LMS 2012 Member Guide

8/2/2019 LMS 2012 Member Guide

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B

Crated with careto suit your needs

2012 Member Guide

A C


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Crated with care to suit your needs

You shape itIt is amazing how, with the necessary care, a ew tender olds can transorm a

piece o paper into something magnifcent, like this peacock. Its the careul and

thoughtul attention to detail that makes it happen.

In the same way, by paying careul attention to your needs and listening to who you

are as a amily or individual, Liberty Medical Scheme shapes healthcare options as

a perect expression o your lie. Its about doing what we can to help your health

fourish so you can shape the lie you want.

Liberty Medical Scheme We care. For you


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Contents

Introduction 04

2012 Benefit Summary and Contributions 06

Prescribed Minimum Benefits 10

Medication 11

Preventative Care Benefits 15

Day-to-Day Benefits 18

What LMS does not cover 22

Making the most of your cover 30

Membership, Registration of Dependants, Contributions and

Debt Management

34

Additional services offered to Scheme members 42

Glossary

Contact Details

44

47

ER24

EmergencyServices

29

Pre-authorisation

In-hospitalDental

OrthodonticTreatment

Hospital/CasualtyAdmissions

Oncology

HIV/Aids

ChronicMedication

23

Major Medical Benefits

HospitalBenets

DiseaseManagementProgrammes

08


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Caring for your

needs and makinghealthcare easier

Healthcare options

relevant to each stage

of your life

Access to quality

treatment

Affordable

contributions and

real value for money

1

4

3

2

Intro

duction

4

Introduction

Liberty Medical Scheme (LMS) at a glance

Liberty Medical Scheme (LMS) is focused on oering members healthcare options that aretruly relevant to each stage of their life.

LMSshapeshealthcareoptionsthatcareforyourneedsbyprovidingqualitybenetsat

aordable prices.

Access to quality treatment

LMS is dedicated to giving you access to quality treatment and care; everything you may

need to live a full and healthy life. We want your healthcare option to enhance your life

choices and deliver the best healthcare you can aord. Most importantly, to give you

peaceofmindknowingthatcomprehensivebenetsareaccessiblewhenyouneedthem.

We provide meaningful cover according to recognised treatment protocols and constantly

updateourbenetsasnewmedicaltechnologybecomesavailable.

2

Affordable contributions and real value for money

AtLMSwebelievethatrealvalueformoneyisaboutoeringqualitybenetsthatareaordable. So even while an inflationary environment necessitates annual rate increases,

these are always kept competitive.

3

1 Healthcare options relevant to each stage of your life

Peoplehavedierentneedsatdierentlifestages.Thisfacthasveryoftenbeenoverlooked

in the healthcare industry, which is why LMS embarked on a unique market segmentation

study.Theresultsofthisstudyenabledustodevelopoptionstocaterfordierentneeds

and make them relevant to you as your requirements change.

Wealsoreviewourbenetdesigncontinuallytoensurethatwehavewhatyouneedto

make the best decisions for you and your family.


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Intro

duction

5

Caring for your needs and making healthcare easier

LMS takes its customers needs to heart and our service level is of the highest in theindustry. Members receive regular communications aimed at addressing various questions

and concerns. Inaddition, you are able toaccess up-to-date informationonour user-

friendly website www.libmed.co.za.

4

*Note:The LMS rate will indicate what the Scheme is prepared to pay in respect of a particular

service, but is not confirmation of the amount payable as this would be subject to your

entitlement to benefits in terms of the rules at the time the claim is submitted.

How does Liberty Medical Scheme set its rate?

LMS rate

TheLMSratereferstothetariwhichtheSchemewillpayforaparticularhealthcare

service (e.g. consultations, medicines, procedures, examinations, etc)

LMSconsultsandreviewstheinformationissuedbyarangeofexpertstoarriveattheLMS

rate.TheseexpertsincludeLibertyHealth,theDepartmentofHealth,theMedicalScheme

Industry and LMS actuaries. LMS also looks at various economic indicators, e.g. the current

andforecastCPIrate

TheLMSrateforeverysinglehealthcareserviceisdeterminedannually,asmedicalcosts

increase each year

Becauseofthemultitudeofhealthcareservicesitisnotpracticaltopublishalistwithallthe taris. If you or your doctor want to know what the LMS rate is for a particular healthcare

service, please call the LMS Contact Centre on 0860 002 163 and make sure you have the

treatment/taricode(s)onhand*.

Some healthcare providers charge the LMS rate and some dont:

Everyhealthcareproviderisentitledtosethis/herownfees

PleasenotethattheSchemealsonegotiatesdirectlywithcertainprovidergroupse.g.

hospitals, pathologists, radiologists, etc to ensure competitive rates for members

IfyourproviderchargesmorethantheLMSrate,youmustpaythedierencebetween

theLMSrateandthechargedamount.Pleasealsorefertothesectiononpage19

dealingwithco-paymentsrecoveredfromtheMSF. Youhavethepowertonegotiatefees.ManyproviderswillchargetheLMSrate,orat

least lower their fees, if you ask them to or if you pay cash at the time of service.


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PaidfromS

avingsexceptBonaPlus

coveredbyCareCross

Contributions

Liberty Baby Programme

International Travel Benefit Additional

Services**

2012

BenefitSummarya

ndContributions

6

2012 Benefit Summary and Contributions

Network Option Hospital

Bona Plus Gold Focus

A network of care Starting out as a family

Payment Rate 100% LMS rate 100% LMS rateHospitalisation

(sub-limits apply to certain benefits)R980 000 per family Unlimited

Hospital Network Freedom of choice Freedom of choice

Chronic Conditions Covered 27 PMBs 27 PMBs

Additional Chronic Conditions Covered

Disease Management

Casualty Benefit

Preventative Care Benefit

Day Procedures (out-of-hospital)

Crime Trauma Benefit

MRI/CT Scans (0ut-of-hospital)

Dentistry (basic and specialised)

CareCross Network:

GP Consultations

Basic Dentistry Medication

Optometry

Pathology

Radiology

Self-funded

Principal Member R 1 085 R 1 067

Adult Dependant R 831 R 900

Child Dependant*** R 318 R 405

Day-to-DayExtender

paidfromR

isk

MajorMedicalBenefits(MM

B)

*Asavingscomponentisincludedinthecontributionsoftheseoptions.**FormoreinformationontheseadditionalservicesoeredtoLMSmembers,pleaserefertopages42and43.***Childdependantmeansadependentchildundertheageof21,orachildwhoisafull-timestudent,uptoand

includingage26(proofofstudytobesupplied).


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7

ptions. Saver Options Complete Options

Platinum Focus Gold Saver* Platinum Saver* Titan* Platinum Complete*

Excellent risk cover Everything a family needs Meeting your familys needs Perfect cover for the family The ultimate healthcare option

00%/200% LMS rate 100% LMS rate 100%/200% LMS rate 100% LMS rate 100%/200% LMS rate

Unlimited Unlimited Unlimited Unlimited Unlimited

Freedom of choice Freedom of choice Freedom of choice Freedom of choice Freedom of choice

27 PMBs 27 PMBs 27 PMBs 27 PMBs 27 PMBs

37 4 37 37

elf-funded Savings

Member: R 2 496

Adult: R 2 040 Child: R 912

Savings

Member: R 2 160


Savings

Member: R 3 084


Self Payment Gap

Member: R 700

Adult: R 430

Child: R 160

Threshold Level

Member: R 3 784

Adult: R 2 902

Child: R 988

Threshold Limit

Member: R 3 080 Adult: R 1 820

Child: R 800

Savings Member: R 5 580

Adult: R 4 140 Child: R 1 596

Self Payment Gap Member: R 1 763 Adult: R 1 325 Child: R 514

Threshold Level Member: R 7 343 Adult: R 5 465 Child: R 2 110

Threshold LimitUnlimited:

GP Consultations Specialist Consultations Basic Dentistry Basic Radiology Pathology

Limited: All other benets

1 474 R 1 388 R 1 802 R 1 718 R 3 103

1 326 R 1 138 R 1 618 R 1 375 R 2 305

476 R 510 R 583 R 464 R 892

Please note for a more comprehensive overview of benefits you can

request a Benefit Schedule or view it on www.libmed.co.za


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Hospital BenefitsTheHospitalBenetcoversthecostofadmissionstoanyhospitalincludingprivatehospitals

(subjecttopre-authorisationandtherelevantmanagedhealthcareprogramme).LMSwillpay

the hospital bill and associated costs, e.g. specialist consultations, anaesthetists, blood tests

andx-raysfromthisbenet.Someoftheseservicesaresubjecttofurtherpre-authorisation.

Co-paymentsandsub-limitsareapplicableoncertainbenets.Formoredetailspleasevisit

the website www.libmed.co.za.

Youcanchooseanyhospitalandanyspecialist,ensuringthatyouwillreceivethequalitycare

you require.

Cover for Hospital and associated costs:

BonaPlus,GoldFocus,GoldSaverandTitancoverallcostsuptotheLMSratewhilethePlatinumFocus,PlatinumSaverandPlatinumCompleteoptionscovercostsupto2xtheLMSrate,for

certainbenets.

Sub-limitsmayapplyinrespectofcertainservices.AnycostinexcessoftheLMSrateorasub-

limit will be for the members account.

Co-payments:

Pleasereadthebelowinformationrelatingtoco-payments.

Certainhospitalproceduresaresubjecttoco-payments.Priortoahospitaladmission,please

check the option information or call the Contact Centre to establish which procedures have

co-payments.Youwillberesponsibletopaytheco-paymentdirectlytothehospitalatthe

time of your admission.

Co-paymentsareappliedtospeciedproceduresonalloptions,excludingPlatinumComplete.

Wherespeciedproceduresaredonein-hospital,youwillhavetopaytheco-paymentto

the hospital

LMSwillpayalltheotherapprovedservicesthatarerelatedtotheprocedurefromthe

HospitalBenet

Theco-paymentisnotappliediftheprocedureisdoneinthedoctorsroomsorata

registered day clinic.

Day procedures that do not attract a co-payment:

Certaindiagnosticandminorsurgicalproceduresdonotattractaco-paymentiftheyare

performedinthedoctorsroomsordayclinic.Theseproceduresare:

Diagnosticcystoscopy Proctoscopy/sigmoidoscopy

Lasertonsillectomy Vasectomy

Lumbarpuncture Colonoscopy

Needleaspirationofjoint,bursaorganglion

Majo

rMedicalBenefits

8

Major Medical Benefits

Remember: Some healthcare providers may charge more than the LMS rate, so we encourage

you to negotiate with your chosen healthcare provider and ensure that you are informed

beforehand of the fees that will be charged.


