BENEFIT BROCHURE. #caring4life

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1 BENEFIT BROCHURE 2017 #caring4life

2 WHY SIZWE? We offer a range of medical aid products, starting with a network healthcare product ideal for lower-income earners right up to premium medical aid products for high-income earners. To assist you in making an informed choice on our various benefit options, have a look at what each option offers. DISCLAIMER: This brochure is for information purposes only and does not supersede the rules of the Fund. A full set of the rules is available on our website:

3 2017 HEALTH OFFERINGS HOSPITAL The Hospital Care Option offers peace of mind knowing that in the event of hospitalisation, extensive cover is available at any private hospital. In addition, the Hospital Care Option provides cover for 27 Chronic Disease List (CDL) conditions. Our Affordable Care Option offers generous comprehensive cover with unlimited hospitalisation in any private hospital. It also covers additional chronic conditions with specialised dentistry and preventative benefits. This option is suitable for young and healthy families. Our Full Care Option offers comprehensive cover and generous benefits to cover families and individuals who need access to unlimited hospitalisation at any private hospital. This option also offers additional chronic conditions, specialised dentistry, GPs, specialists, acute medication, preventative care benefits and more rich benefits. This is the only option which offers Top-up cover when in hospital up to 200% of the Sizwe rate. This is our entry-level option. Gomomo Care Option provides excellent value for money. GPs, specialists and acute medicines are accessible through a selected network provider. Dentistry, radiology and pathology are also available from a network provider. No overall limit for hospitalisation at any private hospital. Covers the 27 Chronic Disease List (CDL) conditions. Primary Care Option offers good value for money with unlimited hospitalisation at any private hospital. This traditional option has generous day-to-day benefits which cover acute medicines, GPs, specialists, radiology, pathology and more to meet the needs of any family. 2

4 OUT OF HOSPITAL BENEFITS Prescribed Minimum s () are paid at cost.

5 HOSPITAL OPTION STRUCTURE Major Medical only Major Medical; Day-to-day through network Major Medical; Day-to-day Major Medical; Day-to-day Major Medical; Day-to-day OUT OF HOSPITAL BENEFITS - Prescribed Minimum s () are paid at cost. OVERALL DAY-TO-DAY LIMIT COVERS GENERAL PRACTITIONERS, SPECIALISTS (EXCLUDING PSYCHIATRISTS), ACUTE MEDICINES, PATHOLOGISTS, PHYSIOTHERAPISTS AND RADIOLOGISTS, subject to managed care rules, formulary and clinical protocols of the DSP (Designated Service Provider) M: R5 390 M+1: R7 980 M+2: R9 330 M+3: R M+4: R M+5: R M+6+: R M: R9 330 M+1: R M+2: R M+3: R M+4: R M+5: R M+6+: R M: R M+1: R M+2: R M+3: R M+4: R M+5: R M+6+: R GENERAL PRACTITIONERS ADDITIONAL GP VISITS PER FAMILY ON THE OPTION ONLY. Select a GP as your chosen doctor for all GP visits Out-of-area: 4 per beneficiary, subject to pre-authorisation Limited number of visits M: 4 M+1: 9 M+2: 12 M+3: 14 M+4: 15 M+5: 16 M+6+: 17 Limited number of visits M: 7 M+1: 14 M+2: 16 M+3: 18 M+4: 20 M+5: 21 M+6+: 22 Limited number of visits M: 12 M+1: 20 M+2: 25 M+3: 29 M+4: 30 M+5: 31 M+6+: 32 SPECIALISTS (EXCLUDING PSYCHIATRISTS), ACUTE MEDICINE, PATHOLOGISTS, RADIOLOGISTS AND PHYSIOTHERAPISTS All visits are subject to mandatory referral from a GP All visits are subject to mandatory referral from a GP All visits are subject to mandatory referral from a GP M: 2 M+1: 6 M+2: 7 M+3: 8 M+4: 9 M+5: 10 M+6+: 11 M: 4 M+1: 8 M+2: 9 M+3: 10 M+4: 11 M+5: 12 M+6+: 13 M: 7 M+1: 12 M+2: 15 M+3: 16 M+4: 17 M+5: 19 M+6+: 20 4

