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Health Plans | Value Core

Benefits Value Core Option 2020

OPTION

VALUE CORE 2020
Overall Annual Limit

No Overall Annual Limit

Subject to sub limits not being exceeded

Prorated benefits are applicable if you join after the 1st of January of a benefit year.

Yes

Statutory prescribed minimum benefits.  Services rendered payable at 100% of cost at DSP*

No Annual Limit

3 Month General Waiting Periods (Subject to the rights of interchangeability)

Yes

12 Months condition specific waiting period for pre-existing conditions (Subject to the rights of interchangeability)

Yes

Claims received later than the last day of the 4th month in which the service was rendered will not be covered.

Yes
Emergency medical cover whilst traveling outside of South Africa. (Subject to PMBs)

100% of Scheme rates payable in RSA currency.
Subject to completion of documentation prior to leaving RSA.
Subject to approval by Scheme.

 

Benefits (In hospital)

HOSPITALISATION AND ASSOCIATED COSTS – PROVINCIAL AND PRIVATE

OPTION

VALUE CORE 2020

Items 1.01 – 1.25
Limited collectively and subject to authorisation.

Note:  All Admissions to hospitals and services listed below must be pre-authorised by the Scheme/preferred provider or within 48 hours in the case of an emergency. 

Failure to comply with this rule will result in a levy of R 1 000 per admission.  Please note that treatment protocols apply.


Private Hospitals

100% of Scheme Tariff*

Unlimited subject to pre-authorisation, use of the Netcare Hospital Group (DSP*), clinical protocols and formulary*

Subject to sub-limits not being exceeded

Failure to comply utilising a DSP* provider will result in non-payment

In case of PMB voluntary use of non-DSP will result in a 10% co-payment* per admission except for emergency admissions

1.01 Accommodation, Theatre Fees, Medicines, Intensive Care
Subject to Pre-authorisation and PMB’s

100% of DSP Tariff*

TTO benefit for 7 days.

Subject to formulary*

1.02 Surgical Procedures including GP and Specialist Consultations.

Subject to Pre-authorisation and PMB’s


100% of Scheme Tariff*

1.03 Diagnostic Investigations
E.g. Radiology, Pathology, MRI/PET/CAT scans etc.
Subject to Clinical protocols and PMB’s. 

Authorisation must be obtained prior to the examination or within 24 hours in case of emergency.
All specialised radiology subject to pre-authorisation.

100% of Scheme Tariff*

1.04 Blood Transfusions

100% of Scheme Tariff*

1.05 Oncology
Subject to PMB’s as prescribed.  Treatment subject to designated service provider guidelines and pre-authorisation.

100% of DSP Tariff*

Limited to R 287 842 per beneficiary per annum

PMB & Non-PMB Oncology treatment based on DSP* ICON* Standard Protocols

1.06 Psychiatric Treatment including Clinical Psychology
Subject to PMB’s, managed care protocols and pre-authorisation by the Scheme.

All treatment in hospital, including accommodation, medicines, materials, procedures, consultations, and psychiatry/psychology therapy sessions.

100% of Scheme Tariff*

Subject to 21 Days per beneficiary or up to 15 out-patient contacts per annum (Subject to PMB’s)

Non PMB’s – 14 days per family subject to a limit of R 20 511
Payment up to 3 days for Psychologist charging therapy sessions with Psychiatrist in the same admission, thereafter pre-authorisation required with treatment plan.

1.07 Drug & Alcohol Rehabilitation

Subject to PMB’s, Managed care protocols and pre-authorisation


100% of Scheme Tariff*

Limited to R 19 345 per family per annum

1.08 Organ Transplants

Subject to PMB’s and pre-authorisation


100% of Scheme Tariff*

PMB based on Department of Health Protocols, Unlimited

1.09 Dental Hospitalisation
Subject to pre-authorisation, and treatment protocols and PMB’s

100% of Scheme Tariff*

Anaesthetist and Hospital cost is payable from hospital benefit. 
Provider fee subject to available Advanced Dentistry Benefit.
Benefit is payable from hospital benefit only in the following cases:

  • Extensive conservative treatment for children under 7 years of age and more than 3 teeth involved
  • Removal of symptomatic impacted wisdom teeth if pre-authorised as a day case only

1.09.1 Maxillo-facial and Oral Surgery                                



100% of Scheme Tariff*

Maxillo-facial and oral surgery limited to symptomatic wisdom teeth.
Anaesthetist and Hospital cost is payable from hospitalisation:
Removal of symptomatic impacted wisdom teeth if pre-authorised as a day case only.
All other procedures subject to PMB only

1.10 Renal Dialysis

Subject to PMB’s and to pre-authorisation

100% of Negotiated Tariff*

Unlimited benefits for PMB admissions.
Subject to Treatment Protocols and formulary*.