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DiseaseManagementPr

ogrammes

9

Disease Management Programmes

FormoreinformationontheCancerandHIV/Aidsprogrammes,pleaserefertopage27.

Asthma support

Most people with asthma should be able to enjoy a normal lifestyle, including getting a good

nightssleepandparticipatinginsportandothernormaldailyactivities.TheAsthmaSupport

Programmeenablesyoutoachievethisbyfocusingontheappropriateuseofmedication,whileproviding education and counselling to help you understand and manage the disease.

Thisincludes:

Howtomanageyourcondition,includingusinginhalersandpeakowmeters

Howtoreduceasthmasymptomswithoutaectingyourlifestyle

Howtoreducethenumberofhospitalandemergencyroomvisits

Diabetic support

Thisprogrammehelpsyoutocontrolyourbloodsugarandaddressesissuessuchasthe

importanceofscreeningtestsandlifestyleadjustments,whichcanimprovethewell-being

ofdiabeticpatientsvastly.Theprogrammealsoeducatesyouonthecorrectmedicinemanagement and monitoring.

Thisincludes:

Howtoachievegoodglucosecontrol

Addressingriskfactorsforcardiovasculardisease

Discussingscreeningteststhatmayhelppreventlong-termcomplications

Cardio support

If you have had angina or a heart attack, you will know how important it is to manage your

medicationproperlyandtackleanylifestylerisksyoumayhave.TheCardioSupportProgramme

provides the care and guidance you need to do this.

Thisincludes: Bloodpressuremanagementprinciples Stopsmokingprogrammes

Weight-lossprogrammes Exerciseprogrammes

Disease Management ProgrammesOurDiseaseManagementProgrammeshelpprovidethecareyouneedtoliveahealthyand

fulllife.Thereareprogrammesforasthma,diabetes,coronaryheartdiseaseandotherlifestyle

conditions such as epilepsy and bipolar mood disorders.

Case managers identify eligible candidates from members who have one of these conditions,

alsocarefullyconsideringthefollowing:

Doestheconditionseemparticularlysevere?

Isthememberhavingdicultycontrollingthecondition?

Hasthememberbeenhospitalisedasaresultofthecondition?

Youmayalsoapplyforthisbenet.

Allmemberswhoareregisteredontheseprogrammesareprovidedwitheducation,advice

and support from registered healthcare professionals, as well as with a review of the

medication currently being used.

Theprogrammewillkeepyouinformedaboutyourconditionandassistyouinmanagingyour

conditioncondentlysothatyoucanleadabetterqualityoflife.


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PMBswereintroducedintotheMedicalSchemesActtoensurethatmembersofmedical

schemeswouldnotrunoutofbenetsforthetreatmentofcertainconditions.PMBstherefore

ensure continued quality care when you need it most.

TheDepartmentofHealthtookvariousfactorsintoaccountwhendecidingonthediseasesto

becoveredunderPMBs,suchas:thenatureofthediseaseandhowthatdiseasewouldaect

the quality of life of the individual; the most prevalent conditions; the aordability of the

treatmentandthenancialimpactonmedicalschemes.

IntermsoftheMedicalSchemesAct,medicalschemeshavetocovercostsrelatedtothe

diagnosis,treatmentandcareasprescribed(bytheAct).Theseinclude:

Anyemergencymedicalcondition(thisisamedicalconditionwhichisofasuddenand

unexpected onset that requires immediate medical or surgical treatment at a time where

failure to provide this treatment would result in serious impairment of bodily functions,

serious dysfunction of a bodily organ or part, or would place the persons life in serious

jeopardy)

Asetof270medicalconditions,and

27chronicconditions.

PMBsarenotsubjecttoannualbenetlimits.PMBsarepaidfromavailablebenetlimitsand

oncetheselimitsareexceeded,fundingforfurthertreatmentofPMBconditionsiseected

strictlyinaccordancewiththetreatmentprescribedbytheAct.

EachcasewillbeassessedintermsoftheActandinaccordancewiththeSchemesmanaged

healthcare programmes and clinical protocols.

PrescribedMinimum

Be

nefits(PMBs)

10

Prescribed Minimum Benefits (PMBs)


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11

Med

ication

Medication

Generic medication

Astheexpirationdateofthepatentapproaches,anydrugmanufacturer(includingthe

one that produced the brand name version) may apply for permission to produce a

genericversionofthemedication.Companiesmakinggenericversionsdonothaveto:

Dotheresearchthatwasneededtocreatethedrugintherstplace

Putthedrugthroughclinicaltrials;or

Setupmarketingcampaignsforthegenericdrug

Eliminatingthesethreefactorsfromthecostofmanufacturingmeansagenericcanbe

sold at a far lower price than the brand name version.

A generic drug must: Containthesameactiveingredientsastheinnovatordrug(inactiveingredients

may vary)

Beidenticalinstrength,dosageformandrouteofadministration

Havethesameuseindications

Meetthesamebatchrequirementsforidentity,strength,purityandquality

BemanufacturedunderthesamestrictstandardsoftheMedicineControlCouncils

good manufacturing practice regulations required for innovator products

Medicineswithinaspecicgenericgroupareeitheridenticaltoeachother(exceptfortheir appearance or their packaging) or otherwise very similar (for example, only the

inactiveingredientsdierslightly).Thus,agivenillnesscanbetreatedwithanyone

medicine within such a group.

Brand name medication

Brandnamemedicationsaredevelopedunderpatentprotection.Adrugcompany

mayspendyearsonresearchandtestingbeforebringinganewdrugtomarket.A

manufacturers initial price for a new medication includes all the development costs it

incurred for the drug and it is therefore normally very expensive.


12/52

LMS uses a medication formulary which is a list of prescription drugs, both generic and

brandnames,thatitwillfund.Thepurposeoftheformularyistosteeryoutothemost

cost-eectivemedicationsthataresucientlyeectivefortreatingyourhealthcondition.

Thismeansyouwillgetthequalitymedicationyouneedtocareforyourhealthbut

atareasonableandmanagedcost.Youwillpaymoreifyouandyourdoctorchoose

a medication that is not covered on the formulary. Usually, the formulary is updated

annually, although it is subject to change throughout the year.

Theextended formularyappliestoPlatinumComplete,

PlatinumSaverandPlatinumFocusoptions.Thestandard formularyappliestoTitan,GoldSaver

andGoldFocusoptions.

TheCareCross formularyappliestoBonaPlus.

Refer to the diagram below for an example of how the formulary is applied .

What will you pay for medication?

IfamemberonanyoptionbuysTabletAorB,a50%co-paymentwillbeappliedasthe

medication is not on any formulary

IfamemberonanyofthePlatinumoptionsbuysTabletsCGaco-paymentwill not

apply as they are on the extended formulary

IfamemberonanyoftheotheroptionsbuysTabletsCE,a50%co-paymentwill be

applied as the medication is not on the standard formulary, but if a member buys

TabletForGnoco-paymentwillapplyastheyareonthestandardformulary.

Med

ication

12

Medication (cont.)

In- and out-of-formulary medication

Out-of-formulary

Generic TabletR 180for30tablets

B

Brand Name Tablet

R 200for30tablets

A

Generic Tablet

R 160for30tablets

Generic Tablet

R 140for30tablets

D

Generic Tablet

R 120for30tablets

E

Generic Tablet

R 80for30tablets

G

Generic Tablet

R 100for30tablets

FC

Standard formulary(Titan, Gold Saver, Gold Focus)

Extended formulary (Platinum Complete, Platinum Saver, Platinum Focus)

Note:Please refer to

www.libmed.co.za underthe Member section for

the formulary lists.


13/52

Med

ication

13

How does your chronic medicine cover work?

ClinicalprotocolsandguidelineswillapplytothetreatmentofachronicconditionlistedontheChronicConditionsList(CDL)-standardandextendedformularies

Medicationontheformulary,authorisedbyChronicMedicineManagement,willbe

reimbursedsubjecttotheMaximumMedicineReferencePrice(MMRP)

Medication(otherthanforPMBs)notontheformularywillnotbecovered

IfmedicationisforaPMBconditionandvoluntarilyobtainedfromaproviderotherthanan

approvedDSP,thenaco-paymentof50%willapply

IfmedicationisforaPMBconditionandtheformularyincludesanappropriatedrug,but

youvoluntarilychooseanotherdrugoutsideoftheformulary,thenaco-paymentofthe

greaterof50%oftheamountchargedortheamountthatwouldhavebeenpayableinrespect of the formulary drug applies

Theco-paymentinrespectofPMBmedicineistobepaidatthepointofservice,asbylaw

itmaynotbepaidfromyourMSF.

Medicine exclusions

Certainmedicinesareexcludedforpaymentfromtheacuteorchronicmedicationbenetfor

variousreasons.Theseinclude:

Medicationnotproventohaverelevantclinicalvalue

Medicationthatismoreexpensivethanequallyeectiveandsafealternatives

Medicationpronetoabuse

Somecombinationproducts,whereitismoreappropriatetousesingleingredientproducts

Newly-registeredproductsunderreview

Someexpensivechronicmedicationissubjecttostrictclinicalprotocolsandguidelinesand

requires additional authorisation.

Note:LMS has adopted industry-related Maximum Medicine Reference Pricing (MMRP) to help us

manage the costs of prescription medication. The Maximum Medicine Reference Price is a reference

pricing system that uses a benchmark (reference) price for generically similar products.


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Pharmacy Group Retail

pharmacyservices

Courier

pharmacyservices

**Acute

medicines

**Chronic

medicines

Customer Care Line and Website

Clicks

(including

directmedicines)

Yes *Yes Yes Yes 0860254257

www.clicks.co.za

Dis-Chem Yes No Yes Yes 0800201170

www.dischem.co.za

MediRite

(in Checkers &

Shoprite stores)

Yes No No Yes 0219835119

www.medirite.co.za

Pharmacy Direct No Yes No Yes 0860027800

www.pharmacydirect.co.za

Scriptnet Yes No Yes Yes 0105910150

www.scriptnet.co.za

We Care Yes No Yes Yes 0878093122

www.we-care.co.za/store-locator.php

Pharmacy Preferred Provider Network

LMS has negotiated preferred rates with these providers to help you save on dispensing fees.AsanLMSmemberyoucanuseanyserviceprovider,butitisinyourbestintereststousea

PreferredProviderwhereverpossibletoavoidorlimitco-payments.

