Guide - 2018
A Brief history of Sizwe Medical Fund and Sechaba Medical Solutions In the late 1960s, black (African) doctors in the Rand, which consisted of Johannesburg, Pretoria, the Eastrand and Vereeniging formed themselves into The South African Medical Discussion Group (SAMDG). The group discussed matters of interest in respect of black doctors and their patients, as the South African Medical Association (SAMA) was only open to white membership then. Black specialists could only work as General Practitioners (GPs) with specialist qualifications, as specialist fees were only affordable to medical aid members. Black specialists who worked in public hospitals were not recognised, but were humiliated as they could not give orders to white juniors and white nurses of all ranks. Many black specialists elected to go into exile and practice in the United States of America (USA) and in Canada. The SAMDG met once a month on a Sunday afternoon, hosted by members at their homes. Spouses attended meetings and held their own meeting while members discussed the business of the day. In 1976, the SAMDG which was chaired by Dr. Mzamane of Katlehong in the Eastrand appointed its executive team. It was in 1976 that Dr. Mokgesi who had a practice in Sebokeng, met a white colleague, Dr. Loots at a clinical meeting at the Johannesburg General Hospital. He suggested that it would be good to register a medical aid scheme and a private hospital for blacks. He introduced the matter to some government officials who would make registration of a black company in the urban areas possible, as this was not permissible then. The matter of a medical aid scheme and a private hospital for blacks was discussed by the SAMDG and accepted. Dr. Motlana, who was very influential in black circles and highly respected by business leaders and politicians of all sectors of South African society, assumed leadership of the group. In serving as the chairman of the group, he sold the idea to black doctors to take up shares and negotiated with white business to support the initiative. In 1978, the Kwacha Group (Kwacha meaning Day Break in Chewa - a Malawian language) was registered with 38 shareholders. Dr. Loots was the only white shareholder and also served on the board of directors. Sizwe Medical Fund was registered after shareholders had raised R3 million as security to meet medical claims. Lesedi Clinic opened its doors soon after Sizwe Medical Fund started operating. The Kwacha Group was later changed to Sechaba Group Holdings (Pty)Ltd. The motivation for forming the Kwacha Group To provide medical aid cover for Blacks To lead the black population in matters of healthcare To enable black specialists to open private practice To give black private patients and their doctors access to X-rays, other investigations and expensive medications which were out of reach for virtually all who had no medical aid cover Although Dr. Motlana tried to persuade the powers that be to allow black civil servants of the day to join Sizwe, the government refused and instead registered other medical schemes to cater for various civil servants races. The first members of Sizwe Medical Fund were drawn from the Barlow Rand Group, Iscor, PUTCO, steel companies and coal mining companies in Witbank and Middleburg as well as motor industry workers from Port Elizabeth and Uitenhage. Forty years later, the initiative by our founding fathers continues to thrive. Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care Dr Tlakula pg 2 Sizwe History Sizwe Medical Fund - Guide 2018 pg 3
HOSPITAL CARE GOMOMO CARE PRIMARY CARE AFFORDABLE CARE FULL BENEFIT CARE The Hospital Care Option offers peace of mind knowing that in the event of hospitalisation, extensive cover is available at a private hospital. In addition, the Hospital Care Option provides cover for 27 Chronic Disease List (CDL) conditions. 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 a private hospital. Covers the 27 Chronic Disease List (CDL) conditions. 2018 HEALTHCARE OFFERINGS Primary Care Option offers good value for money with unlimited hospitalisation at a private hospital. This traditional option has generous day-today benefits which cover acute medicines GPs, specialists, radiology, pathology and more to meet the needs of any. Our Affordable Care Option offers generous comprehensive cover with unlimited hospitalisation at 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. Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care pg 4 2018 Healthcare Offerings - Subject to CMS approval Sizwe Medical Fund -- Guide 2018 pg5 5
