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2016P R I M A R YC A R E
BENEFITSGUIDE
#caring4life
Primary Care 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, general practitioners (GPs), specialists, radiologists, pathologists and more to meet the needs of any family. Suitable for but not limited to young couples and families who require comprehensive and very generous
day-to-day cover. This option allows you to access any private hospital,27 Chronic Disease List (CDL) conditions and preventative care benefits.
PRIMARY CARE
Prescribed Minimum Benefits (PMBs) are paid at cost 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.
Includes: General Practitioners, Specialists (excluding Psychiatrists), Acute Medicines, Pathologists, Radiologists and Physiotherapists.
OUT OF HOSPITAL LIMITS
% Benefit 100% Sizwe Rates Limit
Member R5 390
Member +1 R7 980
Member +2 R9 330
Member +3 R10 670
Member +4 R12 020
Member +5 R13 370
Member +6+ R14 720
GENERAL PRACTITIONERS Falls within day-to-day benefit with the following sub-limits
100% Sizwe Rates Number of visits
Member : 4
Member +1 : 9
Member +2 : 12
Member +3 : 14
Member +4 : 15
Member +5 : 16
Member +6+ : 17
SPECIALISTS (Excluding Psychiatrists) Subject to refferal from a GP. Non-referral will result in a co-payment. Falls within day-to-day benefit with the following sub-limits
100% Sizwe Rates Number of visits
Member : 2
Member +1 : 6
Member +2 : 7
Member +3 : 8
Member +4 : 9
Member +5 : 10
Member +6+ : 11
ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) Falls within day-to-day benefit with the following sub-limits
Sub-Limit
Member R1 680
Member +1 R3 030
Member +2 R3 370
Member +3 R3 820
Member +4 R3 930
DAY-TO-DAY BENEFITS
RADIOLOGY AND RADIOGRAPHY Falls within day-to-day benefit with the following sub-limits
% Benefit 100% Sizwe Rates
General Radiology/ Radiography Covered within day-to-day
Specialised Radiology (separate limit for MRI/CT/Angiograms
combined in and out of Hospital ) R16 630 per family per year
PHYSIOTHERAPY Falls within day-to-day benefit with the following sub-limits
% Benefit 100% Sizwe Rates
PATHOLOGY Falls within day-to-day benefit with the following sub-limits
% Benefit 100% Sizwe Rates
HIV Pathology Tests Falls within the Well-Care HIV/AIDS Management Programme
DENTISTRY Subject to Dental Management Programme - call 0860 109 556
Conservative Dentistry
% Benefit 100% Sizwe Rates
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
% Benefit 100% Sizwe Rates
Crowns and Bridges No benefit
Orthodontics (Braces) No benefit
Implants No benefit
Partial Metal Frame Dentures No benefit
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
% Benefit 100% Sizwe Rates
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.
OPTICAL Optical benefits managed by PPN (Preferred Provider Negotiators). Choose
either spectacles (frames and lenses) or contact lenses once every 2 years
Eye Test
% Benefit 100% Sizwe Rates
Limit 1 test per beneficiary every 2 years
Combined Frames and Lenses
% Benefit 100% Sizwe Rates
OPTICAL (Continued from previous page)
Sub-limits
Member R1 120
Member+1 R1 240
Member+2 R1 290
Member+3 R1 350
Member+4 R1 460
Member+5 R1 570
Member+6+ R1 630
Multi-focal/Varifocal Lenses
Sub-limit R450 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
% Benefit 100% Sizwe Rates
Limit Included in above limit
MENTAL HEALTH Limited to Psychiatrists, Clinical and Counselling Psychologists relating
to mental health. Psychiatry, Clinical and Counselling Psychologists only
related to mental health. This excludes Educational Psychologists, Social
Workers and Registered Counsellors
% Benefit 100% Sizwe Rates
Family Limit R4 610 per year