LMS has contracted with the following pharmacies for chronic and acute medication and will

pay up to the maximum negotiated dispensing fee.

Pharmacy Designated Service Provider Network

TheSchemehasappointedPharmacyDirectastheDSPforallanti-retroviralmedication.

Clicks(includingdirectmedicines)hasbeenappointedastheoncologyDSPtotheScheme.

MembersontheBonaPlusoptionmustcontactCareCrossforthedesignatedpharmacy

serviceprovidersforthisoption.Refertopage47formoreinformation.

Med

ication

14

Pharmacy Service Providers

*Normalcourierordeliveryofpatient-readyparcelatClicksstores.

**Uptothemaximumnegotiateddispensingfeeof26%/R26limit.

Medication (cont.)


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Benets Agelimits Gender Nappi

codes

Description

PapSmear 18-60years Females 4566

4559

Vaginalorcervicalsmears

Note4559paidattheequivalentvalueof4556

Cholesterol From16years All 4027 Cholesterol

BloodGlucose All All 4050

4057

GlucoseStrip-test

Glucose:Quantitative

Immunisation for

Children

Uptoage5 All Seetable2 Seetable2

FluVaccinations All All 700767

702733

732818

732826

812307

813338

836591

838853

711345

711737

HiberixSglDose0.5ml+SalineDiluent

X-uprelled0.5mlsyringe

Inexal0.5mlVac

Inuvac0.5ml

AgrippalS10.5mlprelledSyringe

VaxigripSingleDose0.5mlprelled

VaxigripSingleDose0.25mlprefPaed

MutagripSingleDose0.5mlprefAdult

Fluvax

Fluarix

HIVTest All All 3932

4614

0016

0017

Antibodiestohumanimmunodeciencyvirus(HIV):ELISA

RapidBloodTest

Pre-testcounselling

Post-testandcounselling

TBTest All All 0221

872938

882348

Allergy:Skin-pricktests

Tuberculinppdrt/23-15tests(10x1.5ml)

Biocine

BoneDensityTest

onceevery3years

From50years Females 3604

39173

50120

Bonedensitometry

Bonedensitometry

X-raybonedensitometry

15

Prev

entativeCareBenefi

ts(PCBs)

Thisbenetfocusesontheearlydetectionofseriousmedicalconditions.Earlydetectionwill

help you stay healthy, which is why LMS will cover a variety of screening and diagnostic tests

as well as vaccinations.

LMSwillpayforthersttestorimmunisationperbeneciaryineachofthebelowmentioned

categoriesatthelesserof100%ofcost,MaximumMedicineReferencePriceoruptotheLMS

rate.Specicimmunisationsforbabiesandchildrenarelistedseparately.

Thebenetdoesnotcovertheconsultationcostassociatedwiththetestorotherassociated

costs.Thesecostswillbepaidfromtheavailableday-to-daybenetsorwillbeself-fundedby

the member.

LMS covers you and your family for the annual screening and diagnostic tests and vaccinations

listedbelow:

Preventative Care Benefits (PCBs)

Table 1: Preventative Care Benefits


16/52

16

Prev

entativeCareBenefi

ts(PCBs)

Preventative Care Benefits (PCBs) (cont.)

Benets Agelimits Gender NAPPIcodes

Description

ProstateTest

onceevery3years

From45years Males 4519 Prostate-specicantigen

Mammogram

onceevery2years

From40years Females 3605

34100

39175

Mammography:Unilateralorbilateral,includingultrasound

X-raymammographyincludingultrasound

Mammography:Unilateralorbilateral

ChlamydiaTest From25years Females 3906 Identication:Chlamydia

EyeTest

1peryear

(onlyGoldSaver

option)

Child

Dependant

under the age

of21

All 11001

11081

11021

11041

OptometricExamination

OptometricExamination&VisualFields

OptometricRe-Examinationwithinsixmonthsof

11001/11081

Consultation:15min.withoutperformingOptometricExam

DentalCheck-up

1peryear

(onlyGoldSaver

option)

Child

Dependant

under the age

of21

All 8101

8901

8104

Oralexamination

Consultation at consulting rooms

Limited oral examination

Table 1: Preventative Care Benefits (cont.)

Table 2: Vaccinations available to babies and children

*MeaslesonlyORMeasles,MumpsandRubellavaccinationmaybegiven.

Pleasenotethatconsultationsassociatedwiththeabovetestsandimmunisationsdonotformpartofthisbenet.

Vaccine method

Age of child

At

birth

6

weeks

10

Weeks

18

Weeks

9

Months

12

Months

14

Months

>5

Years

BCG(upperarm);Polio(dropspermouth)

Polio(dropspermouth)Diphtheria;

TetanusandWhoopingCough;HepatitusB;

HaemophilusInuenzaeB(injection

to thigh)

Polio(dropspermouth)Diphtheria;TetanusandWhoopingCough;Measles*(injection

to thigh)

Polio(dropspermouth)Diphtheria;Tetanus

(injection to thigh)

ConjugatedPneumococcalVaccine


17/52

17

Prev

entativeCareBenefi

ts(PCBs)

Nappi Codes are supplied to assist you in the billing process

Note:Please call the LMS Contact Centre on 0860 002 163 to confirm the correct Nappi Code

before your appointment. The list of vaccinations and immunisations is a guideline only and

is subject to change.

Nappi Code Description Immunisation Type

700210

700356

701658

701659

730394

731501

869317

Engerix-b(new)monodose1ml

Engerix-bpaed(new)monodose0.5ml

Heberbiovachbsgldose0.5mlpaediatric

Heberbiovachbsgldose1mladult

H-bvaxvaccine

Hebagamim(HepatitisBigim)

Hebagamim(HepatitisBigim)

HepatitisBVaccine

811165

825522

Moraten berna c syringe

Rouvax sgl dose syr

MeaslesVirusVaccine

700772

792004

879452

Priorixsgldose0.5mlw/pfsyr+dil

Trimovaxsingleprelledsyringe

Morupar single dose

Measles,Mumps&RubellaVirusVaccine(MMR)

888559

812919

804150

832693

832707

Tetagamim2ml

TetagamIm2ml

TetagamIm1ml

Tetavaxsingledosesyringe0.5ml

Tetavaxvial40iu/0.5mlvac

TetanusVaccines

872962

882348

Bcgintradermalinfant20dose

Biocinetest-ppdmultipuncturedevice

TuberculosisVaccines(BCG)

703226

700767834203

Actacel-pasteur0.5ml

Hiberixsgldose0.5ml+salinediluentCombact-hibsingledosesyringe

HaemophilusInuenzaeBVaccines

700773

700768

707522

707285

713229

711258

Infanrixdtpahb1mlprelledsyringe

Tritanrix-hb0.5mlsingledose

Pentaximprelledsyringe0.5ml

InfanrixHexa

AdacelQuadra

Tetraxim

Diphtheria-HepatitisB-Pertussis-Tetanus

Combinations

703335

708854

812331

823678

Tdpolio0.5ml

ImovaxPolio

Polioral10dosetrivalent

Opv-merieux10dose

PoliovirusVaccine

703367

842443

Diftavaxprelledsingledosesyringe

Dtvax0.5mlsingledose

Diptheria-TetanusToxoid(DT)

703994

825158

707285

Infanrixprelledsyringe0.5ml

Dtp-merieuxsingledosesyringe

InfanrixHexa

PertussisVaccines

705032

714999

715858

Prevenar

Synorix0.5mlprelled

Prevenar13

PneumococcalVaccines


18/52

Day-

to-DayBenefits

18

Yourday-to-daybenets(MedicalSavingsFacilityandThresholdBenet)areusedtocover

thecostsofeligibleexpensessuchas:

GPandspecialistconsultations

Routinemedication

Optometry

Pathology

Basicradiology

Alternativetherapies

Mentalhealth

Auxiliaryservices

Basicandspecialiseddentistry(excludingTitan)

Day-to-Day Benefits

1

2

3

Medical

SavingsFac

ility

SelfPayment

Gap

Thresho

ld

Beneft

ThresholdLe

vel

ApplicableonlyonPlatinumComplete,

PlatinumSaver,TitanandGoldSaveroptions.

Yourday-to-dayclaims(e.g.consultations,

optometry and dentistry) are paid fromyour savings.

Medical Savings Facility (MSF)

ApplicableonlyonPlatinumCompleteand

Titanoptions.

When your savings are depleted, you will have to

payyourday-to-dayexpensesoutofyourpocket

untilyoureachtheThresholdLevel.OnlycertaintypesofclaimsaccumulatetotheThresholdLevel.

Ensurethatyousubmitallyoureligibleclaimsto

LMSwhileyouareintheSPG.

Self Payment Gap (SPG)

ApplicableonlyonPlatinumCompleteand

Titanoptions.

Thisisasafety-netthatprovidescoverfor

yourday-to-dayexpensesonceyoursavings

havebeendepletedandyourtotalday-to-dayclaimshavereachedthepre-determined

ThresholdLevel.

Threshold Benefts (THB) paid at 100% LMS rate


19/52

19

Day-

to-DayBenefits

Medical Savings Facility (MSF)

ApplicableonlyonPlatinumComplete,PlatinumSaver,TitanandGoldSaveroptions ThisisaseparatepersonalMSFinwhichfundsareheldforyouandyourdependants

exclusive use.

Availability of annual savings

TheannualMSFismadeavailableinadvanceforimmediateuse

Theamountavailabletopayforbenetsconsistsofpositivesavingsandcreditsavings.

Credit savings (advanced annual savings) may not be utilised to pay for claims arising priortothestartofthenancialyear

TheMSFispro-ratedformembersjoiningLMSafter1Januaryinaccordancewiththe

number of months remaining in the year

Astheyearprogresses,themonthlycontributionstothesavingsfacilityareosetagainst

this advanced credit amount

TheMSFispro-ratedifadependantresignsduringthebenetyear.

Positive savings can be used to pay for: Eligibleday-to-dayexpenseswherebenetlimitshavebeenexhausted

Co-paymentsapplicabletoin-hospitalproceduresmaybeclaimedfromapositive

savings balance

ThesepaymentswillnotaccumulatetotheThresholdLevel(whichappliesonlyto

TitanandPlatinumComplete).

