) need to be registered by the network GP with MediKredit, for which certain clinical or pathology
    information may be required.
•   Chronic condition management is subject to consultation, pathology and treatment protocols
•   Medication is limited to the Progressive Select chronic formulary.
•   Medication can be obtained from dispensing GP network doctors, Resolution Health Pharmacy Network pharmacies (www.
    resomed.co.za), or Optipharm courier pharmacies (needs to be organised by the doctor through MediKredit). Optipharm will
    contact members after their first script with the SMS number for requesting re-fills in future. Optipharm will deliver medication
    monthly to a physical address. Members will have to pay upfront for any chronic medication outside these sources and claim back
    from Resolution, which will be restricted to the Progressive Select chronic formulary and network mark-ups
•   Chronic medication from a specialist must be subsequently followed-up by a member’s GP unless there are justifiable reasons for
    continuing with the specialist, for which pre-authorisation is required.
•   On-going chronic medication also requires certain clinical and pathology information to be submitted on www.resomed.co.za

PATHOLOGY

•   The list of Foundation and Progressive Select pathology (e.g. laboratory) approved tests applicable to GP’s and specialist’s is
    available at www.resomed.co.za
•   Any additional tests outside this list require pre-authorisation or members will be required to pay up front. These will be limited to
    PMB conditions
•   The following laboratories are the Scheme’s Preferred Providers for pathology:

    •    Ampath Laboratories
    •    Lancet Laboratories
    •    PathCare
    •    Vermaak & Partners Pathologists

•   Services outside the Preferred Provider network may have co-payments.

RADIOLOGY

•   The list of Foundation and Progressive Select radiology approved tests applicable to GP’s and specialists is available at www.
    resomed.co.za. This list covers basic X-rays and sonars
•   Any additional tests outside this list require pre-authorisation or members will be required to pay up front. These will be limited to
    PMB conditions
•   ‘Specialised Radiology’ e.g. CT and MRI scans, require pre-authorisation and are subject to the specialised radiology benefit
•   There is no radiology provider network and Progressive Select members may consult any radiologist

KIDNEY DIALYSIS

•   National Renal Care (NRC) is the designated dialysis provider for Resolution members. The list of their facilities is available at
    www.resomed.co.za
•   All dialysis requires pre-authorisation
•   Members using dialysis networks outside National Renal Care may be liable for large co-payments.
•   Dialysis is usually monitored by specialists – confirm they use National Renal Care as their provider for their dialysis patients
    otherwise members may be liable for co-payments



    10
ONCOLOGY BENEFITS

•   Progressive Select oncology benefits are provided by the ICON network of doctors and protocols.
•   The list of ICON oncologists is available at www.resomed.co.za
•   All oncology treatment e.g. chemotherapy and radiotherapy requires pre-authorisation

HOSPITALISATION

•   The following hospital networks are available for Progressive Select members:

    •    NHN
    •    NetCare
    •    Clinix
    •    Lifehealthcare
    •    Medi-clinic

•   Members should confirm their specialist is based in one of these network hospitals to avoid co-payments.
•   The list of hospitals within each network is available at www.resomed.co.za
•   All hospitalisation requires pre-authorisation
•   Co-payments may be applicable for in-hospital procedures which may also be performed out-of-hospital
•   Doctors are limited to the Preferred Provider networks.

MATERNITY BENEFITS

•   Antenatal GP, specialist or midwife visits are limited to 6 consults in total per pregnancy
•   Specialist (obstetrician) visits for maternity are additional to the specialist visits in the Primary Network Benefit. No authorisation
    is required for these but the obstetrician needs to be in the specialist network to avoid co-payments
•   Confinements require pre-authorisation
•   Hospitalisation for maternity benefits is limited to the hospital networks
•   Home deliveries are also funded from the maternity benefit

