Sizwe Medical Fund Benefits and Contribution 2017

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Sydney Hodges
6 years ago
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1 Prescribed Minimum Benefits: PMBs are paid at 100% Sizwe negotiated rates except where Sizwe has a DSP arrangement in place. No co-payments apply on PMBs. Subject to pre-authorisation where applicable, excluding life threatening emergencies. Top Up Cover No No No No No Sizwe Tariff + 200% Day to Day benefits Includes: General Practitioners, Specialists (Excluding Psychiatrists), Acute Medicines, Pathologists, Radiologist & Physiotherapists R 5,390 R 9,330 R 15, R 7,980 R 13,370 R 20, R 9,330 R 15,390 R 23, R 10,670 R 16,740 R 26, R 12,020 R 18,760 R 28, R 13,370 R 20,790 R 31, R 14,720 R 22,690 R 34,150 General Practitioners Falls within day-to-day limit with the following sub-limits ed to stipulated number of visits : 4 : 7 : : 9 +1 : : 20 Required benefits for full year +2 : : : 25 Subject to Chosen GP Out Subject to +3 : : : 29 of area visits: 4 +4 : : : 30 GP visits per beneficiary Subject +5 : : : 31 to pre-authorisation +6+ : : : 32 Specialists (Excluding Psychiatrists) Falls within day-to-day limit with following sub-limits All visits subject to referral from a 1st visit subject to referral from a GP. Except Gynaecologist, Pediatrician GP for children up to 12 months. : 2 : 4 : 7 +1 : 6 +1 : 8 +1 : 12 ed to stipulated number of visits Required benefits for full year +2 : 7 +2 : 9 +2 : 15 Subject to All visits subject to referral from +3 : 8 +3 : : 16 a GP. Non +4 : 9 +4 : : 17 referral will result in a co-payment. +5 : : : : : : 20 Acute Medicines & Pharmacy Advised Therapy (PAT)- falls within day-to-day benefit with the following sub-limits Required R 1,680 R 3,250 R 4, benefits for full year Subject to R 3,030 R 4,940 R 7, Formulary Out of area R 3,370 R 5,840 R 8,990 Subject to +3 medicines : No limit subject to R 3,820 R 6,290 R 10, formulary R 3,930 R 7,190 R 10, Over the counter: R280 per family R 4,150 R 7,420 R 11, per annum R 4,490 R 7,640 R 12,020 Radiology & Radiography - falls within day-to-day benefit with the following sub-limits Basic Radiology and pathology Subject to avaiable savings R 1,000 R 1,100 R 1, R 1,900 R 2,200 R 2,750 Radiology & Radiography 100% Sizwe rate General Radiology/Radiography Required benefits for full year No No No No No Specialised Radiology Combined In and Out of Hospital R6,770 per family R23,960 per family R per family in hospital only R17,710 per family Preauthorisation required R26,920 per family Preauthorisation required R35,420 per family Interventional Radiology Subject to pre-authorisation Subject to pre-authorisation and Pathology 100% Sizwe rate