A percentage of the total contribution is allocated to the MSF:

Option MSF Allocation

PlatinumComplete 15%

PlatinumSaver 10%

Titan 15%

GoldSaver 15%


20/52

The Self Payment Gap

WhenthefundsinyourMedicalSavingsFacilityaredepleted,youwillgothroughaperiod

duringwhichyouneedtopayforclaimsforday-to-daytreatmentfromyourownpocket.This

iscalledtheSelfPaymentGap.WhenyouareinyourSelfPaymentGapyoumustcontinueto

submitclaimstotheSchemeeveniftheclaimsarepaidfromyourownpocket.TheSchemewill

keeptrackoftheseout-of-pocketexpensesuntilyoureachapre-determinedThresholdLevel.

The Above Threshold Benefit

OnceyoureachyourThresholdLevel,theSchemewillpayfurtherclaimsforday-to-day

treatmentfromtheAboveThresholdBenet.ClaimsarepaidfromtheAboveThreshold

BenetaccordingtotheSchemerateandsubjecttocertainbenetsub-limits.

Day-

to-DayBenefits

20

Day-to-Day Benefits (cont.)

The funds in the Medical Savings Facility (MSF) remain in your name at all times

Anypositivebalanceleftoverattheendofeachyeariscarriedovertothefollowing

year after four months

Ifyouresignyourmembershipandbecomeamemberofanothermedicalscheme

on a savings option, the positive balance will be transferred to your new scheme

fourmonthsaftertheresignationdate.Youneedtosupplyyournewschemes

information, bank details and your new membership number to LMS to make this

transfer possible

Ifyouresignyourmembershipanddonotbecomeamemberofanothermedical

scheme or if you become a member of a scheme on an option that does not providea medical savings facility, any positive balance will be refunded to you after four

months from the resignation date

Ifyouareonasavingsoptionandyoumovetoanon-savingsoptiononLMS,any

positive balance will be refunded to you four months after the resignation date

Ifyouhaveanegativesavingsbalancewhenyouresignyourmembership,youwill

need to pay this balance back to the Scheme by date of resignation

Ifyouhaveanegativesavingsbalanceattheendoftheyear,youwillneedtopay

thisbalancebacktotheSchemeby31December

Anyamountsduebyamemberwillbeo-setagainstanypositivesavingsbalance

on resignation.


21/52

Day-

to-DayBenefits

21

Note:Ensure that you submit all your eligible claims to LMS while you are in the Self

Payment Gap. This will ensure you reach the Threshold Level so that your Threshold Benefit

becomes available.

There are a few important things you should know about the

Self Payment Gap and the Above Threshold Benefit TheAboveThresholdBenetisonlyavailableonthePlatinumCompleteandTitan

options

TheThresholdLevelyoumustreachtobeabletoclaimfromtheAboveThreshold

BenetisjustthesumofyourMedicalSavingsFacilityandyourSelfPaymentGap.

Theseamountsaredeterminedatthestartoftheyearandarebasedonthenumberof

dependants you have

IfyoujoinedtheSchemeduringtheyear,yourMedicalSavingsFacility,SelfPayment

GapandThresholdLevelwillbepro-ratedbasedonthenumberofmonthsleftinthe

yearatthetimeyoujoinedtheScheme.However,ifyoujoinedafter1Octoberyour

benetswillbepro-ratedasifyoujoinedon1October

CertainexpenseswillnotbetakenintoaccountwhentheSchemedetermineswhether

ornotyouhavereachedyourThresholdLevel.Thisincludesexpensesinexcessofthe

Scheme rate, expenses for medication in excess of the Maximum Medicine Reference

price,expensesformedicationdispensedover-the-counter,expensesinrespectof

Schemeexclusionsandclaimsinexcessofbenetsub-limits.Pleasecontactthe

Schemes Contact Centre for further information.


22/52

Likeothermedicalschemes,therearecertainbenetsthatLMSdoesnotcoveratall.Belowis

alistofthemostcommonexclusions.Forafulllist,pleaserefertotheRulesofLMS.Forfurther

information please call the LMS Contact Centre on 0860 002 163.

Wha

tLMSdoesnotcove

r

22

What LMS does not cover

Summary of most common exclusions

4Dpregnancyscans(unlessauthorisedfor

certain medical conditions)

Abdominoplasties

Allcostsrelatedtowilfully-orself-inicted

injuries

Anabolicsteroids

Anti-addictionandanti-habitagentsAppointmentsnotkept

Aphrodisiacs

Aromatherapy

Arttherapy

Articialdiscreplacements

Autopsies

Ayurvedics

Backrests,chairseats,beds,mattresses,

orthopaedic shoes and boots (unless

specicallyauthorised)

Breastaugmentationandreductions

Bulk-formingandstimulantlaxatives

Circumcisionsfornon-medicalreasonsapart

from newborns

Cochlearimplants

Cosmeticprocedures

Cosmeticpreparations,emollients/

moisturisers

CPAPmachine

Dentalimplants

Drugsforthetreatmentofimpotenceandsexual dysfunction

Depilationtreatment(hairremoval)

Erectiledysfunctionsurgicalprocedures

Erythropoietin

Eveningprimroseoilandsh-liveroil

preparations and combinations

Feeschargedforwritingofmotivations

Food,nutritionalsupplements

Frailcare

GenderrealignmentGrowthhormones

Harvestingoforgansfromadonorwhoisnot

amember/dependantoftheScheme

Humidiers

Hyperbaricoxygentreatment

Immunosuppressivesandimmunostimulants

Infertilitytreatment,reversalofvasectomy

and reversal of tubal ligation

Iridology

Keloidsurgeryandrevisionofscars,exceptfollowing burns or for functional impairment

occurring during the period of cover under

LMS

Massages

Medicatedshampoosandconditioners

Morethanonespouse/common-lawspouse

MRI/CTscansorderedbyaGP

Obesity-relatedsurgicaltreatment

Organdonationstoanypersonotherthana

member or dependant of LMS

Orthodontictreatmentovertheageof21

years

Orthognathicsurgery(tocorrectjaw

misalignment)

Otoplasties

Pain-relievingmachines

Reexology

Repairstodevicesorprosthesis

Rhinoplastiesforcosmeticpurposes

Sleepstudiesandsleeptherapy

SlimmingpreparationsSoaps,scrubsandothercleansers

Sunglasses,readers,repairstospectacle

frames, coloured contact lenses

Sunscreenandsun-tanningpreparations

Surrogatepregnancies

Telephoneconsultations

Topicalandoralacnepreparations

Travellingexpenses

Veterinaryproducts

Vitaminandmineralsupplements


23/52

23

Pre-authorisation

Pre-authorisation

Why do I require pre-authorisation? Thepre-authorisationprocessalertsLMSthatamember/dependantisscheduledfor

hospitalisation

Themember,doctorandhospitalcanbeinformedbeforehandtowhatextentthetreatment

will be covered by LMS

TheprocessenablesLMStocurbever-increasingmedicalcostsasmembersbenetscanbe

managedinsuchamannerthatthemostappropriateandcost-eectivetreatmentisused

Bycomplyingwiththeprocessofobtainingpre-authorisation,youareassistingtheScheme

in managing these costs, ultimately improving LMS reserve levels and containing increases

in monthly contributions

Pre-authorisationisgrantedbasedonmembershipvalidity,clinicalappropriateness,levelof care, length of hospital stay, Scheme Rules, evidence based on clinical guidelines, the

SchemeRulesandeligibilityforbenets.

Anyemergencymedicalconditionisamedicalconditionwhichisofsuddenand

unexpected onset that requires immediate medical or surgical treatment where failure

to provide this treatment would result in serious impairment of bodily functions, seriousdysfunction of a bodily organ or part, or would place the persons life in serious jeopardy.

What is the definition of an emergency?

Additionalinformationmightberequiredpriortotheauthorisationnumberbeinggranted.

Why at least 48 hours in advance?

In an emergency, the hospital will phone, but the responsibility rests ultimately with

you, the member.

What happens if I am admitted in an

emergency situation and cannot phone?

Pre-authorisation is required for:

PlannedHospitalAdmissions

Casualty/MedicalEmergencyAdmissions

MRI/CTScans

OrthodonticProcedures

In-hospitalDentistry

PshychiatricAdmissions

Prosthesis,etc.


24/52

LMS will pay only if you obtain authorisation

TheauthorisationprocessallowsLMStoensurethatyouareprovidedwiththemostappropriate treatment at the most appropriate cost. It also enables us to monitor the quality

of care you receive.

Pre-authorisation

24

Pre-authorisation (cont.)

In-hospital Dental Pre-authorisation

Remember: Youalsohaveaccesstothein-hospitaldentaltrauma

benet,whichprovidescoverfortreatmentrequiredasaresultof:

Facialfractures

Cancers

CongenitalabnormalitiesinthecaseofchildrenbornintoLMS

Orthodontic treatment(Gold Saver, Titan, Platinum Saver and Platinum Complete options)

LMScoversorthodontictreatmentfordependantsyoungerthan21.Theorthodonticquote

andmotivationmustbesenttoobtainpre-authorisation.

ForbeneciariesjoiningLMSaftertreatmenthascommenced,theauthorisationwillbebased

onthetreatmentplanandbenetsapplicablewhentreatmentrstcommenced.

Authorisation (A written quote and motivation must be submitted)

GoldSaver,PlatinumSaverandPlatinum

Complete:contact LMS

Contact Centre 0860002163

Email [email protected]

Titan:contact Dental Risk Company (DRC)



Note:Gold Saver and Platinum Saver: Payment is subject to the availability of savings.

Titan: Paid from Day-to-Day Extender, subject to DRC protocol.

Platinum Complete: Payment is subject to MSF and Specialised Dentistry Benefit.

Accountsfromthehospital, dentist and anaesthetist are payable from the hospital

benetsubjecttocertainsub-limits.Thefollowingdentalproceduresarecovered:

Basicdentistryundergeneralanaestheticforchildren8yearsandyounger

Apicectomies

Removalofimpactedwisdomteeth(co-paymentapplicableoncertainoptions)


25/52

Contracted Service Providers:

Optometry Benets: Preferred Provider Negotiators (PPN)(Titan option only)

ThePPNnetworkconsistsofcloseto1900optometrists,givingyouaccesstooptometrists

across the country. Members qualify for substantial cost savings if they use a

PPNprovider.

Pleasevisitwww.ppn.co.za or contact PPN on 086 010 3529tolocateaPPNoptometristin

yourareaortoassistwithinformationonyourbenetavailability.