HOSPITAL CARE Offers peace of mind knowing that in the event of hospitalisation, extensive cover is available at a private hospital. Option Structure Major Medical; Day to day: PMB OVERALL DAY-TO-DAY LIMIT GENERAL PRACTITIONERS SPECIALISTS (excluding psychiatrists), Acute Medicine, Pathologists,Radiologists And Physiotherapists Only PMBs ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY-TO-DAY BENEFIT WITH THE FOLLOWING SUB-LIMITS General Specialist BASIC DENTISTRY SPECIALISED DENTISTRY OPTICAL BENEFITS ACCESSED THROUGH PPN (Chiropractic Treatment, Homeopathy) Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant Ante-natal consultations Pregnancy scans and blood tests Fertility Ante-natal consultation: 9 GP, Midwife Visits 2 Obstetrician visits 2 x 2D scans Blood tests: Two (2) Haemoglobin Measurement tests, One (1) Blood Grouping test, One (1) VDRL test for Syphilis and One (1) HIV blood test s PSYCHOLOGICAL AND PSYCHIATRIC TREATMENT Acute OTC PMB Non-PMB MEDICATION s s CHRONIC CONDITIONS 100% negotiated tariff at Preferred Provider Network Formulary, limit per CHRONIC BENEFITS.Medicines: subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment ) 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) (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if preauthorisation was not obtained) GENERAL PRACTITIONER AND MEDICAL SPECIALIST (All hospital admissions must 100% be Sizwe authorised. for A co-payment of R1 500 will consultations be applied and if visits preauthorisation was not in-hospital obtained) General Overall annual limit Provider Network Top-up cover Co-Payments General scopes Auxillary Services: Dietician, speech therapy, occupational therapy BENEFITS Endoscopic (Laparoscopic surgery) investigations AMBULANCE SERVICES Contracted EUROP ASSIST SA (Telephone number: 0860 11 77 99 Pre-authorisation and managed care apply Unlimited Contracted R1 300 R3 000 PRIVATE HOSPITALS AND NURSING HOMES (Subject to treatment and case management and PMBs. Pre-authorisation required unless it is a medical emergency) Accommodation Clinical limitations and exclusions Unlimited at any private hospital None DENTISTRY (Subject to Dental Management Programme - accessed through DENIS - 0860 109 556) Conservative Dentistry Subject to pre-authorised and managed care Specialised Dentistry ( and Dental Management Programme) Crowns and Bridges Orthodontics (Braces) Implants Partial Metal Frame Dentures No limits but subject to treatment and PMB s at a DSB Subject to PMB, clinical and pre-authorisation (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if preauthorisation was not obtained) Consultation benefits Screening benefit PREVENTATIVE CARE PREVENTATIVE TESTS Subject to a limit of R2 030 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 WELLNESS SCREENING TESTS (blood sugar, cholesterol, blood pressure, BMI and HIV) Hospitalisation (public or private hospitals) delivery, post-natal services and midwifery R310 BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS PROSTHESIS : pre-authorisation and managed care apply ONCOLOGY, subject to PMBs and annual limit of R79 490 per, subject to an annual limit of R37 930 per ; maximum of 3 cardiac stents and 2 vascular stents per per Overall limit of R320 000 per Specialised Radiology (MRI/ CAT scan/ Anglogram) Preauthorisation Interventional radiology Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package Limited to R25 270 per Payable from the hospital limit, subject to pre-authorisation and clinical 3 days withdrawal treatment and up to 21 days rehabilitation at an appropriate facility ORGAN TRANSPLANT AND RENAL DIALYSIS (subject to pre-authorisation, minimum benefit package, treatment and DSP) Subject to PMB conditions and clinical Limited to R200 890 per REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care FEMALE CONTRACEPTIVES pg 8 Hospital Care Sizwe Medical Fund - Guide 2018 pg 9