1.11 Sterilisation/Vasectomy

Subject to pre-authorisation


100% of Scheme Tariff*

Sterilisation limited to R 16 000 per beneficiary per annum

1.12 Internal and External Prosthesis
Subject to PMB’s, pre-authorisation and protocols.

 

Back surgery/Spinal procedures instrumentation and disc prostheses including all components and fixation devices
Subject to confirmation that beneficiary has completed a course of conservative back treatment.

 

 

 

Joint replacement: Limited to one event per annum unless sepsis or trauma
(Hip, Knee, Shoulder and Ankle)

 

Aphakic Lenses (Subject to protocol and PMB’s)

 

Cardiac stents

 

Cardiac Valves, Aortic stent grafts, peripheral arterial stents grafts, Single/dual pacemaker

Cardiac resynchronization devices (CRT), Implantable Cardioverter Defibrillators (ICD) with Pacing Capabilities (CRT-D)

 

 

Internal sphincters and stimulators

Neurostimulators/Internal nerve stimulator for Parkinson’s Disease

 

Cochlear implants

Insulin pumps and monthly materials

 

Unlisted prosthesis
Artificial Limbs and external prostheses including artificial eyes

 

 

 

Cardiac Valves, Aortic stent grafts, peripheral aterial stents grafts, Single/dual pacemaker

Cardiac resynchronization devices (CRT), Implantable Cardioverter Defibrillators (ICD) with Pacing Capabilities (CRT-D)

 

Internal sphincters and stimulators

 

Neurostimulators/Internal nerve stimulator for Parkinson’s Disease

 

Cochlear implants

 

Insulin pumps and monthly materials

 

Unlisted prosthesis

 

Artificial Limbs and external prostheses including artificial eyes

100% of Negotiated Tariff*

Limited to R 47 990 per family per annum.

 

Sub-Limits:
Limited to a maximum of 2 levels unless clinically motivated and approved or within PMB protocols. R 23 304 per level subject to overall limit not being exceeded. Maximum 1 event per beneficiary per annum

 

R40 987 per annum. Subject to the overall limit and maximum of one procedure per beneficiary per annum. Excludes cement

R5 707 per lens

 

1 per lesion-maximum 3 lesions
Bare metal stents: R13 984 per stent
Drug eluting stents: R19 811 per stent

 

Subject to overall prosthesis limit and PMB protocols

Implantable Cardioverter Defibrillator (ICD); Subject to Scheme protocol and PMB for primary and secondary prevention
Cardiac Resynchronization Therapy (CRT) with Pacing Capabilities (CRT-D); Subject to Scheme protocol and PMB

 

Subject to overall prosthesis benefit

 

No benefit

 

 

Subject to overall limit for prosthesis benefit

Children under 7 years of age only. Subject to clinical protocols and overall limit

Maximum R13 984subject to overall limit

1.13 Physiotherapy & Biokinetics
Subject to PMB’s, treating doctor referral and pre-authorisation by the auxiliary service provider during the admission period
Subject to Scheme protocols

100% of Scheme Tariff*

1.14 Dietician & Occupational Therapy
Subject to PMB’s, treating doctor referral and pre-authorisation by the auxiliary service provider during the admission period