Dental Benefits: Dental Risk Company (DRC)(Titan option only)

TheschemehascontractedwithDRCtoprovidedentalmanagementservices.Basicdentistry

iscoveredat100%ofLMSrateandbasicdentalconsultationsarelimitedto1perannum

perbeneciary.

PleasecontactDRC on 086 111 5057 or via email at [email protected], to assist with

informationonbenetavailability/authorisationrequirementsforadvanceddentistryprocedures.

Pre-authorisation

25


26/52

Pre-authorisation

26


1

Note:While every eort is made to establish member eligibility and availability of funds,

authorisation is not a guarantee of payment. Although benefits are not payable while a waiting

period is still in force, a member needing emergency trauma treatment within the general waiting

period may be covered subject to the Rules of LMS and benefits of the relevant benefit option.

When your request is authorised, you will receive:

Anauthorisation number

Theapprovednumberofdaysinhospital(ifastayisrequired)

ThetariandICD-10code(s)

4

If your hospital stay is extended, the hospital case manager will inform LMS.

Fundingforadditionaldayswillbeapprovedif:

Therequestmeetsclinically-appropriatecriteria

ItiswithintheSchemeRules

Benetsareavailable

5

Planned Procedures

ContactLMSatleast48hourspriortoadmission.

Casualty Medical Emergency

ContactLMSforpost-authorisationwithin48hoursofadmissionor,ifitisa

weekendorpublicholiday,ontherstworkingday.Ifnotauthorised,paymentwill

besubjecttoyourday-to-daybenets.

Tel 0860002163


3 The following information MUST be provided:

Membership number

Patient:nameanddateofbirth

Treatingdoctor:name,telephonenumberandpracticenumber

Hospital:nameandpracticenumber

Reasonforadmission/casualtyvisit

Codes:TariandICD-10code(s)

Dateofadmissionandproposeddateoftheprocedure

If the procedure(e.g.MRIordialysis)willbeperformedoutsidethehospital:

the providers name and practice number

How to request Authorisation for hospital admissions

Ifpre-authorisationisnotobtained,claimswillnotbepaid.Thisdoesnotapply to emergencies.


27/52

Pre-authorisation

27

Note:In addition to the authorisation from the LMS Oncology Management team, you will also need to getseparate pre-authorisation from LMS for any hospitalisation, specialised radiology (e.g. MRI/CT scans and

angiography) or private nursing/hospice services which you may need during the course of your oncology treatment.

LMSprovidesanOncologyProgrammetoassistinthecareofmembersreceivingcancertreatment.

Thefollowingprocessneedstobefollowedforoncologyauthorisations(applicabletoall

optionsincludingBonaPluswhichissubjecttotheDSPIconNetwork):

Upon diagnosis, the doctor sends a treatment plan to LMS, by calling 0860 002 163

oremailing:[email protected]

Thetreatmentplanisreviewed.Ifnecessary,LMScontactsyourdoctortodiscuss

alternativesthatmaybemoreappropriateorcost-eectiveforyou.2

Anauthorisationletterwillbesenttoyouandyourdoctorstating:Anauthorisationnumber

Thetreatmentforwhichfundingisapproved

Thequantitiesforwhichfundingisapproved

Theperiodforwhichtheauthorisationisvalid

3

YourdoctormustadviseLMSofanychangeinyourtreatment.Failuretodothis

mayresultinaclaimbeingrejectedoritbeingpaidfromanincorrectbenet(e.g.

yourMSForotherTHB),astherewillnotbeamatchingoncologyauthorisation.

4

Oncology Pre-authorisation

Member and doctor complete the application formSendtheform,prescriptionandbloodtestresultstoAfA.

2

AfA reviews the application

AfAdiscussesthetreatmentplanwithyourdoctor.3

AfA sends a treatment plan to your doctor setting out your treatment plan,medication, monitoring schedule and any other requirementsAdedicatedcasemanagerwillcontactyouonaregularbasistoprovideyou

with assistance, support and advice about your condition and will reinforce the

importance of using your medication correctly and of having the correct blood

testsdonerelatedtoyourdisease.Condentialityisguaranteed.

4

Note:Anti-retroviral medication is to be obtained via Pharmacy Direct, the Designated Service Provider.

HIV/Aids Registration

The member/doctor can contact AfATel 0860100646 Fax 0800600773Email [email protected]

1Website www.aidforaids.co.zasms (call me) 0834109078


28/52

Pre-authorisation

28


Chronic Medication Pre-authorisation

ThisprocessisapplicabletoalloptionsexceptBonaPlus.MembersonBonaPlusmustcontact CareCross.

Followthefollowingprocessfor:

First-timeapplicants

Changesandadditionstocurrentauthorisation

Change in your authorised chronic medication

NotifyLMSChronicMedicineManagementofthechange

YourChronicMedicineSpecialistwilladviseyouoftherequirements,ifany,togetthechanges

activated.Additionaldocumentation,dependingonclinicalprotocols,mayberequired

Ifthemedicineisnotcovered,itmaybeduetothefactthatthemedicinesarenot

covered in the formulary or fall outside of the medicine management clinical protocols.

Doctor/Pharmacist contacts LMS Chronic Medicine Management

Tel 0860002163

Fax 0216577681


Doctor/Pharmacistsubmitsspecicinformationrelatingtoyourconditionandmedication.

1

The application is reviewed by LMS Chronic Medicine Management

Pharmaceuticalexpertsreviewtherequestand,ifnecessary,yourdoctorwillbe

contacted for additional information.

2

If everything is in order, authorisation is given

Themedicinescanbedispensed,providedyouhaveahand-writtenscriptfrom

your doctor for the medicines listed as per your authorisation.

Youcanviewyourauthorisationonwww.libmed.co.zaorbysendingablankemail

to [email protected].

3

Your request is declined e.g. not in formulary or insufficient information

Aletterofexplanationwillbesenttoyouandacopytotheprescribingdoctor.In

the case where a request was declined pending certain information, please ensure

that the doctor provides the requested clinical information (where relevant).

Foronlineclinicaldecisions,yourdoctorshouldcontacttheChronicMedicine

ManagementContactCentre.Yourrequestwillbereconsideredonceallthe

relevant information has been received.

4


29/52

ER24

29

Note:If for some reason a service provider other than ER24 was used for emergency

transportation, you are still required to inform ER24 of the emergency.

ER24 contact details

Medical emergencies in South Africa084124

Medical emergencies in Lesotho and Swaziland+27(0)102053081

Websitewww.er24.co.za

Cover for Emergency Services (RSA, Lesotho and Swaziland)

AsamemberofLMSyouhaveaccesstotheER24EmergencyContactCentreforthemanagement of any medical emergency.

Thisincludes:

24-houremergencyresponseinrapidresponsevehiclesbyroadandwherenecessary,

air ambulance

24-houremergencytelephonicmedicaladvicewhileparamedicsareresponding

Emergencytransportationtotheclosestandmostappropriatehospital

24-hourCrisisCounsellinglinewheretrainedhealthcareprofessionalswillassistwith

issuessuchasHIV/Aids,trauma,bereavement,rape,etc.

24-houractivationofamedicalemergencybycalling084124

Treatmentandstabilisationatthesceneoftheemergencybeforetransporttoan

appropriate hospital.

ER24


30/52

Tips when consulting providers:

Askyourdoctorifhe/shechargesLMSrates.(Thedoctorshoulddiscloseto/informyouupfrontoftheratesthatwillbecharged).Ifhe/shedoesnotchargeLMSrates,thentryto

negotiate a lower fee or oer to pay a discounted fee in cash upfront, which you can then

claim back from LMS

CheckyourmonthlyclaimsstatementtoseeifthedoctoractuallydidchargeLMSrates.If

yes, then the amount charged will be reflected as equal to the tari amount

Ifyourdoctorasksforbloodtests,conrmthatallthetestsaremedicallynecessary.Ifyou

hadasimilartestdonerecently,informyourdoctorandndoutifare-testisstillnecessary.

Selecting a service providerBesidesevaluatingthemedicalcredentials,experienceandreputationofyourmedical

providers,considerthefollowing:

DotheychargeLMSrates,ordotheychargeatahigherfeestructure?

Willtheygiveyouadiscountforimmediateorearlypayment?

Dotheyrequirepaymentatpointofserviceorwilltheysendyouanaccount?

AretheyelectronicallylinkedtoLMS,whichwillensurequickandecientsettlementofclaims?

Remember: Itmaybeworthseekingasecondopinionbeforeincurringsignicantcostsor

consentingtosurgery.Also,consultageneralpractitionerbeforegoingtoaspecialist.

Visits to providers charging/not charging LMS rates

ProviderswhodonotchargeLMSratesusuallyrequireyoutopaytheaccountupfrontandclaim

themoneybackfromyouravailablebenets.Alwaystrytonegotiateadiscountforearlypayment

ProviderswhochargeLMSratesmayprefertobepaiddirectlybyLMS.However,theymaystillrequireyoutopayupfrontandclaimbackfromLMSafterwards

Ifyouarerequiredtopaytheaccountupfrontandclaimthemoneybackfromyour

availablebenets,pleaserefertothesectionHowtoclaimonthefollowingpage.

Third Party Claims

PleaseinformLMSwheneveranotherpartymaybeliableformedicalexpensesincurredasaresult

of injuries. If you are treated for injuries due to an accident at work, these costs should be covered

byworkmanscompensation.PleaseconsultyourHRconsultantforassistanceinthisregard.

Ifyouaretreatedforinjuriesresultingfromamotoraccident,youmustcompleteanAccident

Report form which will be forwarded to you on request.Makingthemostofyourcover

30

Making the most of your cover

Note:When medication is prescribed, always ask if a generic is available.


31/52

When to expect paymentLMShasaweeklypaymentcycletobothmembersandproviders.Thepaymentofyourclaimsis

subjecttothecorrectinformationbeingsuppliedandmeetingsubmissioncut-otimes.

PleasecontactLMSforassistancewhensubmittingyourclaimtotheRoadAccidentFund.LMSwill

liaise directly with the person or institution involved. If LMS has settled the claim on your behalf,

youmustreimbursethisamounttoLMSwhenyoureceivepaymentfromtheRoadAccidentFund.

PleasenotethatyourclaimswillnotbepaiduntilthecompletedAccidentReportForm

issubmittedtoLMS.TheMotorVehicleAccidentRecoveryUnitcanbecontactedon

(011) 669-3166/7 or (011) 669-3169.