2 Dentistry Subject to, formulary and managed care rules. Conservative Dentistry Consultations, Oral Hygiene, Extractions, Fillings : R2,630 +1: R3,030 +2: R3,290 +3: R3,560 +4: R3,810 R2,800 per family per annum R3,200 per family per annum R3,600 per family per annum +5: R4, : R4,470 Root Canal Treatment Included in above limit Clincal protocols apply Clinical protocols apply Clinical protocols apply Clinical protocols apply Plastic Dentures One set per beneficiary every 1 set per beneficiary every 1 set per beneficiary every 1 set per beneficiary every Subject to MSA Clinical Protocols apply Specialised Dentistry R3,200 per family per annum R3,600 per family per annum 1 crown per family per year. 1 3 crowns per family per year. Crowns and Bridges crown per tooth over a 5 year 1 crown per tooth over a 5 year period. period... Orthodontics (Braces). Restricted to beneficiaries under the age of 18. Restricted to beneficiaries under the age of 18 years. A 35% co-payment applies. years. Implants Clinical restrictions apply 2 implants up to a maximum of R3 500 per implant. Implant supported full dentures, 2 implants per beneficiary every 5 years Metal Frame Dentures 1 partial frame per jaw every 1 partial frame per jaw every 5 years. 1 per beneficiary per year. 5 years. 2 per beneficiary per year... Surgery Clinical Restrictions apply Clinical restrictions apply Clinical restrictions apply Clinical restrictions apply Dental Hospitalisation Subject to pre-authorisation Clinical Protocols and Dental Benefit Management Programme General anaesthetic in hospital Pre-Authorisation required Admission protocols apply Pre-authorisation irequired. Pre-Authorisation required Admission protocols apply... Laughing gas in dental rooms Conscious sedation in rooms Chronic Medicines..... Subject to registration on the Chronic Medicine PMBs subject to pre-authorisation, DSPs and Treatment Protocols 100 % Sizwe rate Benefit Cover for PMB chronic conditions Cover for PMB chronic conditions + 11 additional conditions Cover for PMB chronic conditions Cover for PMB Chronic Conditions Cover for PMB Chronic conditions +13 additional conditions Cover for PMB Chronic conditions + 34 additional conditions Per Beneficiary R7 450 No limit No limit No limit R5 260 non PMB conditions R non PMB conditions Oncology Subject to pre-authorisation, DSPs, Treatment Protocols and PMBs Family limit PMBs apply R 121,920 R 121,920 R 106,500 R 266,250 R 319,500

3 Private Hospitals & Nursing Homes Accommodation Subject to Treatment and Case Management Protocols. unless it is a medical emergency. No No limit No limit No No No Advanced Laparoscopic, Advanced Laparoscopic, Reconstructive & Cardiac Surgery, Reconstructive & Cardiac Surgery, Clinical ations and Exclusions Joint Replacements, Spinal Surgery, Joint Replacements, Spinal Surgery, Breast Reconstructions and Breast Reconstructions and Augmentations. Augmentations. Frail Care Medicine to take home (TTO) General Practitioners In-Hospital Specialists In-Hospital Dental Hospitalisation Psychiatric Hospitalisation ed to a supply of 7 days No No No No No No See Dentistry Benefit Maternity Ante-Natal Consultations Pregnancy Scans Delivery Post Natal Services and Midwifery Provincial Hospitals Must register on the Maternity Programme within 24 weeks of falling pregant Within GP and Specialist limit 9 GP/midwife visits 9 GP/midwife visits 9 GP/midwife visits 2 9 GP/midwife visits 9 GP/midwife visits 2 Specialist visits Subject 2 Specialist visits Specialist visits 2 Specialist visits 6 Specialist visits to 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 2 x 2D scans per pregnancy.. Programme and registration on the Programme and registration on the Programme and registration on Required benefits for full year No No No No No Prosthesis Subject to Pre-authorisation Surgical and Non-Surgical 100% of Sizwe Rate 100% of Sizwe Rate 100% of Sizwe Rate 100% of Sizwe Rate 100% of Sizwe Rate 100% of Cost R 26,625 R 35,950 R 35,950 R 24,270 R 40,450 R 53,400 Optical Eye Test Subject to pre-authorisation 1 test per beneficiary every 24 1 test per beneficiary every 1 test per beneficiary every 1 test per beneficiary every months Frames Frames: R300 per beneficiary every Frames: R465 per beneficiary within Frames: R300 per beneficiary every Frames: R300 per beneficiary every Frames: R300 per beneficiary every. Subject to the combined optical limit