AUXILIARY Audiologists, Chiroprators, Dieticians, Homeopaths, Occupational Therapists, Podiatrists, Speech Therapists, Social Workers and Education Psychologists, Biokenetics and Registered Counsellors
% Benefit 100% Sizwe Rates
Member R900
Member +1+ R1 460
CLINICAL AND MEDICAL TECHNOLOGISTS
% Benefit 100% Sizwe Rates
included in the Auxiliary limit above
MATERNITY
% Benefit 100% Sizwe Rates
Ante-Natal Consultations 9 GP or midwife visits 2 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 Syphillis
1 HIV Blood test, over and above regular Pathology benefits
Delivery Pre-authorisation is required
Post-Natal Services and Midwifery Subject to the Hospital or Maternity Benefit Management Programme
RADIOLOGY AND RADIOGRAPHY Falls within day-to-day benefit with the following sub-limits
% Benefit 100% Sizwe Rates
General Radiology/ Radiography Covered within day-to-day
Specialised Radiology (separate limit for MRI/CT/Angiograms
combined in and out of Hospital ) R16 630 per family per year
PHYSIOTHERAPY Falls within day-to-day benefit with the following sub-limits
% Benefit 100% Sizwe Rates
PATHOLOGY Falls within day-to-day benefit with the following sub-limits
% Benefit 100% Sizwe Rates
HIV Pathology Tests Falls within the Well-Care HIV/AIDS Management Programme
DENTISTRY Subject to Dental Management Programme - call 0860 109 556
Conservative Dentistry
% Benefit 100% Sizwe Rates
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
% Benefit 100% Sizwe Rates
Crowns and Bridges No benefit
Orthodontics (Braces) No benefit
Implants No benefit
Partial Metal Frame Dentures No benefit
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
% Benefit 100% Sizwe Rates
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.
OPTICAL Optical benefits managed by PPN (Preferred Provider Negotiators). Choose
either spectacles (frames and lenses) or contact lenses once every 2 years
Eye Test
% Benefit 100% Sizwe Rates
Limit 1 test per beneficiary every 2 years
Combined Frames and Lenses
% Benefit 100% Sizwe Rates
OPTICAL (Continued from previous page)
Sub-limits
Member R1 120
Member+1 R1 240
Member+2 R1 290
Member+3 R1 350
Member+4 R1 460
Member+5 R1 570
Member+6+ R1 630
Multi-focal/Varifocal Lenses
Sub-limit R450 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
% Benefit 100% Sizwe Rates
Limit Included in above limit
MENTAL HEALTH Limited to Psychiatrists, Clinical and Counselling Psychologists relating
to mental health. Psychiatry, Clinical and Counselling Psychologists only
related to mental health. This excludes Educational Psychologists, Social
Workers and Registered Counsellors
% Benefit 100% Sizwe Rates
Family Limit R4 610 per year
AUXILIARY Audiologists, Chiroprators, Dieticians, Homeopaths, Occupational Therapists, Podiatrists, Speech Therapists, Social Workers and Education Psychologists, Biokenetics and Registered Counsellors
% Benefit 100% Sizwe Rates
Member R900
Member +1+ R1 460
CLINICAL AND MEDICAL TECHNOLOGISTS
% Benefit 100% Sizwe Rates
included in the Auxiliary limit above
MATERNITY
% Benefit 100% Sizwe Rates
Ante-Natal Consultations 9 GP or midwife visits 2 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 Syphillis
1 HIV Blood test, over and above regular Pathology benefits
Delivery Pre-authorisation is required
Post-Natal Services and Midwifery Subject to the Hospital or Maternity Benefit Management Programme
APPLIANCES
% Benefit 100% Sizwe Rates
Member R900
Member+1+ R1 460
WHEELCHAIR (Non-Motorised)
% Benefit 100% Sizwe Rates
Family Limit R1 680 every 2 years
HEARING AIDS 1 per beneficiary every 2 years
% Benefit 100% Sizwe Rates
Family Limit R4 610 every 2 years
CHRONIC MEDICINES Subject to pre-authorisation - 0860 103 455
Subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment protocols.
