Guide 2023

DOCTOR CONSULTATIONS

� Affinity Health members may contact us on 0861 11 00 33 to consult

TELEHEALTH CONSULTING an Affinity Health Nurse Practitioner, who will assess your
symptoms and give you medical advice before issuing you with a
script for medication or referring you to consult with an Affinity
Health network GP.
� Affinity Health is proud to introduce the new Telehealth Consulting
benefit, a convenient way of getting the medical assistance you � Please visit https://www.affinityhealth.co.za/find-doctor/ to
need telephonically, without traveling the distance or spending locate an Affinity Health network GP closest to you.
more money than necessary.
� It is important to call 0861 11 00 33 to check the status of your
� Call 0861 11 00 33 to have a telephonic consultation with an Affinity policy and receive pre-authorisation before visiting a GP.
Health Nurse, Doctor or Mental Health Professional.
� The Affinity Health Network includes Dispensing and Scripting
� The Nurse, Doctor or Mental Health Professional will assess your doctors. Should you consult a dispensing GP, please note that
symptoms and either issue a prescription for acute medication up to medication will be issued to you from the dispensary within the
schedule 4 - provided you are out of the 1 month waiting period - or doctor's rooms. If you consult a scripting GP, the doctor will issue
refer you to your nearest primary healthcare facility or Affinity Health you with a script to take to the pharmacy and collect medication
network GP for further assistance.
according to the Affinity Health formulary.
� Please note that medication will be issued according to the Affinity
� When you receive a script, please collect the medication at a
Health formulary. pharmacy linked to the Affinity Health formulary.

� Network doctors claim directly from Affinity Health, however

additional administration fees may be charged separately by the
practice and cannot be recovered from Affinity Health. These will be
for the members' accounts.

IN-ROOM GP PROCEDURES � Members may consult out-of-network doctors as well, however

important information applies:

� The full consultation fee will have to be paid upfront by the

member. Up to R250 may be claimed back from Affinity
� IMPORTANT – these procedures are only covered if performed by an
Health. For assistance with reimbursement, please email the
Affinity Health network GP.
detailed account and a signed Affinity Health reimbursement
� Pre-authorisation is required before the procedure is performed. form to [email protected].

� These will be covered according to the Affinity Health limits that fall � Out-of-network GPs are unfamiliar with cover rules, which
under this benefit. means that they are unaware of exactly which medication is
covered. Using an Out-Of-Network GP may increase the
� Call 0861 11 00 33 for assistancewith obtaining pre-authorisation. chance of having to pay excess for medication.
 NURSE-LED MEDICAL CONSULTATIONS SPECIALIST
(MEDICAL SOCIETY BENEFIT): VISITS

� Being an Affinity Health member gives you access to conveniently � IMPORTANT – these consultations are only covered if referred by a
located centres with highly skilled Nurse Practitioners that strive to GP and pre-authorisation is required before the consultation.
provide quick services in a clean environment.
� Please call 0861 11 00 33 or email [email protected] with
� This benefit includes Nurse-led medical consultations, basic eye the GP's referral letter, the specialist's name, contact number and
tests, child nutrition and treatment for acute illnesses. practice number to obtain a pre-authorisation number.

� You may also use this benefit to monitor your vital signs and � Please note that only certain specialists are covered, who may
manage your chronic symptoms with medical and lifestyle advice require an upfront payment of the consultation fee. This can be paid
provided by the Nurse Practitioner. The Nurse Practitioner will refer
you as required, should you need further medical assistance. by the member and claimed back from Affinity Health according to
the maximum benefit amounts (R1700 per single member policy per
� There are 14 Medical Society centres. The different locations can year, R3 500 per family policy per year.
be viewed on:
https://www.medicalsociety.co.za/locate-tms-facility/
� In the event that no upfront payment was required, please ensure
that the specialist's account is sent to Affinity Health to claim
benefits.

� Should you be required to pay upfront, please email the detailed

account and a signed Affinity Health reimbursement form to
[email protected].
OPTOMETRY

� Members must call Affinity Health on 0861 11 00 33 for pre-

authorisation before using this benefit.
DENTISTRY
� Only Spec-Savers may be used, unless your nearest Spec-Savers
is located more than 100km from your residential or work address.

� Members are covered for one consultation (eye test), one set of
� IMPORTANT – Affinity Health only covers in-chair dental procedures,
standard frames (the grey sticker range) and lenses (single vision and subject to the Formulary, done by network dentists. Please contact
bifocal lenses. Multifocal lenses will be covered up to the amount for 0861 11 00 33 or visit https://www.affinityhealth.co.za/find-doctor/
bifocal lenses). to obtain the latest provider list.

� Spec-Savers will submit the bill directly to Affinity Health for payment � Pre-authorisation is required, call 0861 11 00 33.
processing according to the Affinity Health benefits.
� Note that the benefit covers 1 full mouth assessment and 1 scale and
polish every 6 months. Infection control, 2 intraoral radiographs, 3
extractions and 3 fillings per Assured Person(s) per year.

ACUTE MEDICATION
PATHOLOGY & RADIOLOGY
� No OTC medication is covered under this benefit.