GUARDIAN BENEFIT

•   The Guardian Benefit is limited to a total R2,750 per family for the year, with sub limits according to the benefit schedule
•   Blood pressure, sugar and cholesterol and BMI checks are only available at the Allegra group of pharmacies (www.resomed.
    co.za)
•   The HIV test will be a rapid test if performed at a pharmacy and a formal HIV test if performed through a pathologist. Voluntary
    counselling and testing (VCT) is also available at all Allegra Pharmacies excepting the MediRite group (www.resomed.co.za)
•   Mammograms are only available at radiology practices, usually located in a hospital
•   The pap smear and PSA benefits cover the pathology specimen tests, and exclude any consultation
•   The vaccination benefit covers the cost of the vaccine, excluding any facility or consultation fees
•   The pharmacist benefit provides additional primary health care medications within a formulary and annual family limit, available
    at all pharmacies
•   Tests and medications are funded at 100% of the Scheme rate

HOME OXYGEN

•   Benefits for home oxygen are limited to PMB conditions
•   The designated service provider for oxygen concentrators and cylinders is VitalAire.
•   Pre-authorisation is required for all home oxygen. Clinical and laboratory information is required to confirm necessity and
    continued benefits

EXTERNAL MEDICAL APPLIANCES

•   External medical appliances are limited to R2,000 per family for the year
•   Sub limits apply within this overall limit
•   The following require pre-authorisation:

    •    Artificial eyes
    •    Artificial larynx
    •    Artificial limbs
    •    CPAP machines
    •    Glucometers
    •    Home oxygen
    •    Speech and hearing aids

•   External breast prostheses and infant apnoea monitors need to be submitted as paper claims by the member after purchase




                                                                                                                                    11
REHABILITATION AND SUB-ACUTE FACILITIES

•   The following are the preferred providers for rehabilitation and sub-acute services:

    •    Clayton House
    •    Parkmed Neuro Clinic
    •    Visit the website: www.resomed.co.za for updated lists

•   Members may be liable for co-payments at other facilities.
•   All rehabilitation and sub-acute services requires pre-authorisation

DRUG AND ALCOHOL MANAGEMENT

•   All benefits for drug and alcohol abuse are limited to PMB regulations and strictly monitored.
•   Pre-authorisation is required for all in- and out-of-hospital benefits.
•   Network centres are:

    •    Elim Clinic
    •    Mkondo Rehab
    •    Sanca Aurora
    •    Sanca Durban Lulama Treatment
    •    Sanra Horison
    •    Sanca Park
    •    Sanca Pretoria
    •    Sanca West Rand
    •    Ramet Centre
    •    Serenity
    •    Stabilis
    •    Visit the website: www.resomed.co.za for updated lists




    12
PROGRESSIVE FLEX AND PRESTIGE PLAN GUIDELINES
PROGRESSIVE FLEX AND PRESTIGE GPs AND SPECIALISTS

•   Progressive Flex and Prestige members are free to choose and are not restricted to a doctor network, but Resolution has a group
    of Preferred Provider doctors which may allow members to avoid possible co-payments should the provider, not contracted,
    charge more than scheme rates. All providers not on the preferred provider lists are reimbursed at the scheme tariff per the benefit
    schedule in the member’s handbook which may therefore incur co-payments. The list of Preferred Providers is available at www.
    resomed.co.za or Client Services

•   Procedures, radiology, pathology and medication related to GP and specialist consultations are covered under the respective
    benefits.

OUT-OF-TOWN GP VISITS

•   These options do not require special processes and service providers will be paid according to scheme rates and the plan
    benefits

CASUALTY BENEFIT

•   The casualty benefit covers the ‘facility fee’ for all treatment and medication given and dispensed at the time of the visit to the limit
    of R1,115 for the year
•   Radiology and pathology is subject to the relevant benefits
•   The casualty doctor fees will constitute a general practitioner visit from the Focus benefit and funded as such
•   Medication is limited to the relevant acute formulary, together with MMAP and reference pricing as applicable

DENTAL AND OPTICAL BENEFITS

•   Progressive Flex and Prestige members may consult any dentist or optician, however when selected from the Dental Preferred
    Provider Network and opticians in the Optical Preferred Provider networks no co-payments will be incurred when remaining inside
    the benefit limits.. Benefits are limited to the relevant plan treatment protocols.
•   Services from outside the networks may incur co-payments
•   Details of the dental and optical preferred provider networks are available at www.resomed.co.za or from Client Services.
•   Benefit limits are provided in the schedule of the Member’s Handbook.