GOMOMO CARE Provides excellent value for money. GPs, specialists and acute medicines are accessible through a selected network provider. Option Structure Provider Out of area visits Basic Radiology and pathology Specialised (Advanced) Radiology in and out: is R 7140 per Major Medical; Day to day: Risk Network OVERALL DAY-TO-DAY LIMIT GENERAL PRACTITIONERS SPECIALISTS, subject to managed care rules, formulary and clinical of the DSP (Designated Service Provider) Subject to managed care rules, formulary and clinical of the DSP 4 visits per year per beneficiary, within the DSP network RADIOLOGY AND PSYCHIATRIC TREATMENT Subject to referreal from a GP : subject to managed care rules, formulary and clinical Combined In and Out of Hospital Only PMBs Acute Over the Counter (OTC) MEDICATION : subject to managed care rules, formulary and clinical of DSP R300 per CHRONIC CONDITIONS (subject to pre-authorisation, registration on the chronic disease management programme, formulary and clinical of the DSP) PMB 26 Non-PMB R7 870 per beneficiary DENTISTRY (Subject to Dental Management Programme - 0860 100 871) (Subject to managed care rules, formulary and clinical ) M: R2 770 M+1: R3 190 M+2: R3 470 M+3: R3 750 M+4: R4 010 M+5: R4 290 M+6: R4 710 OPTICAL BENEFITS (Subject to managed care rules, formulary and clinical of DSP) R490 per beneficiary Frames subject to limits below Cycle Limit per 2 years M: R1 130 M+1: R1 300 M+2: R1 440 M+3: R2 070 OTHER SERVICES (Physiotherapists, Speech Therapists, Clinical Psychologists, Podiatrists, Equipment and External Prostheses) CHRONIC BENEFITS (. Medicines: subject to registration on the Chronic Disease Management Programme. PMBs subject to pre-authorisation, preferred providers and treatment.) Non PMB PMB R7 870 per beneficiary. Cover for 27 PMB chronic conditions (inclusive of HIV/ AIDS) HIV/AIDS (Members are encouraged to register with the HIV/AIDS Management Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for monitoring purposes) Subject to Preferred Provider Disease Management Programme (PPDMP) benefits include counseling, prescription medicine, pathology tests and relevant consultations (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if pre-authorisation was not obtained) Overall annual limit Provider Network AMBULANCE SERVICES Contracted EUROP ASSIST SA (Telephone number: 0860 11 77 99 Accommodation Unlimited BENEFITS Contracted network PRIVATE HOSPITALS AND NURSING HOMES (Subject to treatment, case management and PMBs. Pre-authorisation required unless it is a medical emergency) Clinical limitations Exclusions (ANTENATAL CARE) (subject to managed care rules, formulary and clinical of DSP) Pregnancy scans and blood tests 2X2D scans Blood tests: 2 Haemoglobin Measurement tests, 1 Blood Grouping test, 1 VDRL test for Syphilis and 1 HIV blood test R2 530 per : subject to PMBs Unlimited at a private hospital Advanced laparoscopic, reconstructive surgery, joint replacements, cardiac surgery including cardiac stents, spinal surgery, breast reconstructive surgery Refractive surgery including radial keratotomy, breast reduction, breast augmentation, keloids, frail care Conscious sedation in rooms DENTAL HOSPITALISATION Limited to PMB level of care and limited to PMB level of care GENERAL PRACTITIONER AND SPECIALIST Dietician, speech therapy, occupational therapy for consultations and visits in-hospital Subject to clinical and pre-authorisation (Hospitalisation [public or private hospitals] delivery, post-natal services and midwifery) BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS : subject to PMBs PROSTHESIS (Pre-authorisation apply) R28 090 per beneficiary ONCOLOGY (subject to pre-authorisation, treatment and PMBs) (Subject to Hospital Management Programme and Disease Management Programme. Limited to PMB level of care) (Subject to Hospital Management Programme and Disease Management Programme) ( rules) Psychiatry hospitalisation Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package Limited to 21 days per beneficiary including psychiatrist consultations and 6 in-hospital clinical psychologists subject to PMBs 3 days withdrawal treatment and up to 21 days rehabilitation ORGAN TRANSPLANT AND RENAL DIALYSIS IN HOSPITAL BENEFITS Subject to Prescribed Minimum at DSP REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY No Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care pg 10 Hospital Care Sizwe Medical Fund - Guide 2018 pg 11
