FULL BENEFIT BENEFITS GUIDE. #caring4life

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William Atkins
5 years ago
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1 FULL BENEFIT C A R E 2016 BENEFITS GUIDE #caring4life

Our Full Benefit Care option offers comprehensive cover, generous benefits to cover families and individuals who need access to unlimited hospitalisation at any private hospital.

2 Our Full Benefit Care option offers comprehensive cover, generous benefits to cover families and individuals who need access to unlimited hospitalisation at any private hospital. Full Benefit Care offers additional chronic conditions, speacialised dentistry, General Practitioners (GP s), specialists, acute medication, preventative care benefits. This is the only option which offers additional cover when in hospital up to 200% of the Sizwe Rate.

3 FULL BENEFIT CARE Prescribed Minimum Benefits (PMBs) are paid at Sizwe negotiated rates except where Sizwe has a Designated Service Provider (DSP) arrangement in place. No co-payments apply on PMBs. Subject to pre-authorisation where applicable, excluding life threatening emergencies. DAY-TO-DAY BENEFITS DAY-TO-DAY BENEFITS Includes: General Practitioners, Specialists (excluding Psychiatrists), Acute Medicines, Pathologists, Radiologists and Physiotherapists OUT OF HOSPITAL BENEFITS Member R Member+1 R Member+2 R Member+3 R Member+4 R Member+5 R Member+6+ R GENERAL PRACTITIONERS Falls within day-to-day benefit with the following sub-limits 100% Sizwe Rates Number of Visits Member 12 Member+1 20 Member+2 25 Member+3 29 Member+4 30 Member+5 31 Member SPECIALISTS (excluding Psychiatrists) Falls within day-to-day benefit with the following sub-limits 100% Sizwe Rates Number of Visits Member 7 Member+1 12 Member+2 15 Member+3 16 Member+4 17 Member+5 19 Member ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) Falls within day-to-day benefit with the following sub-limits Sub-limits Member R4 380 Member+1 R7 750 Member+2 R8 990 Member+3 R Member+4 R Member+5 R Member+6+ R12 020

4 RADIOLOGY AND RADIOGRAPHY Falls within day-to-day benefit with the following sub-limits General Radiology/Radiography Covered within day-to-day Specialised Radiology (Separate for R per family per year MRI/CT/Angiograms combined In and Out of Hospital) PHYSIOTHERAPY Falls within day-to-day benefit with the following sub-limits PATHOLOGY Falls within day-to-day benefit with the following sub-limits HIV Pathology Tests Falls within the Well-Care HIV/AIDS Management Programme DENTISTRY Subject to Dental Management Programme - call Conservative Dentistry Consultations/ Oral Hygiene, Extractions, Fillings 2 general checkups a year per beneficiary, once every 6 months Motivation may be requested for extensive restorative treatment plans (fillings) Root Canal Treatment Managed Care protocols apply Plastic Dentures 1 per jaw per beneficiary every 4 years 1 per jaw per beneficiary every 2 years Specialised Dentistry Subject to pre-authorisation and Dental Management Programme Crowns and Bridges 3 crowns per family per year Once per tooth every 5 years. Pre-authorisation is required Orthodontics (Braces) Restricted to beneficiaries under the age of 18 years Implants Clinical restrictions apply. 2 implants per beneficiary per annum limited to R2 350 per implant over a period of 5 years Partial Metal Frame Dentures 1 per jaw per beneficiary every 5 years 2 Per family per annum Pre-authorisation is required Surgery Managed Care protocols apply Dental Hospitalisation Subject to pre-authorisation and Dental Management Programme R1 500 co-payment applies per hospital admission 20% co-payment applies on the hospital account for late authorisations unless in a case of an emergency General anaesthetic in hospital Pre-authorisation is required. Admission protocols apply. Laughing gas in dental rooms 100% Sizwe Rates; subject to managed care protocols Conscious sedation in rooms Pre-authorisation is required. Subject to managed care protocols

5 OPTICAL Optical benefits managed by PPN (Preferred Provider Negotiators) 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 Member R2 360 Sub-limits Member+1 R2 470 Member+2 R2 810 Member+3 R2 920 Member+4 R3 030 Member+5 R3 150 Member+6+ R3 200 Multi-focal/Varifocal Lenses Sub-limit R680 per lens subject to annual limit Contact lenses 1 pair of permanent contact lenses every 2 years or 12 pairs of monthly disposable contact lenses per beneficiary per year Included in above limit Refractive Surgery, including Radial Keratotomy R per family per year MENTAL HEALTH Psychiatrists, Clinical and Counselling Psychologists - only if related to mental health. This excludes Educational Psychologists, Social Workers and Registered Counsellors Family R per family per year AUXILIARY Audiologists, Chiroprators, Dieticians, Homeopaths, Occupational Therapists, Podiatrists, Speech Therapists, Social Workers and Education Psychologists, Biokenetics and Registered Counsellors Member R2 470 Member +1+ R4 150 CLINICAL AND MEDICAL TECHNOLOGISTS included in the Auxiliary above MATERNITY Ante-Natal Consultations 9 GP or midwife visits 6 Specialist visits Pregnancy Scans 2 x 2D scans per pregnancy. Subject to clinical protocols Pathology Tests 2 Haemoglobin Measurement Tests 1 Blood Grouping Test 1 VDRL test for Syphilis 1 HIV Blood Test, over and above regular Pathology benefits