NOMINATION OF ADDITIONAL NETWORK PROVIDERS BY MEMBERS

•   Members may nominate their current or an alternative GP, specialist, dentist or optometrist who is not yet a preferred provider
    to be included in the group in future. Members need to provide their Resolution membership number and contact details and the
    nominated provider’s name, address, telephone number and practice (‘PR’) number to us at:

    •    Resolution Client Services at 0861 796 6400 or email clientservices@resomed.co.za
    •    Agility Global Health Solutions at 012 673 8600 or email info@agilityghs.com
    •    Via their broker

•   The provider will be approached to become a preferred network provider and the member will be informed accordingly of the
    providers decision. This process will take about 3 working days. Note if this is unsuccessful, the member will have to choose
    another provider within the network to avoid co-payments.

ACUTE MEDICATION

•   Acute medication is subject to the relevant plan acute medication formulary. Reference pricing and MMAP may be applicable
    depending on the plan
•   Medication may be obtained directly from dispensing doctors or from a pharmacy. Members may be liable for co-payments outside
    the Resolution Health Pharmacy Network pharmacies listed at www.resomed.co.za

CHRONIC MEDICATION

•   Both the Progressive Flex and Prestige plans cover the 25 CDL (chronic disease list) PMB conditions
•   The Prestige plan also covers chronic treatment for the additional chronic disease list specified in the member’s handbook. There
    is no further benefit for these additional conditions once the chronic benefit is depleted.
•   Chronic condition management is subject to consultation, pathology and treatment protocols
•   All chronic medication is subject to the plan formulary, and MMAP and reference pricing may apply.
•   Chronic condition(s) need to be registered by the clinician with MediKredit, for which certain clinical or pathology information may
    be required.
•   Medication is limited to the chronic formulary of the relevant plan.
•   Medication can be obtained from Resolution Health Pharmacy Network pharmacies (www.resomed.co.za) or Optipharm courier
    pharmacies (needs to be organised with MediKredit). Optipharm will contact members after their first script with the SMS number
    for requesting re-fills in future. Optipharm will deliver medication monthly to a physical address. Co-payments may be applicable
    from other pharmacy providers


                                                                                                                                     13
•   Chronic medication from a specialist should subsequently be followed-up by a member’s GP unless there are justifiable reasons
    for continuing with the specialist
•   On-going chronic medication also requires certain clinical and pathology information to be submitted on www.resomed.co.za

PATHOLOGY

•   There is no restriction on the pathology tests that may be ordered by doctors.
•   Benefits are subject to the plan’s limits
•   The following laboratories are the Scheme’s Preferred Providers for pathology:

    •    Ampath Laboratories
    •    Lancet Laboratories
    •    PathCare
    •    Vermaak & Partners Pathologists

•   Services outside the Preferred Provider network may have co-payments.

RADIOLOGY

•   There is no restriction on radiology investigations that may be ordered by doctors
•   Benefits are subject to the plan’s limits
•   ‘Specialised Radiology’ e.g. CT and MRI scans, require pre-authorisation and are subject to the specialised radiology benefit
•   There is no radiology provider network and members may consult any radiologist

KIDNEY DIALYSIS

•   National Renal Care (NRC) is the designated dialysis provider for Resolution members. The list of their facilities is available at
    www.resomed.co.za
•   All dialysis requires pre-authorisation
•   Members using dialysis networks outside National Renal Care may be liable for large co-payments.
•   Dialysis is usually monitored by specialists – confirm they use National Renal Care as their provider for their dialysis patients
    otherwise members may be liable for co-payments

ONCOLOGY BENEFITS

•   Progressive Flex and Prestige members are free to choose and are not restricted to an oncologist network, but the Progressive
    Flex and Prestige preferred providers (www.resomed.co.za) and their protocols will ensure there are no costly co-payments for
    oncology.
•   All providers not on the preferred provider lists are reimbursed at the scheme tariff per the benefit schedule in the member’s
    handbook which may therefore incur co-payments.
•   All oncology treatment e.g. chemotherapy and radiotherapy requires pre-authorisation and are subject to scheme protocols.