PRIMARY CARE Primary Care Option offers good value for money with unlimited hospitalisation at a private hospital, to meet the needs of any. Option Structure Visits Major Medical; Day to day: Risk OVERALL DAY-TO-DAY LIMIT M: R5 680 M+1: R8 410 M+2: R9 840 M+3: R11 250 M+4: R12 680 M+5: R14 100 M+6+: R15 520 GENERAL PRACTITIONERS M: 4 M+1: 9 M+2: 12 M+3: 14 M+4: 15 M+5: 16 M+6+:17 SPECIALISTS (EXCLUDING PSYCHIATRISTS) Visits All visits subject to referral from a GP M: 2 M+1: 6 M+2: 7 M+3: 8 M+4: 9 M+5: 10 M+6+: 11 ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY - TO - DAY BENEFIT WITH THE FOLLOWING SUB-LIMITS Specialised M: R1 770 M+1: R3 190 M+2: R3 550 M+3: R4 030 M+4: R4 140 M+5: R4 370 M+6+:R4 730 CHRONIC CONDITIONS Subject to PMB chronic conditions, pre-authoristion, registration on the chronic disease management programme, formulary and clinical Subject to managed care R18 680 per for in and out of hospital subject to day-to-day benefits Subject to managed care protocol (Limited to Psychiatrists, Clinical and Counselling Psychologists excludes services covered under Auxillary ) R5 180 per DENTISTRY (Subject to Dental Management Programme - accessed through DENIS - 0860 109 556) Limit per beneficiary Root canal treatment Plastic dentures Crowns and Bridges Orthodontics (Braces) Implants Conservative Dentistry 2 general check-ups a year per beneficiary once in six months. Motivation may be requested for extensive restorative treatment plans (fillings) Subject to managed care 1 set of plastic dentures, full or partial (an upper and a lower) per beneficiary in a 4-year period SPECIALISED DENTISTRY ( and Dental Management Programme) Partial Metal Frame Dentures Surgery No No No No Managed care apply OPTICAL BENEFITS ACCESSED THROUGH (PPN) Cycle Limit Frames Single focus lenses Bi-focal lenses Multi-focal lenses No limit 2 years Limit per beneficiary R320 R175 per lens R380 per lens R380 per lens Contact lenses R1 200 (Speech Therapists, Podiatrists, Occupational Therapists, Social Workers, Dieticians, Audiologists, Chiropractors, Homeopathy, Clinical Technologist, Biokineticist and Registered Counsellors) Risk benefit Annual limit per M: R1 010 per M+1+: R1 630 Chiropractor R1 000 per beneficiary (Subject to registration on maternity programme within 24 weeks of falling pregnant) Ante-natal consultations Pregnancy scans 9 GP/ Midwife/ Specialists visits Additional 2 Specialist visits 2 x 2D scans per pregnancy CHRONIC BENEFITS (. Medicines: subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment.) Cover for 27 PMB chronic conditions (All hospital admissions must be authorised. A co-payment of R1 500 will be applied if pre-authorisation was not obtained) Overall annual limit Provider AMBULANCE SERVICES Contracted EUROP ASSIST SA (Telephone number: 0860 11 77 99 BENEFITS Unlimited Contracted network PRIVATE HOSPITALS AND NURSING HOMES (subject to pre-authorisation and case management and PMB unless it is a medical emergency) Accommodation Clinical limitations and exclusions Exclusions A co-payment will apply to all unauthorised admissions unless it is an emergency. Unlimited at a private hospital Advanced laparoscopic, reconstruction surgery, joint replacements, cardiac surgery including cardiac stents, spinal surgery, breast reconstructive surgery Refractive surgery, breast reduction, breast augmentation, Keloids, Frail Care DENTAL HOSPITALISATION (, Dental Management Programme and clinical subject to R1 500 co-payment) General anaesthetic (Children under the age of 5 for extensive dental treatment) Laughing gas in rooms