6 HOSPITAL OUT OF HOSPITAL BENEFITS - Prescribed Minimum s () are paid at cost. ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY-TO-DAY BENEFIT WITH THE FOLLOWING SUB-LIMITS R280 over-the-counter medication per family within DSP Required benefit for the year. Out of area medicines: no limit, subject to formulary. Within day-to-day with sub-limits: M: R1 680 M+1: R3 030 M+2: R3 370 M+3: R3 820 M+4: R3 930 M+5: R4 150 M+6: R4 490 Within day-to-day with sub-limits: M: R3 250 M+1: R4 940 M+2: R5 840 M+3: R6 290 M+4: R7 190 M+5: R7 420 M+6: R7 640 Within day-to-day with sub-limits: M: R4 380 M+1: R7 750 M+2: R8 990 M+3: R M+4: R M+5: R M+6: R RADIOLOGY AND RADIOGRAPHY Reimbursement Rate GENERAL Risk benefit, subject to protocols, managed care rules, pre-authorisation and basic radiology only Risk benefit, within day-to-day limit Combined limit with pathology Risk benefit, within day-to-day limit Combined limit with pathology Risk benefit, within day-to-day limit Combined limit with pathology SPECIALISED Combined In-Hospital and Out of Hospital R6 770 per family per annum Combined In-Hospital and Out of Hospital R per family per annum Combined In-Hospital and Out of Hospital R per family per annum Combined In-Hospital and Out of Hospital R per family per annum PHYSIOTHERAPY, limited to R2 400 per family subject to PATHOLOGY Risk benefit, within day-to-day limit Risk benefit, within day-to-day limit Risk benefit, within day-to-day limit

7 HOSPITAL OUT OF HOSPITAL BENEFITS - Prescribed Minimum s () are paid at cost. PATHOLOGY (continued) Subject to DSP, protocols, managed care, pre-authorisation and basic pathology only Combined limit with basic radiology M: R1 000 M+1+: R1 900 Combined limit with basic radiology M: R1 100 M+1+: R2 200 Combined limit with basic radiology M: R1 300 M+1+: R2 750 DENTISTRY Conservative Dentistry: Subject to Dental Management Programme Limit per beneficiary or family per annum M: R2 630 M+1: R3 030 M+2: R3 290 M+3: R3 560 M+4: R3 810 M+5: R4 070 M+6+: R4 470 R2 800 per family per annum 2 general check-ups a year per beneficiary Subject to managed care protocols on restorative work R3 200 per family per annum 2 general check-ups a year per beneficiary Subject to managed care protocols on restorative work R3 600 per family per annum 2 general check-ups a year per beneficiary Subject to managed care protocols on restorative work Subject to managed care rules, formulary and protocols of the DSP Root canal treatment: managed care protocols apply Root canal treatment: managed care protocols apply Root canal treatment: managed care protocols apply Specialised Dentistry Plastic dentures 1 full or partial set per beneficiary in a 4 year period 1 full or partial set per beneficiary in a 4 year period 1 full or partial set per beneficiary in a 4 year period Metal dentures 2 partial metal frames per beneficiary in a 5 year period (limited to 1 family member per annum) 2 partial metal frames per beneficiary in a 5 year period (limited to 2 family members per annum) Orthodontic treatment Limited to individuals from age 9-18 years; 35% co-payment Limited to individuals from age 9-18 years Crowns 1 crown per family per annum 3 crowns per family per annum 6

8 HOSPITAL OUT OF HOSPITAL BENEFITS - Prescribed Minimum s () are paid at cost. Specialised Dentistry (continued) Implants R3 500 per implant per annum, subject to 2 implants per beneficiary in a 5 year period OPTICAL BENEFITS ACCESSED THROUGH PPN Limit M: R1 080 M+1: R1 240 M+2: R1 370 M+3+: R1 970 No Limit No Limit No Limit Eye test 1 test per beneficiary in a 2 year period at any network provider 1 test per beneficiary in a 2 year period at any PPN Optometrist 1 test per beneficiary in a 2 year period at any PPN Optometrist 1 test per beneficiary in a 2 year period at any PPN Optometrist Frames Limited to R465 per beneficiary for frames in a 2 year period cycle at DSP R300 per beneficiary in a 2 year period R300 per beneficiary in a 2 year period R300 per beneficiary in a 2 year period Single Focus Lenses Subject to managed care rules, formulary and clinical protocols of the DSP R165 per lens per beneficiary in a 2 year period R165 per lens per beneficiary in a 2 year period R165 per lens per beneficiary in a 2 year period Bi-Focal Lenses Subject to managed care rules, formulary and clinical protocols of the DSP R360 per lens per beneficiary in a 2 year period R360 per lens per beneficiary in a 2 year period R360 per lens per beneficiary in a 2 year period Multi-Focal Lenses Subject to managed care rules, formulary and clinical protocols of the DSP R450 per lens per beneficiary in a 2 year period R660 per lens per beneficiary in a 2 year period R660 per lens per beneficiary in a 2 year period Contact Lenses Subject to managed care rules, formulary and clinical protocols of the DSP R525 per beneficiary R525 per beneficiary R525 per beneficiary Refractive surgery incl, radial keratotomy R5 980 per family per annum R per family per annum