Subject to Scheme protocols

100% of Scheme Tariff*

1.15 Step Down Facilities
In lieu of hospitalisation
Subject to PMB’s, pre-authorisation and protocols.

100% of Negotiated Tariff*

Limited to 14 days per beneficiary per annum

1.16 Private Nursing
In lieu of hospitalisation
Subject to PMB’s, pre-authorisation and protocols.

100% of Negotiated Tariff*

Limited to 14 days per beneficiary per annum

1.17 Rehabilitation Facilities
Subject to PMB’s, pre-authorisation and protocols.

100% of Negotiated Tariff*

Limited to 14 days per beneficiary per annum

1.18 Circumcision
Subject to pre-authorisation

100% of Scheme Tariff*

In and Out of hospital

1.19 Hyperbaric Oxygen Therapy
Subject to PMB’s, pre-authorisation and protocols.

100% of Negotiated Tariff*

Limited to R 42 536 per family per annum

1.20 Negative pressure wound therapy
Subject to PMB’s, pre-authorisation and protocols.

100% of Negotiated Tariff*

Limited to R 26 803 per family per annum

1.21 Medication for Age Related Macular Degeneration
Subject to PMB’s, pre-authorisation and Scheme formulary* and protocol

100% Negotiated Tariff

1.22 Back Surgery
Subject to PMB’s, pre-authorisation and protocols.

100% of Scheme Tariff*

R 5 000 co-payment* applicable for all non-PMB spinal surgery

1.23 Stereotactic Radio-Surgery
Subject to PMB’s, pre-authorisation and protocols.
Only Covered for Primary Central Nervous System Tumours

100% of Scheme Tariff*

1.24 Laparoscopic Hospitalisation and Associated Costs
Subject to PMB’s, pre-authorisation and protocols.
Performed in a Day Hospital or as a day case

100% of Scheme Tariff*

Laparoscopic Hospitalisation & Associated costs will attract a R5 592 except for the following circumstances where no co-payment* will apply:

  • Purely diagnostic laparoscopy
  • Aspiration/excision ovarian cyst
  • Lap-appendicectomy
  • Repair of recurrent or bilateral inguinal hernias

1.25 Exclusions for Hospital Admissions & Treatment Related to:

(In conjunction with the Overall Scheme Exclusion List and subject to PMB’s)
Refer to Scheme Exclusion list

1.26 Deductible* of R5000 will apply to the below procedures in-hospital except for PMB Conditions

Deductible* of R 5 000 will apply to the below procedures in-hospital except for PMB Conditions

  • Joint Replacement
  • Umbilical Hernia Repair
  • Hysterectomy
  • Functional Nasal Surgery
  • Elective caesarean section

DAY HOSPITAL PROCEDURES

OPTION

VALUE CORE 2020

Day Hospital Procedures
Procedures to be done at Designated Service Provider (DSP*) hospital network
Subject to pre-authorisation

Subject to Scheme Tariff*

  1. Umbilical and Inguinal hernia repair
  2. Colonoscopy
  3. Cystoscopy
  4. Gastroscopy and Oesophagoscopy
  5. Hysteroscopy
  6. Grommets
  7. Termination of pregnancy
  8. Breast biopsy
  9. Cataracts
  10. Circumcision
  11. ERCP
  12. Haemorrhoidectomy
  13. Vasectomy
  14. Tubal Ligation
  15. Excision of extensive skin lesions or repair of wounds and skin grafts
  16. Dental procedures
  17. Repair nail bed & Removal of toenails
  18. Minor orthopaedic procedures such as tennis elbow, dupuytren’s contracture, trigger finger, ganglion, carpal tunnel syndrome
Minor Gynaecological procedures – cone biopsy, colposcopy, D&C

Benefits (Out of hospital)

GENERAL PRACTITIONERS AND SPECIALIST

OPTION

VALUE CORE 2020

2.1 Consultations (Out-of-Hospital – Including General Practitioners, Specialist and Outpatient Facilities)

100% of Scheme Tariff*

General Practitioner Consultations:
10 GP Visits per Beneficiary
Limited to 20 GP Visits per Family per Annum.

Specialist Consultations:
Member:  3 Visits
Member + 1 = 5 Visits
Member + 2 + = 7 Visits

Specialist consultations require GP referral or payment will made at GP rates, except for:

  • Paediatricians
  • Gynaecologists

2.2 Diagnostic Investigations
Subject to PMB’s and protocols.

All specialised radiology subject to pre-authorisation.

100% of Scheme Tariff*

Pathology:
Limited to R 2 779 per beneficiary per annum

Radiology:
Limited to R 2 162 per beneficiary per annum

MRI/PET/CAT scans:
Limited to 2 scans per beneficiary per annum

Subject to pre-authorisation

MEDICINES & INJECTION MATERIAL

OPTION

VALUE CORE 2020
3.1 Acute Medicines


 

100% of Reference Price*
Limited to R 5 442 per beneficiary and R 11 046 per family per annum

Subject to medicine formulary* and Protocols, including Materials

Homeopathic Medication excluded
Network Provider Only

3.2 PMB Chronic Disease List Medicines
PMB’s subject to registration and pre-authorisation with the Schemes preferred provider.
Chronic Medication to be Obtained from Preferred Provider Network.