HOSPITALISATION

•   The following hospital networks are available for Progressive Flex and Prestige members:

    •    NHN
    •    NetCare
    •    Clinix
    •    Lifehealthcare
    •    Medi-clinic

•   Members should confirm their specialist is based in one of these network hospitals to avoid co-payments.
•   The list of hospitals within each network is available at www.resomed.co.za
•   All hospitalisation requires pre-authorisation
•   Co-payments may be applicable for in-hospital procedures which may also be performed out-of-hospital
•   Doctors are funded according to the benefit schedule i.e. GP’s at 100% of the Scheme rate and specialists at 150% on Progressive
    Flex and 220% on Prestige. Members may be liable for co-payments outside the Preferred Provider network.

MATERNITY BENEFITS

•   Antenatal GP, specialist or midwife visits are limited to 6 consults for Progressive Flex and 9 visits for Prestige in total per
    pregnancy
•   Specialist (obstetrician) visits for maternity are additional to the specialist visits in the Focus Benefit. No authorisation is required
    for these but the obstetrician needs to be in the specialist network to avoid possible co-payments
•   Confinements require pre-authorisation
•   Hospitalisation for maternity benefits is limited to the hospital networks
•   Home deliveries are also funded from the maternity benefit




    14
GUARDIAN BENEFIT

•   The Guardian Benefit is limited to a total R2,750 per family for the year, with sub limits according to the benefit schedule
•   Blood pressure, sugar and cholesterol and BMI checks are only available at the Allegra group of pharmacies (www.resomed.
    co.za)
•   The HIV test will be a rapid test if performed at a pharmacy or doctor’s clinic and a formal HIV test if performed through a
    pathologist. Voluntary counselling and testing (VCT) is also available at all Allegra Pharmacies excepting the MediRite group
    (www.resomed.co.za)
•   Mammograms are only available at radiology practices, usually located in a hospital
•   The pap smear and PSA benefits cover the pathology specimen tests, and exclude any consultation
•   The vaccination benefit covers the cost of the vaccine, excluding any facility or consultation fees
•   The pharmacist benefit provides additional primary health care medications within a formulary and annual family limit, available
    at all pharmacies
•   Tests and medications are funded at 100% of the Scheme rate

HOME OXYGEN

•   Benefits for home oxygen are limited to PMB conditions
•   The designated service provider for oxygen concentrators and cylinders is VitalAire.
•   Pre-authorisation is required for all home oxygen. Clinical and laboratory information is required to confirm necessity and
    continued benefits

EXTERNAL MEDICAL APPLIANCES

•   External medical appliances are limited to an overall maximum per family for the year
•   Sub limits apply within this overall limit
•   The following require pre-authorisation:

    •   Artificial eyes
    •   Artificial larynx
    •   Artificial limbs
    •   CPAP machines
    •   Glucometers
    •   Home oxygen
    •   Speech and hearing aids

•   External breast prostheses and infant apnoea monitors need to be submitted as paper claims by the member after purchase

REHABILITATION AND SUB-ACUTE FACILITIES

•   The following are the preferred providers for rehabilitation and sub-acute services:

    •   Clayton House
    •   Parkmed Neuro Clinic
    •   Visit the website: www.resomed.co.za for updated lists

•   Members may be liable for co-payments at other facilities.
•   All rehabilitation and sub-acute services requires pre-authorisation

DRUG AND ALCOHOL MANAGEMENT

•   All benefits for drug and alcohol abuse are limited to PMB regulations and strictly monitored.
•   Pre-authorisation is required for all in- and out-of-hospital benefits.
•   Network centres are:

    •   Elim Clinic
    •   Mkondo Rehab
    •   Sanca Aurora
    •   Sanca Durban Lulama Treatment
    •   Sanra Horison
    •   Sanca Park
    •   Sanca Pretoria
    •   Sanca West Rand
    •   Ramet Centre
    •   Serenity
    •   Stabilis
    •   Visit the website: www.resomed.co.za for updated lists




                                                                                                                             15

				
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