Private Health Insurance Standard Information Statement - General Treatment Policy

This Statement provides basic information for the purposes of comparison only. For full explanation of this general treatment
policy please contact the health insurer on 134 135 or visit http://www.bupa.com.au.
HEALTH INSURER: Bupa Australia Pty Ltd
WHO IS COVERED:
Two adults
PRODUCT NAME:
Silver Extras - Couple
MONTHLY PREMIUM: #
$122.40 (before any rebate or loading)
MEDICARE LEVY SURCHARGE:
NOT Exempt
AVAILABLE FOR:
Residents of Western Australia
AVAILABLE FROM:
01 April 2015
# You may be entitled to an Australian Government rebate on this premium. Your premium may include an insurer discount. Check with your insurer for
more details.

PREFERRED SERVICE PROVIDER ARRANGEMENTS: Our Members First network offers access to dental, optical, physio and chiro services.
Get 60% back on most services at these providers, 'no gap' optical packages & kids get 'gap free' physio & dental-conditions apply
SERVICES

COVER

WAITING PERIOD
(MONTHS)

DENTAL

General dental

Major dental

BENEFIT LIMITS
(PER 12 MONTHS)
No annual limit

(Sub-limits apply)

12

$1,000 per person

EXAMPLES OF MAXIMUM BENEFITS

Periodic oral examination - $26.00
Scale & clean - $48.50
Fluoride treatment - $21.60
Surgical tooth extraction - $88.60
Full crown veneered - $910.00

Endodontic

12

(combined limit for major dental & endodontic Sub-limits apply)

Orthodontic

12

$700 per person

$2,000 lifetime limit

Braces for upper & lower teeth, including

removal plus fitting of retainer - 100% of charge

$200 per person

(Sub-limits apply)

Single vision lenses & frames - $161.90

Multi-focal lenses & frames - $200.00

$500 per person

Per eligible prescription - $40.00

$700 per person

Initial visit - $36.00

Subsequent visit - $29.00

OPTICAL (eg prescribed

spectacles / contact lenses)

NON PBS PHARMACEUTICALS

PHYSIOTHERAPY

CHIROPRACTIC

PODIATRY

PSYCHOLOGY

ACUPUNCTURE

(Sub-limits apply)

$500 per person up to $1,000 per policy

(Sub-limits apply)

$400 per person

(Sub-limits apply)

$400 per person

(Sub-limits apply)

$400 per person

NATUROPATHY

REMEDIAL MASSAGE

HEARING AIDS

12

Filling of one root canal - $160.00

Initial visit - $31.00

Subsequent visit - $25.00
Initial visit - $36.00
Subsequent visit - $28.00
Initial visit - $100.00
Subsequent visit - $73.00
Initial visit - $30.00
Subsequent visit - $25.00

(combined limit for acupuncture, naturopathy, Initial visit - $25.00

remedial massage & other services - Sub-limits Subsequent visit - $25.00
apply)

Initial visit - $33.00

Subsequent visit - $23.00

$500 per person

1 appliance(s) every 3 years

Per hearing aid - 60% of charge

(combined limit for hearing aids & other services)

BLOOD GLUCOSE MONITORS

AMBULANCE

12

0 day

$400 per person

1 appliance(s) every 1 year

Per monitor - 60% of charge

(combined limit for blood glucose monitors &

other services)

2 service(s) every year

Comprehensive cover (see insurer for details)

Benefit paid after current PBS patient contribution deducted

OTHER FEATURES: Get covered and be rewarded with a Benefit Bonus feature that increases the amount you get back when you claim
plus no annual maximum on general dental, cover for Travel and Accommodation, Living Well, Natural Therapies and more. For
more details see Important Information available at bupa.com.au

BUP/I17/WBMS20R issued 27 February 2015

www.PrivateHealth.gov.au