Sos classic benefits.pdf

Appendix A
Summary of Covered Medical Services
Premium Plan: This Clinic Prepaid Plan (where available) provides Eligible Members with the right to make use of the relevant
clinic and includes extended covered services, products and procedures beyond those indicated under the Classic Plan (see
below). This Plan is available at all Intl. SOS Clinics in China.
Classic Plan: This Clinic Prepaid Plan (where available) provides Eligible Members with the right to make use of the relevant clinic
and includes a limited number of covered services, products and procedures. This Plan is available at all Intl. SOS Clinics in China.
The following medical services and/or products are covered under this Agreement during normal business hours
Classic Premium
Consultation for Diagnosis and Treatment Provided:
All consultations provided by the Family Practice/Emergency Physicians at the International SOS Clinic. Consultations include brief, standard or extended consultations. Any specialist consultations will not be covered unless specifically specified by Intl.SOS. Prescription visits and medical reports are also covered. Emergency Services:
Emergency Management is provided at the International SOS Clinic, and the first hour of any emergency admission is covered under this plan, including all medication and supplies listed in Appendix B. Whether or not the case is an emergency will be determined by Intl.SOS at its sole discretion. Routine Medication and Disposables - as per Appendix B:
Routine Medication and Disposables listed in Appendix B are covered when prescribed or in the process of providing services or procedures covered in the Clinic Pre Paid Plan. Long term, chronic medications would not be covered under the Clinic Pre Paid Plan, however provision shall be made to maintain alternative or special order medications whenever feasible. The alternative or special order medications will be charged separately. Routine Laboratory Testing:
Extended Laboratory Testing:
Blood Group, Liver Function Tests (Bilirubin, Alkaline Phosphatase and AST), Urea & Creatinine, Potassium, Glucose and Full Blood Count are covered. Vaccinations:
Hepatitis A, Hepatitis B, Tetanus (Adult booster) , Flu Vaccination Extended Vaccinations:
Measles, Mumps, Rubella/MMR, Diphtheria, Tetanus, Pertusis/DTaP (Children), Diphtheria, Tetanus/DT (Adults), Hib, Typhoid, Injectable Polio Vaccine/IPV, Infanrix 5-in-1 (HIB, IPV, DPT) Routine Prenatal Coverage:
Participants enrolled in the annual (12 months) Clinic Pre Paid Program are provided a confirmation pregnancy test (blood HCG) as well as unlimited pre natal consultations, to be conducted by the a doctor at the clinic during normal clinic hours. Extended Pre Natal Care:
Pre natal tests - urinalysis, glucose tolerance, hepatitis screening, TORCH bundle (serology screening) & full blood count. Routine Annual Health Exam:
Participants enrolled in the annual (12 months) Clinic Prepaid Program are provided one (1) Annual Health Exam to be conducted by a doctor at the clinic during normal clinic hours. The exam includes the consultation with the doctor, including the complete patient history and comprehensive physical examination, immunization history and advice (vaccines may incur additional costs), blood pressure, vision test, peak flow meter, weight, height, laboratory tests (routine urinalysis, full blood count, blood glucose, cholesterol), chest X-ray and ECG for patients over 40 years of age. Pediatric physical exam, immunization review (vaccines may incur additional costs), height, weight, developmental assessment, growth charting, vision test (over 4 years) Extended Annual Health Exam:
Participants enrolled in the annual (12 months) Clinic Prepaid Program are provided one (1) Annual Health Exam to be conducted by a doctor at the clinic during normal clinic hours. The exam includes the consultation with the doctor, including the complete patient history and comprehensive physical examination, immunization history and advice (vaccines may incur additional costs), blood pressure, vision test, peak flow meter, weight, height, laboratory tests (tests (routine urinalysis, full blood count, blood glucose, cholesterol, blood group, ESR, creatinine, liver function, uric acid, male PSA), chest X-ray and ECG for patients over 40 years of age. Pediatric physical exam, immunization review (vaccines may incur additional costs), height, weight, developmental assessment, growth charting, vision test (over 4 years) End of APPENDIX A
Clinic Prepaid Plan – (China)

Appendix B
List of Covered Routine Medications & Disposable Items
ANTI-INFECTIVE
DERMATOLOGY
Amoxicillin/Clavulanate 875/125 mg Tablets Mucopolysaccharide Polysulfate 0.3% Cream Amoxicillin/Clavulanate 400/57 mg/5 ml Suspension Amoxicillin/Clavulanate 250/62.5 mg/5 ml Suspension ENT
Tobramycin/Dexamethasone 3.5 gram Eye Ointment STEROIDS
MUSCULOKELETAL/PAIN RELIEF
NUTRITION/HEMATOLOGY
RESPIRATORY SYSTEM
Paracetamol/Pseudoephedrine/Dextromethorphan/Chlorphenamine Tablets GI/ALMENTARY SYSTEM
Paracetamol/Pseudoephedrine/Dextromethorphan/Chlorphenamine Syrup Clinic Prepaid Plan – (China)
Pseudoephedrine/Dextromethorphan/Chlorphenamine Syrup Paracetamol/Pseudoephedrine/Dextromethorphan/Chlorphenamine PED. ANTIHISTAMINES
CVS SYSTEM
Codeine/Ephedrine/Potassium Guaiacolsulfonate/Triprolidine Syrup
Note: The list of medications is subject to change based on availability at the Intl. SOS Clinic. Substitutes will be of equal or better quality at time of
substitution. This list is subject to change without notice.

Disposable Items
Bandage white 10 cm
Clinic Prepaid Plan – (China)
Conforming bandages (non-sterile) 7.5cm, 10cm Conforming bandages (sterile) 5cm, 7.5cm, 10cm End of APPENDIX B
Clinic Prepaid Plan – (China)

Source: http://share.sis.org.cn/sisdhc/files/2010/03/SOS-Classic-Benefits.pdf