% Benefit 100% Sizwe Rates
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
% Benefit 100% Sizwe Rates
Limit No Limit but subject to treatment protocols. PMBs at DSP
% Benefit 100% Sizwe Rates
Limit No Limit
AMBULANCE Europ Assist SA 0860 117 799 Pre-authorisation is required. Contracted Provider
PRIVATE HOSPITALS AND NURSING HOMES Pre-authorisation is required unless in a medical emergency
Accommodation
% Benefit 100% Sizwe Rates
Limit No Limit
Clinical Limitations and Exclusions None
Frail Care No benefits
TTO (Medication to take home) Limited to a supply of 7 days
HOSPITAL ALTERNATIVES Subject to Hospital Benefit Management Programme, Disease Management
Programme and pre-authorisation
% Benefit 100% Sizwe Rates
Limit No Limit
IN-HOSPITAL BENEFITS
CHRONIC BENEFITS
PROVINCIAL HOSPITALS
% Benefit 100% Uniform Patient Fee Schedule (UPFS) Rates
Limit No Limit
PRIVATE NURSING
% Benefit 100% Sizwe Rates
Limit R4 050 per family
BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS Subject to PMBs
% Benefit 100% Sizwe Rates
Family Limit No Limit
GENERAL PRACTITIONERS
% Benefit 100% Sizwe Rates
Limit No Limit
SPECIALISTS
% Benefit 100% Sizwe Rates
Limit No Limit
RADIOLOGY AND RADIOGRAPHY
% Benefit 100% Sizwe Rates
Basic Radiology/ Radiography No Limit
Specialised Radiology (separate limit for MRI/CT/Angiograms R16 630 per family
combined in and out of hospital ) Pre-authorisation required
Interventional Radiology Within Hospital benefit. Subject to pre-authorisation and clinical protocols
PATHOLOGY
% Benefit 100% Sizwe Rates
Limit No Limit
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
Limit 21 days per beneficiary including psychiatric consultations and 6 in-hospital
consultations by a Clinical Psychologist.
Subject to PMBs
PROVINCIAL HOSPITALS
% Benefit 100% Uniform Patient Fee Schedule (UPFS) Rates
Limit No Limit
PRIVATE NURSING
% Benefit 100% Sizwe Rates
Limit R4 050 per family
BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS Subject to PMBs
% Benefit 100% Sizwe Rates
Family Limit No Limit
GENERAL PRACTITIONERS
% Benefit 100% Sizwe Rates
Limit No Limit
SPECIALISTS
% Benefit 100% Sizwe Rates
Limit No Limit
RADIOLOGY AND RADIOGRAPHY
% Benefit 100% Sizwe Rates
Basic Radiology/ Radiography No Limit
Specialised Radiology (separate limit for MRI/CT/Angiograms R16 630 per family
combined in and out of hospital ) Pre-authorisation required
Interventional Radiology Within Hospital benefit. Subject to pre-authorisation and clinical protocols
PATHOLOGY
% Benefit 100% Sizwe Rates
Limit No Limit
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
Limit 21 days per beneficiary including psychiatric consultations and 6 in-hospital
consultations by a Clinical Psychologist.
Subject to PMBs
ONCOLOGY Subject to pre-authorisation,Treatment Protocols and PMBs
%Benefit 100% Sizwe Rates
Family limit R100 000 per year
PROSTHESIS Subject to pre-authorisation,Treatment Protocols and PMBs
Surgical and Non-surgical
%Benefit 100% Sizwe Rates
Family Limit R22 790 per year
Internal Prosthesis
Joints 1 per beneficiary per year
Spine 1 level per beneficiary per year
Cardiac (Pacemaker, internal defibrillators, grafts, valves, etc) Subject to benefit limit PMB protocols
External Prosthesis Subject to the benefit limit and PMB protocols
STENTS
Cardiac Stents
% Benefit 100% Sizwe Rates
Family Limit 3 Stents per year
Vascular Stents
% Benefit 100% Sizwe Rates
Family Limit 2 Stents per year
AUXILIARY IN HOSPITAL
% Benefit 100% Sizwe Rates
Dieticians, Speech Therapists, Occupational Therapists Subject to PMBs, clinical protocols and pre-authorisation
ALCOHOLISM/DRUG ADDICTION/NARCOTISM Subject to pre-authorisation,Treatment Protocols and PMBs
Benefit 3 days withdrawal treatment and 21 days admission at an appropriate facility
ORGAN TRANSPLANTS AND RENAL DIALYSIS Subject to pre-authorisation,Treament Protocols and PMBs
% Benefit 100% Sizwe Negotiated Rates
Limit Unlimited for PMBs
SCREENING TESTS (Preventative care) Mammogram every 2 years for females over 40 years,
pap smear every 2 years for females over 21 years, prostate antigen test.