9 HOSPITAL OUT OF HOSPITAL BENEFITS - Prescribed Minimum s () are paid at cost. MENTAL HEALTH Psychiatrists, Clinical and Counselling Psychologists - only if related to mental health, excludes Educational Psychologists, Social Workers and Registered Counsellors ; subject to Subject to pre-authorisation and managed care rules Risk benefit Risk benefit Risk benefit R4 910 per family R8 140 per family R per family AUXILIARY SERVICES Audiologists, Chiropractors, Dieticians, Homeopaths, Occupational Therapists, Podiatrists, Speech Therapists, Social Workers, Educational Psychologists, Biokineticist and Registered Counsellors. R2 400 per family unless PMB Risk benefit M: R960 M+1+: R1 550 Risk benefit M: R1 440 M+1+: R2 510 Risk benefit M: R2 630 M+1+: R4 420 MATERNITY Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant, subject to registration on the programme Ante-natal consultations Subject to clinical protocols/care plans. Limited to 9 ante-natal visits by either GP or Midwife per pregnancy; 2 Obstetrician visits per referral by GP or Midwife Subject to managed care rules, formulary and clinical protocols of the DSP 9 GP/Midwife visits; 2 Specialist visits 9 GP/Midwife visits; 4 Specialist visits 9 GP/Midwife visits; 6 Specialist visits Pregnancy scans 2 x 2D scans per pregnancy 2 x 2D scans per pregnancy 2 x 2D scans per pregnancy 2 x 2D scans per pregnancy 2 x 2D scans per pregnancy. 8

10 CHRONIC BENEFITS

11 HOSPITAL CHRONIC BENEFITS: Subject to pre-authorisation. CHRONIC MEDICINES: subject to registration on the Chronic Medicine Programme subject to pre-authorisation, preferred providers and treatment protocols. PMB At Cost At Cost At Cost At Cost At Cost Non-PMB Cover for 27 PMB chronic conditions R7 460 per beneficiary. Cover for 27 PMB chronic conditions Cover for 27 PMB chronic conditions R5 260 per beneficiary. Cover for 27 PMB chronic conditions and 13 additional conditions R per beneficiary. Cover for 27 PMB chronic conditions and 33 additional conditions HIV/AIDS Members are encouraged to register with the HIV/AIDS Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for monitoring purposes Subject to treatment protocols and No limit, subject to treatment protocols and No limit, subject to treatment protocols and No limit, subject to treatment protocols and No limit, subject to treatment protocols and 10

12 IN-HOSPITAL BENEFITS

13 HOSPITAL IN-HOSPITAL BENEFITS %BENEFITS Top-up cover (must be applied for within 3 months of hospitalisation) Sizwe negotiated tariff rate + 200% AMBULANCE SERVICES 100% cost as authorised by EUROP ASSIST SA (Telephone number: ) PRIVATE HOSPITALS AND NURSING HOMES Subject to treatment and case management protocols and. Pre-authorisation required unless it is a medical emergency Accommodation A co-payment of R1 500 will apply to all unauthorised admissions unless it is an emergency. Unlimited at any private hospital A co-payment will apply to all unauthorised admissions unless it is an emergency. Unlimited at any private hospital A co-payment will apply to all unauthorised admissions unless it is an emergency. Unlimited at any private hospital A co-payment will apply to all unauthorised admissions unless it is an emergency. Unlimited at any private hospital A co-payment will apply to all unauthorised admissions unless it is an emergency. Unlimited at any private hospital Clinical limitations and exclusions None Advanced laparoscopic, reconstructive & cardiac surgery including stents, joint replacements, spinal surgery, breast reconstructions and augmentations unless a PMB Advanced laparoscopic, reconstructive & cardiac surgery including stents, joint replacements, spinal surgery, breast reconstructions and augmentations unless a PMB None None DENTAL HOSPITALISATION Subject to pre-authorisation, Dental Management Programme and clinical protocols subject to R1 500 co-payment on some options 100% Sizwe Dental Tariff (SDT) Rate General anaesthetic Pre-authorisation is required, subject to managed care protocols Pre-authorisation is required, subject to managed care protocols and limited to level of care Pre-authorisation is required, subject to managed care protocols Pre-authorisation is required, subject to managed care protocols Pre-authorisation is required, subject to managed care protocols Laughing gas in dental rooms 12