Conscious sedation in rooms Pre-authorisation is required, subject to managed care GENERAL PRACTITIONER AND MEDICAL SPECIALIST CHRONIC BENEFITS (. Medicines: subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment.) HIV/AIDS (Members are encouraged to register with the HIV/AIDS Management Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for monitoring purposes) Subject to Preferred Provider Disease Management Programme(PPDMP) benefits include counseling, prescription medicine, pathology tests and relevant consultations for consultations and visits in-hospital Subject to pre authorisation and PMBs, limited to dieticians, speech therapy, occupational therapy and clinical technology apply Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Care Affordable Care Full Care pg 12 Gomomo Care Sizwe Medical Fund - Guide 2018 pg 13
IN HOSPITAL BENEFITS (Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant) Hospitilisation(public or private hospital), delivery, post natal services and midwifery BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS PROSTHESIS ONCOLOGY 100% of the cost of blood transfusions and blood replacement products, limited to PMBs,, treatment, DSPs and PMBs Maximum of 3 cardiac stents and 2 vascular stents per per Annual limit: R 25 600 for both surgical and non-surgical Overall limit of R143 780 per (Subject to clinical ) Specialised Radiology (MRI/CAT scan/ Angiogram) Pre-authorisation Interventional radiology Limited to R18 680 per Payable from the hospital limit, subject to pre-authorisation and clinical (Subject to the Hospital Management and Disease Management programmes) Psychiatry hospitalisation Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package Limited to 21 days per beneficiary Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to PMBs 3 days withdrawal treatment and up to 21 days rehabilitation ORGAN TRANSPLANT AND RENAL DIALYSIS Subject to PMBs at DSPs REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY No PREVENTATIVE BENEFITS PREVENTATIVE TESTS Consultation benefits R1 000 Screening benefits Subject to a limit of R2 020 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 WELLNESS SCREENING TESTS (blood sugar, cholesterol, blood pressure, BMI and HIV) Appliances Non-motorised wheelchair Hearing aids Private nurse ORAL CONTRACEPTIVES OTHER BENEFITS R260 per beneficiary R2 620 per per M: R1 010 M+1+:R1 630 R1 880 per Once in every 4 years R7 500 per One unit per beneficiary every 4 years R4 540 per AFFORDABLE CARE Offers generous comprehensive cover with unlimited hospitalisation in any private hospital. This option is suitable for young and healthy families. Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care pg 14 Primary Care Sizwe Medical Fund - Guide 2018 pg 15
Option Structure Provider Visits Visits Specialised Radiology: (MRI/CAT scan/angiogram) pre-authorisation and managed care Major Medical; Day to day: Risk Any OVERALL DAY-TO-DAY LIMIT M: R9 840 M+1: R14 100 M+2: R16 230 M+3: R17 660 M+4: R19 790 M+5: R21 930 M+6+: R23 930 GENERAL PRACTITIONERS SPECIALISTS Limited number of visits M: 7 M+1: 14 M+2: 16 M+3: 18 M+4: 20 M+5: 21 M+6+: 22 Subject to referral by a GP, with the exception of: Follow-up visits, Emergencies, Gynaecologist and Paediatrician visits for babies up to the age of 12 months. M: 4 M+1: 8 M+2: 9 M+3: 10 M+4: 11 M+5: 12 M+6+:13 ACUTE MEDICINES Within day-to-day M: R3 420 M+1: R5 210 M+2: R6 160 M+3: R6 630 M+4: R7 580 M+5: R7 820 M+6+:R8 060 Subject to clinical Subject to an overall combined in and out of hospital limit of R28 400 per Limited to Psychiatrists, Clinical and Counselling Psychologists subject to R8 580 per Risk benefit Paid from the day-today limit DENTISTRY (Subject to Dental Management Programme - accessed through DENIS - 0860 109 556) Root Canal treatment Plastic dentures Crowns and bridges Dentures metal Orthodontic treatment Conservative Dentistry SPECIALISED DENTISTRY 2 general check-ups a year per beneficiary Motivation may be requested for extensive restorative treatment plans (fillings) Subject to managed care 1 set of plastic dentures, full or partial (an upper and a