How to claim

Wehavemadetheclaimsprocessassimpleaspossibleforyou.Therearehoweversome

rules pertaining to claiming from LMS and vital information is required when claiming that

youneedtobeawareof.Wehavelistedthesebelow:

Makingthemostofyourcover

31

Claiming from the Scheme

Information that must be on

the claimWhat you need to check Sending claims to us

Thecorrectmembership

number

Membernameandinitials

Fullnameofthepatient

Dateofbirthofthepatient

Thecorrectdependantcode

Thedateofservice

Thetari(procedure)code

Theamountcharged

ICD10codeoneveryitem

listed on the claim

Theserviceprovidersname

and practice number

Theclaimmustbelegible

Attachreceiptifyouhavesettled

the account. It needs to be

clearlymarkedasPaid

Makeacopyoftheclaimfor

your own records

Electronically

Email

Post

Most service providers have

the ability to send claims to us

electronically, ensuring a very

short processing time

[email protected]

PrivateBagX35,Claremont,7735

Vital information for claiming:

Ifyourproviderhasclaimedfromuselectronicallyandyoureceiveacopyoftheclaim

(for your information), you do not have to send us the copy

Shouldyourproviderexpectyoutoclaimfromus,pleasesendusafully detailed and

signed claim (not just the receipt). We need the details of what is being claimed to

make sure that we capture and process your claim quickly and correctly

Yourclaimshavetobereceivedbyuswithinfourmonthsfromthedatetheservice

wasprovided,pleaserefertopage32:StaleClaims.


32/52

Whatweneedifyouaddorchangeyourclaimsrefundbankaccountdetails:

Asignedletterfromthememberconrmingthebankdetails

Acopyoftheaccountholdersidentitydocument

Abankstatementoraletterfromthebankconrmingtheaccountnumber.

How will I know what was paid?

Anelectronicmini-statementand/orSMSwillbesenttoyouonceaclaimisprocessed

(Pleaseensurewehaveyourcorrectemailaddressand/orcellphonenumberonourrecords) Youcanalsoviewyourstatementonlineatwww.libmed.co.za

Attheendofeachmonth,astatementissenttoyoucontainingalldetailsofclaimspaid,

savingsbalanceandbenetsavailabletoyou.

Stale claimsClaims received by the Scheme after the end of the fourth month from the last date of the

service rendered, as stated on the claim, are regarded as stale and will not be paid by LMS.

If a claim is submitted within the four month period and is rejected as erroneous or

unacceptableforpayment,itmustbecorrectedandresubmittedwithinaperiodof60days

followingthedateofnoticationofrejection.Ifnot,theclaimwillberegardedasstaleandno

payment will be made.

Managing fraud and abuseFraudcontinuestobeamajorconcerntomostmedicalschemes,costingmillionsofRands

eachyear.Asyouknow,themorefraudthereis,thehighercontributionsbecomeinorderto

counteracttheselosses.Fortunately,LMShasmeasuresinplacetodetectandmanagefraud

andtheabuseofbenets.

Youcancontributetothiseortbycontactingourfraudhotlineanonymouslyifyouare

aware of any provider or patient abusing the system. We urge all members to reconcile theirmonthly claims statements and verify the claims information to ensure that all details are true

and correct and report anything suspicious.

Liberty Health Fraud Hotline: 0800 212 638.

32

Making the most of your cover (cont.)

Note:LMS will not cover any interest or legal fees that are levied on a claim that is

submitted late.

Note:The onus is on the member (and not the provider) to ensure claims are submitted to

LMS for payment.


Note:Please ensure that we have your bank account details to allow for electronic payment.

If we do not have these details (including the documents as set out below) they can be submitted,

via email to [email protected] orfaxed to 021 673 9587.


33/52

Web-based facilities

In these hectic times, isnt it a welcome relief to have access to services that enable you toget the latest information on your medical scheme option according to your schedule and not

ocehours?ThisiswhyLMShasinvestedintechnologytoensurethatyouareabletoaccess

your information when you want it and make your life easier.

33


Note:Please refer to the website for all Scheme forms, formulary lists and much more...

Using the website www.libmed.co.za

No email or Internet access? Just use your cellphone!

Toreceiveyourkeymembershipinformationonyourcellphone,simply SMS the

relevanttwo-lettercodeto39372(SMSsarechargedatstandardSMSrates):

Toconrmyourmembershipdetails:SMSDEto39372

Togetyourbenetbalances:SMSBNto39372 Togetasummaryofyourmostrecentclaims:SMSCLto39372

TorequestyourFinancialAdvisersdetails:SMSBRto39372

Togetalistofself-helpinstructions:SendablankSMSto39372

Torequestacopyofyourcurrenttaxletter:SMSTXto39372(Theletterwillbesent

to your registered postal address)

AnSMSwithalltherequiredinformationwillbesenttoyourcellphone,providedthat

your cellphone number has been registered.

There are other ways to get info quickly just send a blank email

Ouremailserviceisavailable24hoursaday.Allyouhavetodoissendablankemailto

webmail@libertyhealth.co.zaandyouwillgetareturnemailwiththefollowinginformation: Yourmembershipdetails

Aclaimshistory

Benetsusedtodate

Contributionstodate

Acopyofyourlatestclaimsstatement

Acopyofyourcurrenttaxletter

Note:To register your cellphone number call the LMS Contact Centre on 0860 002 163.

Onceyouhaveregisteredonthewebsite,youwillbeableto:

Monitorallthetransactionsonyouraccount

Viewyoursavingsandotherbenetbalances

Viewclaimssubmittedandthepaymentstatusofallclaims Lookupthecontactdetailsandaddressofamedicalprovideryouknow

How to register:Gotowww.libmed.co.za

ClickonRegisteronthetoprightofthepageandfollowthesteps

OryoucancalltheLMSContactCentreon0860002163


34/52

Dependants accepted by LMS and documents required for registration:

Amembercanchoosetoregisteranyofthebelow-listedasdependantstohis/hermembership.

Membership,

RegistrationofD

ependants,

ContributionsandDebtManagement

34

Membership, Registration of Dependants,Contributions and Debt Management

Document(s) Required

Copy of ID/Birth Certificate/hospital confirmation reflecting the babys name

Copy of Marriage Certificate

Copy of Membership Certificate(s)/Affidavit detailing previous membership history*

Affidavit confirming financial dependency of Biological Parent(s)**

Proof of income if employed****

Proof of studies (current proof of registration at a recognised educational institution)

Affidavit confirming financial dependency of Adult Dependant(s)**

Copy of the Doctors disability report

Proof of legal adoption

Membership to LMS is open to anyone who wishes to join, whether as an individual or as part

of an employer group.

Note:

Amembermaynotregistermorethanonespouseand/orpartnerasadependant

Irrespectiveofwhetherbenetsareutilised,contributionsareduemonthly

Newdependants:increasedcontributionswillbeduefromtherstdayoftheregistrationmonth

Newborns:increasedcontributionswillbeduefromtherstofthemonthfollowingthebirth,

although benefits will accrue immediately

Spouses/partnerswillbechargedadultdependantrates,evenifnotyet21yearsold

Financialdependencyisdeterminedaccordingtothedependantsincome,whichshouldnot

exceed the tax threshold per annum for persons below the age of 65 years

Ex-spousesdonotqualifyforregistrationasdependantsunlesstheyqualifyaspartners.


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Membership,

RegistrationofD

ependants,


35

awful

pouse

Life

Partners

Biological

Parent of

Member

***

Biological

Siblings of

Member

***

Members

Own

Minor

Children

*****

Adult

Children incl.

Stepchildren

***

Permanently

Disabled

Children

Stepchildren

***

Adopted

Children

******

*CopyofMembershipCerticate(s)/Adavitdetailingpreviousmembershiphistory(registrationdate,benet

date,resignationdate,any/allwaitingperiodsandexclusions,allregistereddependants).Membershipcardsor

copiesthereofwillnotbeaccepted.Ifnotattached,theLateJoinerPenaltymayapply.

**LMSAdavittemplatesareavailableonwww.libmed.co.za. ***SubjecttoAnnualReview

BiologicalParentsofMember:Fathers-in-lawandmothers-in-lawarenotaccepted

BiologicalSiblings:Biologicalsiblings>21willbechargedadultrates

AdultChildrenincl.Stepchildren:>21anduptoandincludingtheageof26willbechargedadultratesunlessa

full-timestudentatarecognisedinstitutionordisabled

****Proofofincomemustbeprovidedasfollows:

Copyofdependantsmostrecentpaysliporsalaryadviceorgovernmentgrantcard

Commissionstatementsforthelast12months

CopyofdependantslatestSARSincometaxreturn

Writtenconrmationofincomefromdependantshumanresourcesdepartment,onacompanyletterhead

Ifunemployed,yourUnemploymentInsuranceFund(UIF)bluebookoradischargecerticatefromyour

previousemployeroradavitstatingzeroincome

*****Membersownnewbornchildren:IfregistrationwithLMStakesplacewithin30daysofthebirthnowaiting

periodisimposed.(TheDependantRegistrationformisavailableonthewebsite:www.libmed.co.za)

******AdoptedChildren:NowaitingperiodisimposedifregistrationwithLMSiscompletedwithin30daysofthe

adoption.(TheDependantRegistrationformisavailableonthewebsite:www.libmed.co.za)


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Membership,

RegistrationofD

ependants,


36

Membership, Registration of Dependants,Contributions and Debt Management (cont.)

Document(s) Required Member deceased

Certiedcopyofdeathcerticateofmember

CopyofIDofoldmember

CopyofIDofnewmember

Letterfromsurvivingspouse/dependantsindicatingnewmember

Bankingdetailsofnewmember

Signeddeclarationofnewmember(Applicationform.Section8)

Continuation in event of death

Termination of membership (deregistration of dependants):

MemberswhoarerequiredtobelongtoLMSintermsoftheirconditionsofemploymentmay not resign their membership while they are employed by the participating employer,

unless they obtain written consent from their employer

MemberswhoseconditionsofemploymentdonotrequirethemtobelongtoLMSmay

resigntheirmembershipbygivingonecalendarmonthsnotice.Employergroupsmay

resigntheirmembershipbygiving3monthsnotice

IfamemberfailstopayamountsduetoLMS,his/hermembershipwillbeterminated

IftheBoardofTrusteesndsamembertobeguiltyofabusingprivileges,makingfalse

claims,misrepresentationornon-disclosureoffactualinformationorofanymedical

condition,his/hermembershipmaybeterminatedandallcontributionspaidmaybeforfeited.TheBoardmayalsorequirethatsuchamemberrefundanymedicalpayments

disbursed as a result of these actions

Whenadependantisnolongereligibleforregistrationasadependanthe/shewillnotbe

entitledtoanybenets,regardlessofwhetherornotLMShasbeeninformed.