14 HOSPITAL IN-HOSPITAL BENEFITS DENTAL HOSPITALISATION (continued) Subject to pre-authorisation, Dental Management Programme and clinical protocols subject to R1 500 co-payment on some options Conscious sedation in rooms Subject to pre-authorisation and managed care protocols Subject to pre-authorisation and limited to PMB level of care Subject to pre-authorisation and managed care protocols Subject to pre-authorisation and managed care protocols Subject to pre-authorisation and managed care protocols GENERAL PRACTITIONER AND MEDICAL SPECIALIST for consultations and visits in-hospital for consultations and visits in-hospital for consultations and visits in-hospital for consultations and visits in-hospital for consultations and visits in-hospital AUXILIARY SERVICES Dietician, speech therapy, occupational therapy Subject to PMB, clinical protocols and pre-authorisation Subject to clinical protocols and pre-authorisation Subject to pre authorisation and, limited to dieticians, speech therapy, occupational therapy and clinical technology Subject to pre authorisation and Subject to pre-authorisation and PHYSIOTHERAPY Pre-authorisation and managed care protocols apply MATERNITY Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant Hospitalisation (public or private hospitals) delivery, post-natal services and midwifery

15 HOSPITAL IN-HOSPITAL BENEFITS BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS, subject to and annual limit of R per family, subject to 100% of the cost of blood transfusions and blood replacement products, limited to 100% of the cost of blood transfusions and blood replacement products, limited to 100% of the cost of blood transfusions and blood replacement products, limited to PROSTHESIS % limit: pre-authorisation and managed care protocols apply, subject to an annual limit of R per family; maximum of 3 cardiac stents and 2 vascular stents per family per annum, subject to an annual limit of R per beneficiary per annum, Subject to pre-authorisation, treatment protocols and Maximum of 3 cardiac stents and 2 vascular stents per family per annum Annual limit: R % of cost Subject to pre-authorisation, treatment protocols and Maximum of 3 cardiac stents and 2 vascular stents per family per annum Annual limit: R % of cost Subject to pre-authorisation, treatment protocols and Maximum of 3 cardiac stents and 2 vascular stents per family per annum Annual limit: R ONCOLOGY Overall limit of R per family 100% of the cost of materials used in radiotherapy and chemotherapy subject to Overall limit of R per family Overall limit of R per family Overall limit of R per family RADIOLOGY AND RADIOGRAPHY, Specialised Radiology (MRI/CAT scan/ Anglogram) Pre-authorisation and managed care protocols Limited to R per family per annum Combined in-hospital and out-of-hospital limit Limited to R6 770 per family per annum Combined in-hospital and out-of-hospital limit Limited to R per family per annum Combined in-hospital and out-of-hospital limit Limited to R per family per annum Combined in-hospital and out-of-hospital limit Limited to R per family per annum Combined in-hospital and out-of-hospital limit 14

16 HOSPITAL IN-HOSPITAL BENEFITS RADIOLOGY AND RADIOGRAPHY (continued) Interventional radiology Payable from the hospital limit, subject to pre-authorisation and clinical protocols Payable from the hospital limit, subject to pre-authorisation and clinical protocols Payable from the hospital limit, subject to pre-authorisation and clinical protocols Payable from the hospital limit, subject to pre-authorisation and clinical protocols PATHOLOGY MENTAL HEALTH Psychiatry hospitalisation, limited to 21 days per beneficiary per annum Limited to 21 days per beneficiary per annum Limited to 21 days per beneficiary per annum Limited to 21 days per beneficiary per annum Limited to 21 days per beneficiary per annum Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to Alcoholism, drug addiction, narcotism: subject to, pre-authorisation and minimum benefit package 3 days withdrawal treatment and up to 21 days rehabilitation at an appropriate facility 3 days withdrawal treatment and up to 21 days rehabilitation 3 days withdrawal treatment and up to 21 days rehabilitation 3 days withdrawal treatment and up to 21 days rehabilitation 3 days withdrawal treatment and up to 21 days rehabilitation ORGAN TRANSPLANT AND RENAL DIALYSIS Limited to R per family per annum No limit and restricted to level of care Subject to Subject to Subject to