Subject to renewal of prescription every six months.

100% of Reference Price*
Unlimited

Subject to pre-authorisation, treatment protocols and medicine formulary*.

Non-formulary products will incur a 30% co-payment* where these are obtained voluntarily* by beneficiaries.

Benefit Initially payable from limit 3.3 below.

3.3 Other Chronic (Non CDL) Medicines
PMB’s subject to registration and pre-authorisation with the Schemes preferred provider.
Chronic Medication to be Obtained from Preferred Provider Network.

Subject to renewal of prescription every six months.


100% of Reference Price*

R 6 917 per beneficiary Limited to
R 13 960 per family per annum

Subject to pre-authorisation, treatment protocols and medicine formulary*

Non-formulary products will incur a 30% co-payment* where these are obtained voluntarily* by beneficiaries.

3.4 Pharmacy Advised Treatment (PAT)
Over the Counter Medication
Consultation with Pharmacist, restricted to Schedule 0, 1 and 2 medicines.

PAT subject to acute benefit limit

100% of Reference Price*

Limited to R 2 021 per family per annum
Maximum R 156 per script
Included in Limit 3.1 above
Network Provider Only

3.5 Contraceptive benefit

100% of Reference Price*

Limited to R 1 399 per family per annum. Subject to oral, injectable and patch contraceptives only

Subject to the contraceptive formulary*
Network Provider Only

OPTICAL BENEFIT
Contact the Schemes Preferred Provider Network for availability and Locality of Network Optometrists

OPTION

VALUE CORE 2020

4.1 Spectacle Lenses:  In Network
Benefit applicable to members who utilize the Scheme’s Preferred Provider Network Optometrists only

Limited to one pair of spectacles per beneficiary every 24 months


 

100% of DSP Tariff *

R 185 per lens – clear single vision
or
R 420 per lens – clear bifocal
or
R 420 per lens – base multifocal
Fixed tints up to 35%

No benefit for contact lenses if spectacles purchased

4.2 Contact Lenses:  In Network
Benefit applicable to members who utilize the Scheme’s preferred provider network optometrist only

One claim per beneficiary every 24 months

Subject to optical protocol


100% of DSP Tariff*

R 1 810 per beneficiary every 24 months

No benefit for spectacles if contact lenses purchased.

One claim per beneficiary every 24 months

4.3 Frames/Lens Enhancements:  In Network
A frame cannot be claimed alone or with contact lenses.
Benefit applicable to members who utilize the Scheme’s preferred provider network optometrist only

One claim per beneficiary every 24 months

100% of DSP Tariff*

R 795 per beneficiary

4.4 Eye Tests:  In Network
Benefit applicable to members who utilize the Scheme’s preferred provider network optometrist only One claim per beneficiary every 24 months



100% of DSP Tariff*

One comprehensive consultation per beneficiary every 24 months

DENTISTRY BENEFIT

OPTION

VALUE CORE 2020

5.1 Conservative Dentistry (Dentist and Dental therapist)


 

100% of Scheme Tariff*
Unlimited
Consultations, Fillings, Extractions
Two (2) root canal treatments per family per annum

Preventative scale and polish.
Fluoride treatment limited to beneficiaries below the age of 12 years

Conscious sedation for children up to the age of 12 years

Root Canal treatment included in conservative dentistry

X-rays intra-oral covered
Panoramic Radiographs limited to 1 per beneficiary every 24 months

Subject to treatment protocols and pre-authorisation for extensive treatment
Contracted Network Provider Only

5.2 Advanced Dentistry

Subject to pre-authorisation by the Scheme and treatment protocols. 

Failure to obtain pre-authorisation will result in no payment.