Notice period for resignations

MembersarerequiredtogivetheSchemeonecalendarmonthswrittennotice.Amemberis

requiredtoinformLMS,within30days,ofanyeventthatresultsinanydependantnolonger

satisfyingtheconditionsonwhichhe/shewasacceptedasadependantonLMS.Thenoticeof

resignation/deregistrationofdependantmustcomefromthememberonly.

Continuation of membership

AsstipulatedbytheMedicalSchemesAct(ActNo131of1998)allmedicalschemesmust

provide for continuation of membership when a member retires from employment or in the

eventofhis/herdeathtoallowthesurvivingbeneciariestobecomemembers.

Thefollowingdocumentationisrequiredineventofdeath:


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Membership,

RegistrationofD

ependants,


37

Re-instatement of membership

Ifamembervoluntarilyresignshis/hermembershipandrequeststobere-instatedaftertheterminationdate,themembermustre-applyfornewmembershipandunderwriting

maybeimposed.Ifthememberrequeststobere-instatedbeforetheterminationdate,the

membershipwillbere-instated.

Minor members

TheSchemeallowsforregistrationofmembersyoungerthan18yearsofage.Memberrateswill

beappliedeventhoughthemembermaybeunder21.Thefollowingconditionsareapplicable:

Asignedapplicationformissubmittedbytheguardian(s)indicatingbankingdetailsfor

collection of contributions Aletterisobtainedfromtheguardian(s)statingthefollowing:

Thattheguardian(s)isresponsibleforthemember

Therelationshipoftheguardian(s)tothemember

Allcontactdetailsoftheguardian(s)

Terms and conditions applicable to membership:

Noperson,whetheramemberordependant,maybeabeneciaryofmorethanonemedical

scheme at the same time Amembermaynotcede,transfer,pledgeormakeovertoanythirdpartyanybenet,claim,

orpartthereofthathe/shemayhaveagainstLMS

TherelationshipbetweenLMSanditsmembersisatalltimesdeemedtobeoneofthe

utmostgoodfaith.Thememberthereforeacknowledgesandagreestodisclosealland

anyinformationtoLMSthatmayimpactuponadecisionconcerningthemember,his/her

dependantsorhis/herclaim.

Option changes with effect from 1 January

Individual members:Asanindividualmemberyouwillbeabletoprocessonlineoptionchangesbetween1Novemberand30Novemberannually.Visitwww.libmed.co.zaforfurtherdetails.

Employer group members:SubmityouroptionchangesviayourHRdepartment.Employer

groupoptionchangeswillbeacceptedasfollows:

LetteronocialcompanyletterheadfromHRmanagerordirectorconrmingoption

changes for employees

Excelspreadsheetwiththefollowinginformation:

Employeename

Employeenumber

Membershipnumber

IDnumber

Newoption


38/52

Waiting periods

LMSmayimposebotha3monthgeneralwaitingperiodand/ora12monthcondition-specicwaitingperiodifabeneciaryhasnothadmedicalschemecoverforaperiodofatleast90days

precedingthedateofapplication.TheserestrictionsincludetreatmentforPMBconditions.

12 Month condition-specific waiting periods

LMSreservestherighttoimposeacondition-specicwaitingperiodofnotmorethan12

monthsfromthedateofcommencementofcover.Thiswillapplytoamemberand/orany

dependantinrespectofapre-existingcondition.Apre-existingconditionisoneforwhich

amember/dependantwasdiagnosed,treatedorgivenadviceinthe12monthspriorto

application to LMS.

3 Month general waiting periods

LMS reserves the right to impose a general waiting period of three months from the date of

commencementofmembershipofLMSonamemberand/orhis/herdependants,during

which period contributions will still be payable.

LMS also reserves the right to apply the balance of a valid general waiting period that has

been imposed by a previous scheme, or that was applied on a previous option.

If a member requires emergency trauma treatment within the general waiting period, this willbecovered,subjecttotheRulesofLMSandthebenetsoftheselectedoption.

Membership,

RegistrationofD

ependants,


38


Note:Trauma is defined as an event caused by accidental, violent, external and visible means,

where failure to provide the medical attention would place the members health in serious jeopardy.

Category

3Month

general

waiting period

12Month

conditionspecic

waiting period

AppliedtoPMB

Newbeneciarieswhohavenothadcoverfor90days

or more preceding applicationYes Yes Yes

Applicantswhowerebeneciariesforlessthan2years

andapplywithin90daysofleavingNo* Yes* No*

Applicantswhowerebeneciariesformorethan2

yearsandapplywithin90daysofleavingYes No No

Changeofoptionatthebeginningofthebenetyear No* No* No*

Child dependant born during period of membership

andregisteredwithin30daysNo No No

Involuntary transfers due to change of employment

andapplywithin90daysNo* No* No*

Waiting periods

*Balanceofunexpiredwaitingperiodsmaybeapplied


39/52

Membership,

RegistrationofD

ependants,


39

LMSalsoreservestherighttoapplythebalanceofacurrentcondition-specicwaitingperiod

that was imposed by a previous scheme, or that was applied on a previous option, and which

has not yet expired.

Remember: Should you have any questions or need to clarify any of these conditions, please

call our Contact Centre on 0860 002 163. We will be happy to assist you in any way we can.

Late-joiner penalties

LMSmayimposelate-joinerpenaltiesonanewmemberorthedependantofamember,if

thepersonis35yearsorolderandwasnotcontinuouslyamemberofamedicalscheme

sincebefore1April2001,orifhe/shehadabreakincoverageofmorethan3consecutivemonthsafterthisdate.Thelate-joinerpenaltyiscalculatedasapercentageofyour

contribution and applies for life, even on transfer to another medical scheme. It is the

members responsibility to provide adequate proof of previous medical scheme coverage

when applying to LMS.

LMS applies its discretion in accordance with its underwriting policy when imposing

late-joinerpenaltieswhichincertaincasesarelessthanthelegislatedguidelinesas

stipulated above.

Removal of late-joiner penalties

Late-joinerpenaltiesmayberemoved,butonlyfromtherstofthemonthfollowingthe

receiptofthenecessaryproofofpriorcoverage.Aswornadavitmaybeprovidedif

proof of cover is not obtainable, clearly stating the name(s) of the medical scheme(s) and

period(s)ofcoverforpreviousschemes.Ifyouareabeneciaryofamedicalschemeatthe

timeofapplicationtoLMS,amembershipcerticateforcurrentcovermustbeprovided.

Number of years applicant was not a member of

a medical scheme after age 35Maximum penalty

04 5%

514 25%

1524 50%

25+years 75%


40/52

Contributions

Contributionsshallbeduemonthlyinadvanceandbepayablenotlaterthanthe 3rddayfollowing the contribution due date each month

WherecontributionsoranyotherdebtowedtotheSchemehavenotbeenpaidbythedue

date,theyshallbeinarrearsandtheSchemeshallhavetherighttosuspendallbenet

paymentswhichhaveaccruedtoyouirrespectiveofwhentheclaimforsuchbenet

aroseduringtheperiodofdefault,andtogiveyouand/oryouremployernoticethatif

contributionsarenotpaiduptodatewithinthirty(30)days,yourmembershipmaybe

terminated

Ifpaymentsarebroughtuptodatebeforetheactualterminationdate,benetsmay

bere-instatedwithoutanybreakincontinuitysubjecttoLMShavingtherighttolevyareasonable fee to cover any expenses associated with the default

Ifyourmembershiphasbeenterminated,re-applicationformembershipwillberequired

and underwriting may apply

AllpayablecontributionsarecalculatedbyLMSbasedonyourchosenoption,the

numberofdependantsandthelate-joinerpenalties(whereapplicable)

Acceptanceofmembershipforanindividualmemberissubjecttoadebitorderinstruction

signed by the member

Whereamemberhassplitbilling(i.e.memberportionandemployer/pensionfundportion),

the member remains liable for the full contribution.

Debts/Amounts owed to the Scheme

PleasebeawarethatanyamountsowedtotheSchemewillberecoveredbytheSchemein

termsoftheSchemesCreditControlPolicy.

Membership,

RegistrationofD

ependants,


40



41/52

Membership,

RegistrationofD

ependants,


41

Debt process summary

Contributionsaredueontherstofeachmonthandarepayablenolaterthanthe3rddayfollowing the due date each month

AnyotheramountowedbyamemberisadebtduetotheSchemeandrecoverablebyit.

The Debt Process

Action -Nopaymentreceived

If not paid by the due date, the Scheme has the right to suspend the membership.1

Due Date -Suspendmembership/benets

Themembershipshallremainsuspendedforthedurationofthepayment

arrangement until the debt has been settled.

2

30-days - Doublededuction

Ifnotpaidwithin30days,themembershipwillremainsuspendedandadouble

deduction will be lodged via your next debit order.

3

60-days -Terminatemembership

Ifnotpaidwithin60days,themembershipwillbeterminated.4

90-days -Handoverforcollection

Ifthedebtisstilldueafter90days,themembermaybehandedovertodebt

collectorsforcollection.TheSchemeallowspaymentarrangementsforamaximum

ofthreemonthsonly,providedasignedAcknowledgementofDebtformhasbeen

completed by the member.

5

Remember: It is usual for a number of rules, regulations and conditions to apply when

joining a medical scheme. LMS endeavours to help you understand these and know how

they will aect you. If you do have questions or concerns, please call our Contact Centre

on 0860 002 163ordiscussthesewithyourFinancialAdviser.


42/52

ER24-International Travel Benefit

AllactivebeneciariesofLibertyMedicalSchemeontheGoldFocus,GoldSaver,PlatinumFocus,PlatinumSaverandPlatinumCompleteoptionswhotravelinternationally(outsidetheborders

ofSouthAfrica)forleisuremayqualifyforMedicalCover.Thepolicyprovidescoverofuptoa

maximumofR5millionpertripforupto90dayspertrip,irrespectiveofhowmanytripsaremade

during the year.

Additionalinsuranceisrequiredfor

Beneciariesover the age of 80 wanting to travel

Beneciariestravellinginexcess of 90 days per trip

Beneciariespartakinginhazardous pursuits e.g. mountain climbing, scuba diving, any contact

sports, motorcycling, skiing, etc.