1 test per beneficiary per annum limited to males over 40 years
% Benefit 100% Sizwe Rates
Limit R1 800
WELLNESS BENEFITS
R 376
R 1 730
R 2 160
R 376
R 1 350
R 1 410
R 376
R 430
R 430
R0 - R500
R501 - R8 270
R8 271+
ONCOLOGY Subject to pre-authorisation,Treatment Protocols and PMBs
%Benefit 100% Sizwe Rates
Family limit R100 000 per year
PROSTHESIS Subject to pre-authorisation,Treatment Protocols and PMBs
Surgical and Non-surgical
%Benefit 100% Sizwe Rates
Family Limit R22 790 per year
Internal Prosthesis
Joints 1 per beneficiary per year
Spine 1 level per beneficiary per year
Cardiac (Pacemaker, internal defibrillators, grafts, valves, etc) Subject to benefit limit PMB protocols
External Prosthesis Subject to the benefit limit and PMB protocols
STENTS
Cardiac Stents
% Benefit 100% Sizwe Rates
Family Limit 3 Stents per year
Vascular Stents
% Benefit 100% Sizwe Rates
Family Limit 2 Stents per year
AUXILIARY IN HOSPITAL
% Benefit 100% Sizwe Rates
Dieticians, Speech Therapists, Occupational Therapists Subject to PMBs, clinical protocols and pre-authorisation
ALCOHOLISM/DRUG ADDICTION/NARCOTISM Subject to pre-authorisation,Treatment Protocols and PMBs
Benefit 3 days withdrawal treatment and 21 days admission at an appropriate facility
ORGAN TRANSPLANTS AND RENAL DIALYSIS Subject to pre-authorisation,Treament Protocols and PMBs
% Benefit 100% Sizwe Negotiated Rates
Limit Unlimited for PMBs
SCREENING TESTS (Preventative care) Mammogram every 2 years for females over 40 years,
pap smear every 2 years for females over 21 years, prostate antigen test.
1 test per beneficiary per annum limited to males over 40 years
% Benefit 100% Sizwe Rates
Limit R1 800
WELLNESS SCREENING CONSULTATIONS Blood sugar, cholesterol, blood pressure, BMI and HIV testing
% Benefit 100% Sizwe Rates
Limit R240 per beneficiary per year
CONTRACEPTIVES
% Benefit 100% Sizwe Rates
Limit R2 360 per family per year
Income Bracket Principal Member Adult Dependant Child Dependant
PRIMARY CARE CONTRIBUTIONS 2016
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 please go visit www.sizwe.co.za or call us on 0860 10 08 71
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
Ground Floor, Shop 13
Norton Rose House
8 Riebeek Street, Cape Town
Tel: +27 (21) 402 9600
Fax: +27 (21) 418 1400
DURBAN
7th Floor, Royal Towers
30 Dorothy Nyembe Street
Durban, 4000
Tel: +27 (31) 304 4829
Fax: +27 (31) 304 4839
PORT ELIZABETH
Ground Floor, Block E,
Southern Life Gardens,
70 2nd Avenue, Newton Park
Port Elizabeth, 6000
Tel: +27 (41) 503 1000
Fax: +27 (41) 503 1302
WELKOM
429 Stateway
Doorn (The Itec Building)
Welkom
Tel: +27 (57) 353 1475
EMALAHLENI
71 Mandela Drive
Cnr Plumer and Mandela Drives
(Opposite Lollipop Daycare Centre)
Emalahleni
Tel: +27 (13) 690 3342
SIZWE MEDICAL FUNDREGIONAL OFFICES