� Affinity Health works with a medicine formulary. This means that the � Members can make use of any Radiology or Pathology laboratory, as
prescribed medication that is not on our formulary will not be referred by a medical practitioner.
covered, and that members may be required to make a co-payment.
� Pre-authorisation is important for you to understand what will be
� Remember to ask your Doctor to prescribe medication in accordance covered.
with Affinity Health's formulary.
� The formulary includes basic x-rays and blood tests only, according
� Should you have any problems claiming medication, contact Affinity to Affinity Health's protocol and pricing.
Health on 0861 11 00 33 while you are at the pharmacy for further
assistance. � When a member is referred, we recommend that the member obtain
a tariff code for the referral. In this way, the member can be certain
� Remember that if members use a dispensing doctor, the medication whether the relevant test is covered or not.
must be collected from the dispensary within the doctor's practice
and that a script from a dispensing doctor will not be valid at any � Call 0861 11 00 33 or email [email protected] with the
other pharmacy. relevant tariff codes for pre-authorisation.

OVER-THE-COUNTER MEDICATION CHRONIC MEDICATION

� Members must call 0861 11 00 33 or use the Affinity Health app to � Only members on the Day-to-day or Combined Plans qualify for the
obtain Pre-authorisation before using this benefit. Chronic Essential Benefit.

� A chronic medication application form can be obtained by emailing

� This benefit is linked to the Telehealth Consulting benefit with a Nurse
[email protected].
Practitioner.
� Both the member and the treating doctor will be required to
�
This benefit is subject to the maximum benefit amounts (R500 per complete specific sections of the application form.
single member policy per year, R1 000 per family policy per year) and
the Affinity Health Formulary. � A complete chronic medication application form, your most recent
prescription and pathology report are required to begin the
application process.

� Upon receipt, the chronic application will undergo a validation

process,and you will be notified of the outcome via email or SMS
within 48 hours.

� There is an additional monthly surcharge per condition per member.

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 MATERNITY SCANS

� This benefit covers two growth sonars referred by your

network GP, subject to the Affinity Health Formulary.

� Call us on 0861 11 00 33 so we can refer you to a network GP

who provides this service from within their practice rooms.

� Members may also ask us for assistance via WhatsApp on

079 479 3230 or chat to us live during office hours on
www.affinityhealth.co.za.

HIV CHRONIC MEDICATION CASUALTY ROOM BENEFIT

MANAGEMENT PROGRAMME

� The programme caters to the medical and lifestyle needs of � Affinity Health provides an immediate Casualty Room Treatment
members living with HIV/AIDSby providing them with suitable benefit as a result of an accident, which is activated as you apply. The
treatment and tools to live a healthy life. benefit is an amount of up to R1 000 per policy. This benefit is only
available to first time applicants.
� Members are required to email their latest prescription, updated
viral load report and a complete chronic medication application form � This benefit is available 24/7, to be claimed for accident or illness
to [email protected] for further assistance. emergencies.

� Contact us on 0861 11 00 33 for more information. � This benefit pays up to R4 750 per policy per year, depending on the
plan chosen.

� Pre-authorisation is required. Call 0861 11 00 33 in the event of an

emergency.

HOSPITAL BENEFITS

� PRE-AUTHORISATION IS REQUIRED: Affinity Health has a 24-hour hospital pre-authorisation line. Members MUST call in for pre-authorisation before going to the
hospital to ensure that Affinity Health can contact the hospital to arrange admission prior to the members arrival.

� Pre-authorisation can also be obtained via our WhatsApp line 071 314 5862 or you may send us a please-call-me request to 071 314 5862, and one of our pre-
authorisation agents will contact you back within minutes. Call 0861 11 00 33 to speak to a pre-authorisation agent and let us know what has happened.

� The agent will assess and define the event as either an illness or accident event, according to the Affinity Health Hospital benefits.

� Please note: illness and planned admissions generally require specific documentation – the admission letter, quotes from the treating provider and facility, pathology
and radiology reports and a signed cession form – these can be emailed to [email protected].

� An injury report is required in the event of an accident.

� For planned admissions, please contact Affinity Health at least 48 hours prior to the procedure/admission to ensure authorisation is provided timeously.

� IMPORTANT – Please remember to send us the cession form (which you will receive when the guarantee of payment is issued) before admission. Affinity Health cannot
pay any accounts without a signed cession form.

� If the Casualty Benefit was previously claimed within the year, only the remaining benefit amount will be payable.

� Continuation of cover for illness events will be considered part of the same claim event and only the maximum benefit amount will be payable. This will be
for admissions for the same or a related illness condition within a 6 month period.

� Accident continuation will also be linked to the initial accident event, as readmission for surgery or further treatment may be required. Treatment cover period is up
to 6 months.

� Members are urged to contact Affinity Health post – discharge. Friendly staff will assist the member in ensuring everything pertaining to the case is updated to secure
a smooth, hassle-free claims process.

� If there are any changes to your treatment plan during admission, please contact Affinity Health.

� All related accounts need to be emailed to [email protected] within 7 days of discharge. Please note that no accounts may be paid until the
hospital account has been received.

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