17 HOSPITAL IN-HOSPITAL BENEFITS ORGAN TRANSPLANT AND RENAL DIALYSIS (continued) RENAL DIALYSIS Reimbursement Rate Restricted to, subject to pre-authorisation, minimum benefit package, treatment protocols and DSP Restricted to, subject to pre-authorisation, minimum benefit package, treatment protocols and DSP Restricted to, subject to pre-authorisation, minimum benefit package, treatment protocols and DSP Restricted to, subject to pre-authorisation, minimum benefit package, treatment protocols and DSP Restricted to, subject to pre-authorisation, minimum benefit package, treatment protocols and DSP REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY Limited to R5 980 per family per annum Limited to R per family per annum OVERALL ANNUAL LIMIT Unlimited Unlimited Unlimited Unlimited Unlimited HOSPITAL REIMBURSEMENT RATE with top-up cover PROVIDER NETWORK Any Any Any Any Any 16

18

19 PREVENTATIVE BENEFITS 18

20 HOSPITAL PREVENTATIVE BENEFITS WELLNESS SCREENING CONSULTATIONS Subject to a family limit of R1 920 for flu vaccine and pneumococcal vaccine. Mammograms: once in a 2 year cycle for females over 40 years Papsmear: once in a 2 year cycle for females over 21 years Prostate-Specific Antigen (PSA): once per year for males over 40 years Access through HIP (Health Improvement Programme) Subject to a family limit of R1 920 for flu vaccine and pneumococcal vaccine. Mammograms: once in a 2 year cycle for females over 40 years Papsmear: once in a 2 year cycle for females over 21 years Prostate-Specific Antigen (PSA): once per year for males over 40 years Subject to a family limit of R1 920 for flu vaccine and pneumococcal vaccine. Mammograms: once in a 2 year cycle for females over 40 years Papsmear: once in a 2 year cycle for females over 21 years Prostate-Specific Antigen (PSA): once per year for males over 40 years Subject to a family limit of R2 500 for flu vaccine and pneumococcal vaccine. Mammograms: once in a 2 year cycle for females over 40 years Papsmear: once in a 2 year cycle for females over 21 years Prostate-Specific Antigen (PSA): once per year for males over 40 years BLOOD SUGAR, CHOLESTEROL, BLOOD PRESSURE, BMI AND HIV R300 Access through HIP R255 R255 R255 ORAL CONTRACEPTIVES R2 490 per family per annum R2 490 per family per annum R2 490 per family per annum OTHER BENEFITS: IN-HOSPITAL OR OUT-OF-HOSPITAL Appliances M: R960 M+1+: R1 550 M: R1 440 M+1+: R2 510 M: R2 510 M+1+: R4 180 Wheelchair Subject to R1 790 per family R2 990 per family R4 170 per family Hearing aids R5 500 per family R8 600 per family R per family Private nursing R4 310 per family R6 430 per family R8 610 per family

21 IMPORTANT CONTACT DETAILS CHRONIC MEDICATION PROGRAMME: Tel: Fax: / HOSPITAL PRE-AUTHORISATION, HOSPITAL BENEFIT MANAGEMENT PROGRAMME: Tel: DENTAL BENEFIT MANAGEMENT: Tel: Fax: WELLNESS PROGRAMME HELPLINE FOR ASTHMA, CARDIOVASCULAR DISEASE, DIABETES AND MENTAL HEALTH: Tel: Fax: HIV/AIDS MANAGEMENT PROGRAMME: Tel: Fax: /56 EUROP ASSISTANCE SA, MEDICAL EMERGENCIES, 24-HOUR AMBULANCE SERVICES AND MEDICAL ADVICE: Tel: SIZWE BABY PROGRAMME: Fax: TIP-OFFS ANONYMOUS FRAUD LINE: Tel: Fax: CHRONIC MEDICATION PROGRAMME: Tel: Fax: /

22 2017 CONTRIBUTIONS EFFECTIVE FROM 01 JANUARY 2017

23 INCOME CODE INCOME BRACKET PRINCIPAL MEMBER ADULT DEPENDANT CHILD O R0 R0 - R10 R R R7 865 R R R R1 R R1 122 R2 060 R1 601 R795 R1 122 R1 623 R1 546 R335 R410 R407 R420 R R R1 988 R1 623 R475 HOSPITAL 650 All R1 700 R1 300 R R0 - R530* R531 - R8 766 R R407 R1 907 R2 326 R407 R1 488 R1 519 R1 519 R407 R480 R R0 - R R R R2 733 R2 843 R2 511 R2 610 R630 R R R3 657 R3 R R R0 - R R R4 210 R4 885 R3 R R4 441 R4 441 R860 R960 * Full-time students only. Terms and conditions apply

24

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