lower) per beneficiary in a 4-year period 1 Crown per per year 2 partial frames (an upper and a lower) per beneficiary in a 5 year period, limited to 1 member per Pre-authorisation and clinical Restricted to beneficiary 9 years and younger than 18 years of age, 35% co-payment) OPTICAL BENEFITS ACCESSED THROUGH PPN Cycle Frames Single focus lenses Bi-focal lenses Multi-focal lenses 2 years Limit per beneficiary R800 R175 per lens R380 per lens R695 per lens Contact lenses R1 500 (Speech therapy, Podiatry, Occupational Therapy, Social Worker, Dietetics, Audiology, Homeopathy, Biokineticist and Registered Counselor) M: R 1 510 M+1+: R 2 640 (ANTENATAL) (Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant) Ante-natal consultations Pregnancy scans and blood tests Infertility 9 GP, Midwife or specialists visits Additional 2 Obstetrician /specialist visits 2X2D scans Blood tests: 2 Haemoglobin Measurement tests, 1 Blood Grouping test, 1 VDRL test for Syphilis and 1 HIV blood test CHRONIC MEDICINES PMB conditions 27 Limit Non PMB R5 540 per beneficiary M: R5 540 M+1: R11 090 M+2: R16 640 M+3: R22 190 M+4: R27 730 M+5: R33 300 M+6+:R38 850 (All hospital admissions must be authorised R1500 co-payment will be applied if authorisation was not obtained except in emergencies) Annual Limit Provider Network AMBULANCE SERVICES for consultations and visits in-hospital (Dietician, speech therapy, occupational therapy) s; limited to PMBs PROSTHESIS (, treatment and PMBs) Reimbuirsement ONCOLOGY Subject to pre authorisation and PMBs (Pre-authorisation apply) (Hospitalisation [public or private hospitals] delivery, post-natal services and midwifery) Any 100% cost as authorised by EUROP ASSIST SA (Telephone number: 0860 11 77 99) PRIVATE HOSPITALS AND NURSING HOMES (Subject to treatment and case management and PMBs. Pre-authorisation required unless it is a medical emergency. A co-payment will apply to all unauthorised admissions unless it is an emergency.) Accommodation HIV/AIDS (Members are encouraged to register with the HIV/AIDS Management Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for monitoring purposes) Clinical limitations and exclusions Unlimited at any private hospital None DENTAL HOSPITALISATION (, Dental Management Programme and clinical subject to R1 500 co-payment) General anaesthetic (Children under the age of 5 for extensive dental treatment) Laughing gas in rooms Conscious sedation in rooms Subject to treatment and PMBs Pre-authorisation is required, subject to managed care Subject to pre-authorisation and managed care GENERAL PRACTITIONER AND SPECIALIST BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS 100% of cost Maximum of 3 cardiac stents and 2 vascular stents per per Annual limit: R42 670 R314 170 per Consultation benefits Screening limits Appliances PREVENTATIVE BENEFITS Non-motorised wheelchair Hearing aids ORAL CONTRACEPTIVES OTHER BENEFITS Private nurse R6 780 Chiropractors Specialised Radiology (MRI/CAT scan/ Angiogram) Pre-authorisation Interventional radiology Psychiatry hospitalisation Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package Limited to R28 400 per per, pre-authorisation and managed care Payable from the hospital limit, subject to pre-authorisation and clinical Limited to 21 days per beneficiary per Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to PMBs 3 days withdrawal treatment and up to 21 days rehabilitation ORGAN TRANSPLANT AND RENAL DIALYSIS Restricted to PMBs, subject to pre-authorisation, minimum benefit package, treatment and DSP REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY Limited to R6 310 per R1 470 per Subject to R2 020 per for flu vaccine and pneumococcal vaccine Mammogram every 2 years for women above age 40 years Pap smear every 2 years for women above 21 years Prostate-Specific Antigen (PSA) once per year for males over 40 years R2 620 per per Subject to managed care and formulary M: R1 510 M+1+1: R2 640 Limited to R3 150 per Once in every 4 years R12 000 per One unit per beneficiary every 4 years R1 300 per beneficiary Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Care Full Care pg 16 Affordable Care Sizwe Medical Fund - Guide 2018 pg 17
