GOMOMO BENEFITS GUIDE. #caring4life

Transcription

1 GOMOMO C A R E 2016 BENEFITS GUIDE #caring4life

2 Gomomo Care is our entry-level option and it provides excellent value for money. General Practitioner s (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 in-hospital at selected network hospitals and it covers the 27 Chronic Disease List (CDL) conditions. Gomomo Care option is suitable for young individuals and families. This option offers comprehensive day-to-day cover from your selected network provider plus an additional 4 visits outside of the network.

3 GOMOMO CARE DAY-TO-DAY BENEFITS GENERAL PRACTITIONERS Subject to managed care rules, formulary and clinical protocols. All beneficiaries must nominate a GP for co-ordination of hospital services. Out of Area Visits 4 visits per beneficiary per year, subject to pre-authorisation SPECIALISTS GP referral to a specialist is manadatory, subject to manged care rules, formulary and clinical protocols ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) Over the counter medication limit RADIOLOGY Subject to managed care rules, formulary and clinical protocols of the Designated Service Provider (DSP) R265 Subject to managed care clinical protocols of the DSP General Radiology/ Radiography Specialised Radiology (separate limit for MRI/CT/Angiograms combined In and Out of Hospital ) R6 360 per family per year PATHOLOGY Subject to managed care clinical protocols of the DSP DENTISTRY Subject to Dental Management Programme - call Member R2 470 Member +1 R2 840 Member +2 R3 090 Member +3 R3 340 Member +4 R3 580 Member +5 R3 820 Member +6 R4 200 Dental Hospitalisation Subject to pre-authorisation, Hospital Management Programme and Disease Management Programme ed to PMBs. Subject to in Hospital OPTICAL Choose either spectacles (frames and lenses) or contact lenses once every 2 years Eye Test 1 test per beneficiary every 2 years Combined Frames and Lenses

4 OPTICAL (continued from previous page) Frame limit MATERNITY Sub-limits Member R1 010 Member+1 R Member+2 R Member+3+ R R465 per beneficiary every 2 years Subject to managed care rules, formulary and clinical protocols of the DSP Ante-Natal Consultations 2 x 2D scans per pregnancy Haemoglobin test Blood grouping test Syphillis test HIV Elisa test AUXILIARY Physiotherapists, Speech Therapists, Clinical Psychologists, Podiatrists, Equipment and External Prosthesis R2 250 per family subject to PMBs CHRONIC BENEFITS CHRONIC MEDICINES R7 000 per beneficiary per year 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 procols IN-HOSPITAL BENEFITS No AMBULANCE Europ Assist SA Pre-authorisation is required % Benefit 100% of cost as authorised by the contracted service provider PRIVATE / PUBLIC HOSPITALS Pre-authorisation is required unless in a medical emergency Subject to Treatment and Case Management Protocols and PMBs. Accommodation 100% Sizwe DSP Rates Out patient care 100% Sizwe Rates for out patient services, materials and medicines

5 PRIVATE / PUBLIC HOSPITALS (continued from previous page) Clinical ations and Exclusions TTO (Medication to take home) HOSPITAL ALTERNATIVES Advanced laparoscopic surgery, reconstructive surgery, joint replacement, cardiac surgery (including cardiac stents), spinal surgery, breast reconstructive surgery ed to a supply of 7 days Subject to Hospital Benefit Management Programme, Disease Management Programme and pre-authorisation. for services rendered at a registered step-down facility, nursing facility and hospice No BLOOD TRANSFUSIONS AND BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS % Benefit 100% of Cost Family No GENERAL PRACTITIONERS No SPECIALISTS No RADIOLOGY for diagnostic procedures performed by a GP or specialist. ed to PMBs Basic Radiology/ Radiography No Specialised Radiology (separate limit for MRI/CT/Angiograms combined in and out of hospital ) R6 360 per family per year PATHOLOGY No HIV pathology tests Falls within the Well-Care HIV/AIDS Management Programme DENTAL HOSPITALISATION See Dentistry Benefit MATERNITY HOSPITALISATION See Maternity Benefit PSYCHIATRIC HOSPITALISATION Subject to pre-authorisation % Benefit 21 days per beneficiary including psychiatric consultations and 6 in-hospital consultations by a Clinical Psychologist. Subject to PMBs

6 ONCOLOGY Subject to pre-authorisation, Treatment Protocols and PMBs PROSTHESIS Subject to pre-authorisation, Treatment Protocols and PMBs Surgical and Non-surgical Family limit R per beneficiary per year AUXILIARY IN HOSPITAL ed to Dieticians, Speech Therapists, Occupational Therapists Subject to clinical protocols and pre-authorisation PHYSIOTHERAPY ALCOHOLISM/DRUG ADDICTION/NARCOTISM Subject to pre-authorisation, Treatment Protocols and PMBs Benefit ORGAN TRANSPLANTS AND RENAL DIALYSIS 3 days withdrawal treatment and 21 days admission at an appropriate facility Subject to pre-authorisation, Treament Protocols and PMBs Subject to PMBs at the DSP GOMOMO CARE CONTRIBUTIONS 2016 Income Bracket Principal Member Adult Dependant Child Dependant R0 - R6 360 R700 R690 R290 R R7 420 R1 030 R1 020 R370 R R9 540 R1 530 R1 420 R370 R R1 890 R1 490 R380 DISCLAIMER: This summary is for information purposes only and does not supercede the rules of the Fund. In the event of any discrepancies between this benefit brochure and the scheme rules, the Rules will prevail. For a copy of the rules go please visit or call us on

7 SIZWE MEDICAL FUND REGIONAL OFFICES JOHANNESBURG 6th Floor, 56 Von Wielligh Street Cnr Albertina Sisulu (formerly Market Street) and Von Wielligh Street, Johannesburg Tel: +27 (11) CAPE TOWN Ground Floor, Shop 13 Norton Rose House 8 Riebeek Street, Cape Town Tel: +27 (21) Fax: +27 (21) DURBAN 7th Floor, Royal Towers 30 Dorothy Nyembe Street Durban, 4000 Tel: +27 (31) Fax: +27 (31) PORT ELIZABETH Ground Floor, Block E, Southern Life Gardens, 70 2nd Avenue, Newton Park Port Elizabeth, 6000 Tel: +27 (41) Fax: +27 (41) WELKOM 429 Stateway Doorn (The Itec Building) Welkom Tel: +27 (57) EMALAHLENI 71 Mandela Drive Cnr Plumer and Mandela Drives (Opposite Lollipop Daycare Centre) Emalahleni Tel: +27 (13)

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