Four easy steps to ensure that you are covered when you travel:

AdditionalServices

42

Additional services offered to Scheme members

ObtaindetailsofyourpolicywordingfromER24 on

Local 010 205 3100

International +27 10 205 3100

BusinesshoursMondaytoFriday8:0017:00

[email protected]

1

ObtainadditionalinsuranceifrequiredfromER24on011 319 6500 or via

email [email protected]

Obtainanembassy letter for your visa by phoning Chartis on 0860 100 491

(selectoption6)3

Should you require any medical assistance while travelling, contact the emergency

number +27 10 205 31004

Note:ER24istheserviceproviderfortheInternationalTravelBenetasofJanuary2012.


43/52

AdditionalServices

43

Liberty Baby

Havingchildrenisoneoflifesexcitingadventuresandtoenhancethisexperience,weoerLibertyBabytoexpectantmomsonGoldSaver,Titan,PlatinumSaverandPlatinumCompleteoptions.

LibertyBabyisdesignedtoinformmoms-anddads-to-be,oersupportandgivesoundadvice.

If you are expecting a baby, please call us on 0861 116 019andwewillregisteryouonLibertyBaby.

AsamemberofLibertyBabyyouwillreceiveababybagthatincludes:

Pregnancyandbabybooklets

Productsformomandbaby

Emergencyguide

Somefantasticdiscounts

FormoreinformationonLibertyBabyvisitwww.libmedbaby.co.za

You also have:

Accesstoa24-hourmedicaladviceline,whichismannedbytrainedprofessionals

AccesstotheLibertyBabywebsite

AphonecalleverytrimesterfromLibertyBabytomakesurethatyouandyourbabyare

making healthy progress

Emailsonthestagesofpregnancyformomanddad


44/52

Beneciary Amemberandanyofhis/herregistereddependantswhoisentitledtobenets.

Co-payment When a member is liable for a portion of the costs incurred for

treatmentand/ormedicationreceived.

Cost Theactualamountchargedbytheserviceproviderforservices

rendered.

Credit Savings TheadvancedannualsavingsthatLMSmakesavailableon1Januaryof

everyyear,evenifyouhaventyetmadethefullcontributiontotheMSF.

Day-to-DayExtender

Thisisacollectionofout-of-hospitalbenetswhicharepaidfromScheme risk rather than from savings.

Designated

ServiceProvider

(DSP)

AhealthcareproviderorgroupofprovidersselectedbyLMStoprovide

speciedhealthcareservicestoitsmembers.Ifamembervoluntarily

usesanon-DSP,aco-paymentmayapply.

Eligibleexpenses Medicalexpensesthatarespecicallyincludedinthe2012LMSbenet

schedule;thatarenotlistedunderexclusions;thatareunrelatedto

conditionsforwhichaspecicwaitingperiodisineectandthatare

not incurred during a general waiting period.

Formulary

Medicine

AdenedlistofmedicinesforwhichLMSwillpay.Thelistisbasedon

clinical evidence and protocols.

GenericMedicine Amorecost-eectiveversionofthebrandedmedicinesthatcontain

the same active ingredients and are identical in strength.

ICD10code Thecompulsorydiagnosticcodeusedbyproviderstoindicatewhatthe

medical diagnosis is for treatment received. Claims that do not contain

anICD10codecannotbepaidintermsofcurrentlegislation.

LMS rate TheLibertyMedicalScheme(LMS)rateistherateatwhichtheScheme will pay for a particular health service and which is either the

negotiated rate with providers or in the absence of a negotiated rate,

thelowerofcosts,UPFS(Staterates)orthetariasdeterminedbythe

BoardofTrustees.

Major Medical

Benet(MMB)

Thisisacollectionofhigh-costbenetssuchashospitalisation,certain

day procedures, oncology (cancer) treatment, costs incurred due to

crime trauma, emergency transport and more.

Maximum

Medicine

ReferencePrice

Themaximumreimbursablepriceforamedicineorgroupofmedicines

according to a reference pricing system that allocates a price to a group

ofdrugsthataresimilarinecacy,safetyandquality.Glossary

44

Glossary

Useful definitions


45/52

MedicineExclusions

AlistthatstipulatescategoriesofdrugsNOTcoveredbyLMS.

Medicine

Management

Protocols

Clinical guidelines and protocols formulated for the provision of care

andtreatmentrelatedtospecicdiseases.

Medical Savings

Facility(MSF)

Thisisusedforeligibleday-to-dayexpensesasspeciedinLMSs

Rules. Contributions to a savings facility are set at a percentage of total

contributions.

Negotiated

DispensingFee

AchargeagreedtobetweentheSchemeanddispensersandproviders

in respect of the dispensing of registered medicines.

PositiveSavings ThemonthlysavingscontributionsthatLMShasreceived,buthavenotyet

beenusedbyyou.Thisincludessavingscarriedoverfrompreviousyears.

Pre-authorisation NotifyingtheSchemeatleast48hoursbeforeadmissiontohospital

orreceivingcertainservicesasprovidedforintherulesfornon-

emergencyeventsorwithin2businessdaysafteradmissionor

treatment in an emergency.

Preferred

Providers

TheseareproviderswithwhomtheSchemehasnegotiatedpreferred

rates.Ifamemberusesthem,noco-paymentapplies.

Prescribed

Minimum

Benets

Thebenetscontemplatedinsection29(1)(o)oftheActandwhich

includetheprovisionofthediagnosis,treatmentandcarecostsof:

ThediagnosisandtreatmentpairslistedinAnnexureAofthe

Regulations,subjecttoanylimitationsspeciedtherein;and

Anyemergencymedicalcondition.

Prescribed

MinimumBenet

Condition

Aconditioncontemplatedinthediagnosisandtreatmentpairslistedin

AnnexureAoftheregulationsoranyemergencymedicalcondition.

PreventativeCare

Benet

Cover for certain tests and immunisations that help you to monitor

yourhealthandpreventpossiblefutureillness.Refertopages15to17

of this guide for a list of eligible expenses.

Pro-ratingof

benets

Whenamemberjoinslaterthan1January,benetsfortherstyear

are decreased in accordance with the number of months remaining inthe year. G

lossary

45

Useful definitions


46/52

Glossary

46

Glossary (cont.)

Disclaimer

ThisisamarketingoverviewandsummaryoftheLibertyMedicalScheme,servicesand

complementaryproducts.Everyattempthasbeenmadetoensurecompleteaccuracyofthis

brochure.However,intheeventofaconictbetweenthisbrochureandtheregisteredRules

oftheScheme,theruleswillprevail.E&OE.

RiskBenets Allthebenetsundermajormedicalbenets:Hospitalisation,ChronicCover,DiseaseManagement,Day-to-DayExtenderandThreshold

Benets,aresubjecttotherateandlimitsspeciedintheBenet

Schedule.Unusedbenetscannotbecarriedovertothefollowingyear.

SelfPaymentGap

(SPG)

TheperiodaftertheMSFhasbeendepletedandyoumayhavetopay

forday-to-dayexpensesoutofyourownpocket,untiltheThreshold

Level is reached.

ThresholdBenet

(THB)

Thisprovidesadditionalcoveroncetotaleligibleday-to-dayexpenses

reachaparticularThresholdLevel.Thislevelisbasedonthenumberandtypeofdependantsaprincipalmemberhas.LMSpaysday-to-day

expensesfromtheThresholdBenetattheLMSrate.

Useful definitions (cont.)


47/52

47

Contact Details

Cont

actDetails

Banking Details

Account holder Liberty Medical SchemeBank StandardBankBranch ClaremontBranch code025109Account number 240402235

CareCross Contact Centre (Bona Plus option only)

Contact numbers and support services


Chronic Contact Centre 0860102182Enquiries [email protected] www.carecross.co.za

Dental Risk Company (DRC) (Titan option only)


Authorisations:Fax 0866871285Email [email protected] queries [email protected] enquiries & escalations [email protected]

Chronic Medicines and Disease Management Programmes

Approvalandregistrationofchronicmedicationcoverasperqualifyingconditions.

Tel 0860002163Fax 0216577681Email [email protected]

Claims Submission

Forprocessingofclaims


48/52

Cont

actDetails

48

Contact Details (cont.)

Hospital AuthorisationsAdmissiontohospitalsandregisteredmedicalinstitutions.

Tel 0860002163Fax 0216577711Email [email protected]

Liberty Baby

Applicable only on Gold Saver, Titan, Platinum Saver and Platinum Complete options.

Tel 0861116019

Alternative Tel 0117042151Fax 0117044645Email [email protected] www.libmedbaby.co.za

HIV Management Programme

AdministeredbyAfA.

Tel 0860100646Fax 0800600773Email [email protected] www.aidforaids.co.zasms (call me) 0834109078

Financial Adviser Contact Centre

AdedicatedFinancialAdviserContactCentretoassistwithenquiryresolutionand

information requests (8:00 - 17:00, Monday to Friday).

Tel 0860002168Fax 0216577581Email [email protected] address PrivateBagX35,Claremont,7735

ER24 Emergency transportation

Medical emergencies in South Africa 084124Medical emergencies in Lesotho and Swaziland +27(0)102053081Website www.er24.co.za

ER24 International Travel Insurance (option dependent):

Applicable only on Gold Focus, Gold Saver, Platinum Focus, Platinum Saver andPlatinum Complete 0ptions.

Policy wording detail ER24onLocal:0102053100 International:+27102053100

Medical emergency Local:0102053100

International:+27102053100


49/52

Cont

actDetails

49

Liberty Medical Scheme Contact Centre

AdedicatedContactCentretoassistwithenquiryresolutionandinformationrequestedby current and prospective Liberty Medical Scheme members and healthcare service

providers (8:00 - 17:00, Monday to Friday).

Tel 0860002163

Fax 0216577571


Postal address PrivateBagX35,Claremont,7735

Preferred Provider Network (PPN) (optical benefit on Titan option only)Contact Centre 0860103529

Visitwww.ppn.co.zatolocateaPPNoptometristinyourarea

Oncology Management Programme

Requests for the registration and approval of treatment options related to oncology.

Tel 0860002163

Fax 0216577621


New BusinessSubmission to the new business team of new membership applications, as well as additions

of dependants and newborns. Send the additional documentation related to a membership

applicationoraddition(optionspecicrequirements,asperSchemesrules)tothene

Documents

LMS 2012 Member Guide