FULL BENEFIT CARE offers comprehensive cover and generous benefits to cover families and individuals who need access to unlimited hospitalisation at any private hospital. OPTION STRUCTURE Provider Visits Major Medical; Day to day: Risk Any OVERALL DAY-TO-DAY LIMIT M: R16 230 M+1: R21 930 M+2: R24 650 M+3: R27 490 M+4: R30 350 M+5: R33 190 M+6+:R36 020 GENERAL PRACTITIONERS Subject to availability in day to day limits M: 12 M+1: 20 M+ 2: 25 M+3: 29 M+4: 30 M+5: 31 M+6+:32 SPECIALISTS (EXCLUDING PSYCHIATRISTS) Visits M: 7 M+1: 12 M+2: 15 M+3: 16 M+4: 17 M+5: 19 M+6+:20 ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY-TO-DAY BENEFIT WITH THE FOLLOWING SUB-LIMITS Specialised Radiology (MRI/CAT scan/angiogram) Subject to day-to-day limits M: R4 620 M+1: R8 170 M+2: R9 480 M+3: R10 790 M+4: R11 480 M+5: R12 090 M+6+:R12 680 CHRONIC MEDICINES PMB conditions 27 limit R37 360 per in-hospital and out of hospital limit subject to pre-authorisation preferred provider and treatment M: R10 970 M+1: R21 960 M+2: R32 820 M+3: R43 800 M+4: R54 780 M+5: R65 760 M+6+:R76 750 Subject to day-to-day limit DENTISTRY (Subject to Dental Management Programme - accessed through DENIS - 0860 109 556) Root canal treatment Plastic dentures Orthodontic treatment Conservative Dentistry SPECIALISED DENTISTRY Subject to day-to-day benefits 2 general check-ups a year per beneficiary Motivation may be requested for extensive restorative treatment plans (fillings) Subject to managed care 1 set of plastic dentures, full or partial (an upper and a lower) per beneficiary in a 4-year period 2 Partial metal frames (upper and lower) per beneficiary in a 5-year period, limited to 2 members per 3 Crowns per per year Implants limited to R3 690 per implant Pre-authorisation required and benefit limited to age 9 and younger than 18 years of age. 20% co-payment will apply if authorisation is obtained after the treatment. OPTICAL BENEFITS ACCESSED THROUGH PPN Cycle per beneficiary 2 years Frames R1 000 Single focus lenses Bi-focal lenses Multi-focal lenses R175 per lens R380 per lens R695 per lens Contact lenses R1 700 (Limited to Psychiatrists, Clinical and Counseling Psychologists. excludes services covered under the auxiliary benefit) Subject to R16 540 per (Speech Therapy, Podiatry, Occupational Therapy, Social Worker, Dietetics, Audiology, Homeopathy, Biokineticist and Registered Counselor) M: R2 770 M+1+: R4 660 (ANTENATAL) (Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant) Ante-natal consultations Pregnancy scans and blood tests Infertility 9 GP, Midwife or Specialist visits 6 Specialist visits 2X2D scans Blood tests: 2 Haemoglobin Measurement tests, 1 Blood Grouping test, 1 VDRL test for Syphilis and 1 HIV blood test Subject to PMB regulation Annual Provider IN-HOSPITAL BENEFITS Dietician, speech therapy, occupational therapy Subject to PMBs, clinical protocol and pre authorisation Pre-authorisation and managed care apply (Hospitalisation [public or private hospitals] delivery, post-natal services and midwifery) AMBULANCE SERVICES Contracted EUROP ASSIST SA (Telephone number: 0860 11 77 99 Unlimited Any BENEFITS PRIVATE HOSPITALS AND NURSING HOMES (Subject to treatment and case management and PMBs. Pre-authorisation required unless it is a medical emergency) Accommodation CHRONIC BENEFITS (. Medicines: subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment.) PMB conditions 27 Non-PMB (Subject to a maximum of R10 970 per beneficiary) Clinical limitations and exclusions Unlimited at any private hospital None DENTAL HOSPITALISATION (, Dental Management Programme and clinical subject to R1 500 co-payment on some options) General anaesthetic (Children under the age of 5 for extensive dental treatment) Laughing gas in rooms Conscious sedation in rooms subject to pre-authorisation, preferred providers and treatment M: R10 970 M+1: R21 960 M+2: R32 820 M+3: R43 800 M+4: R54 780 M+5: R65 760 M+6+:R76 750 HIV/AIDS MANAGEMENT PROGRAMME (Members are encouraged to register with the HIV/AIDS Management Programme. This benefit includes relevant consultations, counselling, medication and the cost of blood tests for monitoring purposes) No limit, subject to treatment and PMBs Pre-authorisation is required, subject to managed care GENERAL PRACTITIONER AND MEDICAL SPECIALIST BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS Subject to an annual limit R 79 490 per Subject to PMBs Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Full Care Care pg 18 Affordable Care Sizwe Medical Fund - Guide 2018 pg 19