100% of Scheme Tariff*

R 4 452 per beneficiary limited to R 6 363 per family per annum.
Crowns, Impacted wisdoms and Orthodontics

Partial metal frame dentures
Subject to above available limit
Limited to 1 set per beneficiary every 5 years

Acrylic (Plastic) Dentures
Subject to above available limit.
Limited to 1 per beneficiary every 4 years

Contracted Network Provider Only

5.3 Maxillo-Facial & Oral, including Dental Surgery
(Consultations, Surgical procedures and Operations) Subject to PMB’s, pre-authorisation and protocols.

100% of Scheme Tariff*

(included in limit 5.2)
Benefit is payable from hospitalisation in cases of accidents, injury, congenital abnormalities and oncology related procedures only.

AUXILIARY BENEFIT

OPTION

VALUE CORE 2020

6.1 ALTERNATIVE SERVICES
Homeopathy, Naturopathy, Chiropractor and Podiatry

100% of Scheme Tariff*

Collectively limited to R 3 753 per family per annum
Medicine dispensed limited to Acute Medication Limit (3.1).

Homeopathic Medication Excluded

6.2 REMEDIAL AND OTHER THERAPIES
Audiology, Speech therapy, Dieticians, Hearing Aid Acousticians, Occupational Therapy, Orthotics, Social Workers and Speech Therapy

100% of Scheme Tariff*

Collectively limited to R 3 625 per family per annum

6.3 PHYSIOTHERAPY OUT OF HOSPITAL Biokinetics & Physiotherapy

100% of Scheme Tariff

R 1 701 per beneficiary limited to R 2 820 per family per annum.

APPLIANCES

OPTION

VALUE CORE 2020

7. Appliances
E.g. Hearing Aids, Wheelchairs and calipers etc.

Subject to pre-authorisation

100% of Negotiated Tariff*
Limited to R 14 007 per family per annum

  • Stoma Care – Subject to a sub limit of R 7 225 per family per annum
  • Wheelchairs – one claim per Beneficiary every 36 months subject to pre-authorisation.
  • Hearing aids – one claim per beneficiary every 24 months subject to pre-authorisation.
  • Blood pressure
    monitors-Subject to a sub limit of R550 for beneficiaries registered for Hypertension

OTHER BENEFITS

OPTION

VALUE CORE 2020

8.1 Air/Road Ambulance & Emergency Services

The Schemes preferred provider must be contacted should you require an Ambulance – failure to adhere to this could result in you being held liable for costs incurred.


100% of Scheme Tariff*
24-hour access to Call Centre including telephonic Nurse advise line.
Emergency: 
Subject to authorisation within 72 hours after the emergency. 

  • Emergency response by road or air to scene of incident and transfer from scene, to closest, most appropriate facility
  • Escort return of stranded minors can be arranged

Non-emergency:  Subject to pre-authorisation beforehand.
•           Facilitation of medically justified inter-facility transfers. Inter-hospital transfers must be done by preferred provider only.

•           Medical repatriation

8.2 Psychology & Psychiatry Treatment
Subject to PMB’s and referral from GP or Specialist, failure to do so will result in no payment.
Subject to confirmed diagnosis, treatment plan and managed care protocols



100% of Scheme Tariff*

R 2 948 per beneficiary, Limited to R 7 412 per Family.

8.3 Infertility
Subject to PMB’s at State/Public Facilities



100% of Scheme Tariff*

8.4 Hospice and Private Nursing

Subject to PMB’s, pre-authorisation and protocols.



100% of Negotiated Tariff*

Subject to combined limit of a maximum period of 14 days per annum-except for PMB’s

HOSMED BAMBINO PROGRAM
Hosmed cares about its maternity mothers and this program aims to assist them during this time by providing advice and benefits.

OPTION

VALUE CORE 2020

9.1 Hosmed Bambino Program
Subject to Registration on Hosmed Bambino Program.
At 7 months of maternity the Scheme offers a free maternity bag.


100% of Scheme Tariff*

PMB Based on Clinical Protocols

9.2 Hospital Confinement:



NVD – Limited to 2 days
Caesarean – Limited to 3 days

9.3 Home Delivery:
By Registered Midwife pre-authorisation required



Limited to R 5 826/pregnancy. 