4 Optical: Single focus lenses Included in combined limit 100% of Sizwe Rate R 1, R 1,240 R 165 per lens R165 per lens per beneficiary every R165 per lens per beneficiary every R165 per lens per beneficiary every +2 R 1, R 1,970 Bi-focal lenses Within the combined optical limit R360 per lens R360 per lens per beneficiary every R360 per lens per beneficiary every R360 per lens per beneficiary every Veri-focal lenses R 360 per lens Subject R360 per lens per beneficiary every R660 per lens per beneficiary every R660 per lens per beneficiary every Within the combined optical limit to Contact Lenses Included in above One pair of permanent contact lenses every or 12 pairs of monthly disposable contact lenses per beneficiary per annum. 100% of Sizwe rate Included in above R 525 R525 per beneficiary R 525 per benficiary R 525 per beneficiary Refractive Surgery Family R 5,980 R 11,490 Ambulance EUROP ASSIST SA Contracted Provider Mental Health (Psychiatry, Clinical & Counselling Psychology - only if related to mental health), excludes Educational Psychologists, Social Workers and Registered Counsellors Family Included in Specialist benefit R7,190 R 4,910 R 8,140 R 15,677 Appliances Subject to PMBs and R 1,240 R 960 R 1,440 R 2, Pre-Authorisation R 2,160 R 1,550 R 2,510 R 4,180 Hearing Aids One unit per beneficiary every Family R 5,500 R 8,600 R 12,700 Auxiliary Dieticians, Speech Therapists and Occupational. Clinical protocols apply Clinical protocols apply Clinical protocols apply Clinical protocols apply Clinical protocols apply Out of Hospital Physiotherapy,Speech Therapy, Clinical Psychologists, Podiatry, Equipment and external prosthesis Audiology, Chiropractics, Dietetics, Homeopathy, Occupational Therapy, Podiatry, Speech Therapy, Orthoptic Treatment, Social Workers, Educational Psychologists and Clinical and Counselling Psychologists, Biokineticists and Registered Counsellors M: ed to R2,250 per family per M: 960 M:1,440 M:R2,630 M+1+ annum M+1+:R1,550 M+1+:R2,510 M+1+:R4,420 Alcoholism/Drug Addiction/Narcotism PMBs at DSPs 3 days withdrawal treatment plus 3 days withdrawal treatment plus 21 3 days withdrawal treatment plus 3 days withdrawal treatment plus 21 3 days withdrawal treatment plus 3 days withdrawal treatment plus 21 Benefit 21 days Rehabilitation at an days rehabilitation at an appropriate 21 days rehabilitation at an days Rehabilitation at an appropriate 21 days rehabilitation at an days rehabilitation at an appropriate Organ Transplants & Renal Dialysis Subject to pre-authorisation, Treatment Protocols and PMBs PMBs at DSPs R R PMBs at DSPs PMBs at DSPs PMBs at DSPs HIV/Aids s are encouraged to register with the HIV/AIDS This benefit includes No limit but subject to No limit but subject to treatment No limit but subject to treatment No limit but subject to treatment No limit but subject to treatment No limit but subject to treatment treatment protocols and PMBs protocols and PMBs protocols and PMBs protocols and PMBs protocols and PMBs protocols and PMBs

5 Preventative care: Screening tests (Blood Sugar, Cholesterol, Blood Pressure, BMI, HIV testing once pa. Mammogram, Pap Smear one test per beneficiary every two years. Mammograms restricted to females over 40 years and pap smears restricted to females over 21 years. Prostate antigens restricted to men over 40 years once pa. Family Within GP, Pathology limit R 1,920 R 1,920 R 1,920 R 1,920 R 2,500 Wellness screening tests Within GP, Pathology limit R 300 R 300 R 255 R 255 R 255 Female Contraceptives Blood sugar, cholesterol, blood pressure, BMI, HIV R2 490 per family per annum R2 490 per family per annum R2 490 per family per annum 2017 CONTRIBUTIONS Gomomo Care R1 666 R 1,546 R R2 060 R 1,623 R 420 Savings Care 2017 Income Bracket Income Category Risk Savings Total Contribution Principal 580 R 1,713 R 302 R 2,015 Adult Dependant R 1,481 R 261 R 1,742 Child Dependant R 416 R 74 R 490 Income Bracket Income Category Risk Savings Total Contribution Principal 590 R 2,380 R 420 R 2,800 Adult Dependant R 1,907 R 336 R 2,243 Child Dependant R 472 R 83 R 555 Hospital Care Income Bracket Principal Adult Dep Child Dep R1 700 R1 300 R 400 Primary Care R 407 R 407 R R 1,907 R 1,488 R R 2,326 R 1,519 R 480 Affordable Care R 2,733 R 2,511 R R 2,843 R 2,610 R R 3,657 R 3,251 R 730 Full Benefit R 4,210 R 3,825 R R 4,885 R 4,441 R 960

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AFFORDABLE BENEFITS GUIDE. #caring4life AFFORDABLE C A R E 2016 BENEFITS GUIDE #caring4life Our Affordable Care option offers generous comprehensive cover with unlimited hospitalisation in any private hospital. It also covers additional chronic