per Specialised Radiology (MRI/CAT scan/ Angiogram) Pre-authorisation Interventional radiology Psychiatry hospitalisation Alcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package Limited to R37 360 per per Combined in-hospital and out-of-hospital limit Payable from the hospital limit, subject to pre-authorisation and clinical Limited to 21 days per beneficiary per Psychiatrist consultations and 6 in-hospital Clinical Psychologists subject to PMBs 3 days withdrawal treatment and up to 21 days rehabilitation ORGAN TRANSPLANT AND RENAL DIALYSIS Subject to PMBs REFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMY R12 120 per per PREVENTATIVE BENEFITS Consultation benefits Screening benefits PREVENTATIVE TESTS R1 470 per Subject to R2 875 per 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 WELLNESS SCREENING TESTS (blood sugar, cholesterol, blood pressure, BMI and HIV) limit: pre-authorisation apply PROSTHESIS ONCOLOGY 100% of cost, treatment and PMBs Maximum of 3 cardiac stents and 2 vascular stents per per Annual limit: R56 330 Overall limit of R377 010 R260 per beneficiary ORAL CONTRACEPTIVES R2 620 per per Appliances PREVENTATIVE BENEFITS OTHER BENEFITS Non-motorised wheelchair Hearing Aids Private nurse Chiropractors M: R2 640 M+1+: R4 400 Limited to R4 390 per Once in every 4 years R18 000 per One unit per beneficiary every 4 years R9 080 per R2 000 per beneficiary Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Full Care pg 20 Full Care Sizwe Medical Fund - Guide 2018 pg 21
2018 Contributions Traditional Traditional Traditional HOSPITAL CARE GOMOMO CARE PRIMARY CARE AFFORDABLE CARE FULL BENEFIT CARE Contribution Income Band Contribution Income Band Contribution Income Band Contribution Income Band Contribution Income Band PRINCIPAL R1 500 All R837 R1 167 R1 665 R2 068 R0 - R7 147 R7 148 - R8 337 R8 338 - R10 719 R10 720 + R419 R1 964 R2 396 R0 - R562 R563 - R9 292 R9 293 + R2 815 R2 928 R3 767 R0 - R15 955 R15 956 - R25 999 R26 000+ R4 336 R5 032 R0 - R 25 999 R26 000+ ADULT R1 100 All R827 R1 167 R1 608 R1 688 R0 - R7 147 R7 148 - R8 337 R8 338 - R10 719 R10 720 + R419 R1 533 R1 565 R0 - R562 R563 - R9 292 R9 293 + R2 586 R2 688 R3 349 R0 - R15 955 R15 956 - R25 999 R26 000+ R3 940 R4 574 R0 - R 25 999 R26 000+ CHILD R500 All R348 R423 R463 R494 R0 - R7 147 R7 148 - R8 337 R8 338 - R10 719 R10 720 + R419 R494 R494 R0 - R562 R563 - R9 292 R9 293 + R649 R680 R752 R0 - R15 955 R15 956 - R25 999 R26 000+ R886 R989 R0 - R 25 999 R26 000+ % of total contribution paid to savings account 0% 0% 0% 0% 0%
IMPORTANT CHRONIC MEDICATION PROGRAMME: Tel: 0860 103 455 011 353 0030 Fax: 011 353 0352/0076 Email: chronic@sizwemedfund.co.za HOSPITAL PRE-AUTHORISATION, HOSPITAL BENEFIT MANAGEMENT PROGRAMME: Tel: 0860 101 176 DENTAL BENEFIT MANAGEMENT: Tel: 0860 109 556 Fax: 0866 770 336 Email: sizweenq@denis.co.za WELLNESS PROGRAMME HELPLINE FOR ASTHMA, CARDIOVASCULAR DISEASE, DIABETES AND : Tel: 0860 103 455 Fax: 011 221 5238 Email: wellnessqueries@sizwemedfund.co.za HIV/AIDS MANAGEMENT PROGRAMME: Tel: 0860 103 454 Fax: 011 221 5235/56 CONTACT DETAILS EUROP ASSISTANCE SA, MEDICAL EMERGENCIES, 24-HOUR AMBULANCE SERVICES AND MEDICAL ADVICE: Tel: 0860 117 799 SIZWE BABY PROGRAMME: Fax: 011 221 5218 Email: sizwebaby@healthichoices.com TIP-OFFS ANONYMOUS FRAUD LINE: Tel: 0800 204 702 Fax: 0800 007 788 Email: sizwemedical@tip-offs.com CHRONIC MEDICATION PROGRAMME: Tel: 0860 103 455 011 353 0030 Fax: 011 353 0352/0076 Email: chronic@sizwemedfund.co.za Sizwe History 2018 Offerings Hospital Care Gomomo Care Primary Care Affordable Care Full Care pg 24 Full Care Sizwe Medical Fund - Guide 2018 pg 25
queries@sizwe.co.za 0860 100 871