100% of Negotiated Tariff*

9.4 Maternity Ultrasounds(s):



Limited to 2 2D ultrasounds per pregnancy for In and Out of Hospital

9.5 Maternity Visit(s):



Additional 6 GP consultations and 3 specialist consultations per Pregnancy (Once these limits have been reached further ante-natal consultations will be paid from the day-to-day benefit)

9.6 Antenatal Pathology Screening:
Haemoglobin, Syphilis, Chlamydia, Bacteriuria, Hepatitis B and Rhesus incompatibility



100% of Scheme Tariff*

9.7 Antenatal Classes:
By Registered Nurse



No Benefit

9.8 Immunisation benefit



Immunisation as per the Immunisation schedule by the Department of Health up to 12 months of age

HOSMED WE CARE

OPTION

VALUE CORE 2020

10.1 Wellness Programme


100% of Scheme Tariff*

  • 1 Free Pap Smear for Females over 18 Years per beneficiary per Annum
  • 1 Free Mammogram for Females over 40 Years per beneficiary per Annum
  • 1 Free PSA for Males over 40 Years per beneficiary per Annum
  • 1 Free Cholesterol Test over 20 Years per beneficiary per Annum
  • 1 Free Flu Vaccine per beneficiary per Annum
  • 1 Free Blood Sugar Test over 15 Years per beneficiary per Annum
  • 1 Free Colon Cancer Blood Test over 50 years per beneficiary per Annum
  • 1 Free Blood Pressure test per beneficiary per Annum
  • 1 Free HIV Test per beneficiary per Annum
  • Free HPV vaccination per beneficiary between 9 and 12 years of age
  • 1 Free Pneumococcal vaccination per beneficiary over the age of 65 years of age per Annum

10.2 HIV/AIDS Management Programme
Benefits are subject to PMB’s and registration on the Scheme’s programme



100% of Scheme Tariff*

Treatment is subject to the treatment Care plan and clinical protocols per CDL

10.3 Chronic Disease Management Programme (CDL)

Benefits are subject to registration on the Scheme’s programme



100% of Scheme Tariff*

Treatment is subject to the treatment Care plan and clinical protocols per CDL

OVERALL ANNUAL LIMIT OUT OF HOSPITAL

OPTION

VALUE CORE 2020

11.  Overall Annual Limit on Out of Hospital Benefits For:
 
3.1 Acute Medicines
5.3 Advanced Dentistry
6.1   Alternative Services (Homeopathy,
         Naturopathy etc)
6.2   Remedial & Other Therapies
         (Audiology, Dieticians etc),                                                            
6.3 Biokinetics & Physiotherapy

8.2 Psychology & Psychiatry Treatment


Collectively Limited to per Family per annum:

M         -     R 9 906
M+1     -     R 20 918
M+2     -     R 22 754
M+3     -     R 25 200

  • Scheme Tariff*:            As defined in Rule 4.9.68

“the Tariff determined or adopted by the Board in respect of the payment for healthcare services rendered to Beneficiaries by service providers who are not subject to a DSP* Tariff or a Negotiated Tariff, determined using the 2006 National Health Reference Price List (NHRPL) with the application of a year on year inflationary increase, as contemplated in Rule 15.11”

  • DSP*:                             As defined in Rule 4.9.28

“Designated Service Provider”

  • DSP Tariff*:                   As defined in Rule 4.9.29

“The fee determined in terms of an agreement between the Scheme and a service provider or a group of service providers in respect of the payment for the relevant health services”

  • Negotiated Tariff*:     As defined in Rule 4.9.54

“a Tariff negotiated and agreed ad hoc for services rendered between the Scheme and a healthcare service provider for services rendered by the relevant service provider to the Scheme or to Beneficiaries and which is different from the Scheme Tariff;”

  •  Reference Price*:        As defined in Rule 4.9.66

“The maximum reimbursable price for a list of generically similar or therapeutically equivalent products with a cost lower than that of the original medicine.” 

  • Formulary*:                  As defined in Rule 4.9.38

“A list of medicines that the Scheme will pay for the treatment of acute and chronic conditions as per the benefit option the member has selected”

  • Co-payment*:               As defined in Rule 4.9.21

“a specified rand amount a beneficiary will be liable to self-fund for the cost of a specified medical treatment as stipulated in the benefits per option”

  • Deductible*:                 As defined in Rule 4.9.26

 “A specific percentage or rand amount of the total hospital account related to a specific procedure as stipulated in the benefits per option that the beneficiary is liable for”

  • ICON*:                           Independent Clinical Oncology Network

  • Voluntarily*:               Of one’s own free will.

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