6 MATERNITY (continued from previous page) MATERNITY Delivery Pre-authorisation is required Post-Natal services and Midwifery Subject to the Hospital or Maternity Benefit Management Programme APPLIANCES Member R2 360 Member+1+ R3 930 WHEELCHAIR (Non-motorised) Family R3 920 every 2 years HEARING AIDS 1 unit per beneficiary every 2 years Family R9 770 every 2 years CHRONIC BENEFITS CHRONIC MEDICINES Subject to pre-authorisation Subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment protocols Member R9 770 Member +1 R Member +2 R Member +3 R Member +4 R Member +5 R Member +6+ R Per Beneficiary per year R9 770 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 No limit but subject to treatment protocols. PMBs at DSP IN-HOSPITAL BENEFITS No Top-Up Cover ( must be applied for within 3 months of hospitalisation) Sizwe Rates plus 200% AMBULANCE Europ Assist SA Pre-authorisation is required. Contracted Provider

7 PRIVATE HOSPITALS AND NURSING HOMES Subject to Treatment and Case Management Protocols and PMBs. Pre-authorisation is required unless in a medical emergency Accommodation No Clinical ations and Exclusions None Frail Care No benefits TTO (Medication to take home) ed to a supply of 7 days HOSPITAL ALTERNATIVES Subject to Hospital Benefit Management Programme, Disease Management Programme and pre-authorisation Subject to hospital limit PROVINCIAL HOSPITALS No PRIVATE NURSING Pre-authorisation is required R8 090 BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS Subject to PMBs Family No subject to PMBs GENERAL PRACTITIONERS No SPECIALISTS No RADIOLOGY AND RADIOGRAPHY Basic Radiology/ Radiography No Specialised Radiology (separate limit for MRI/CT/Angiograms R per family per year combined In and Out of hospital) Pre-authorisation required Interventional Radiology PATHOLOGY Within hospital benefit. Subject to pre-authorisation and clinical protocols 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 21 days per beneficiary including psychiatric consultations and 6 in-hospital consultations by a Clinical Psychologist. Subject to PMBs

8 ONCOLOGY Subject to pre-authorisation, Treatment Protocols and PMBs Family limit R PROSTHESIS Subject to pre-authorisation, Treatment Protocols and PMBs Surgical and Non-surgical % Benefit 100% of Cost Family limit R per year Internal Prosthesis Joints Spine Cardiac (Pacemaker, internal defibrillators, grafts, valves, etc) External Prosthesis 1 per beneficiary cycle 2 levels per year done in one procedure Subject to the benefit limit PMB protocols Subject to the benefit limit and PMB protocols STENTS Cardiac Stents Family 3 Stents per year Vascular Stents Family 2 Stents per year AUXILIARY IN HOSPITAL Dieticians, Speech Therapists, Occupational Therapists Subject to PMBs, clinical protocols and pre-authorisation ALCOHOLISM/DRUG ADDICTION/NARCOTISM Benefit ORGAN TRANSPLANTS AND RENAL DIALYSIS Subject to pre-authorisation, Treatment Protocols and PMBs 3 days withdrawal treatment and 21 days admission at an appropriate facility Subject to pre-authorisation, Treament Protocols and PMBs Unlimited for PMBs WELLNESS BENEFITS SCREENING TESTS (Preventative care) Mammogram, pap smear, prostate antigen test. 1 test per beneficiary every 2 years. Mammograms and pap smears restricted to females over 21 years. Prostate antigens restricted to men over 40 years R1 800 per family per year WELLNESS SCREENING CONSULTATIONS Blood sugar, cholesterol, blood pressure, BMI and HIV testing R240 per beneficiary per year CONTRACEPTIVES R2 340 per family per year

9 FULL BENEFIT CARE CONTRIBUTIONS 2016 Income Bracket Principal Member Adult Dependant Child Dependant R0 - R R3 830 R3 480 R780 R R4 530 R4 120 R890 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

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) 353 0199 CAPE TOWN

10 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)

AFFORDABLE BENEFITS GUIDE. #caring4life

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