PRIMARY CARE 2016 - Sizwe · RADIOLOGY AND RADIOGRAPHY Falls within day-to-day benefit with the...

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


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 0860 109 556

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 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


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


Limit 1 test per beneficiary every 2 years

Combined Frames and Lenses


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


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


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


Member R900

Member +1+ R1 460

CLINICAL AND MEDICAL TECHNOLOGISTS


included in the Auxiliary limit above

MATERNITY


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


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


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 0860 109 556

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 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


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


Limit 1 test per beneficiary every 2 years

Combined Frames and Lenses


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


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



AUXILIARY Audiologists, Chiroprators, Dieticians, Homeopaths, Occupational Therapists, Podiatrists, Speech Therapists, Social Workers and Education Psychologists, Biokenetics and Registered Counsellors


Member R900

Member +1+ R1 460

CLINICAL AND MEDICAL TECHNOLOGISTS


included in the Auxiliary limit above

MATERNITY


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


Member R900

Member+1+ R1 460

WHEELCHAIR (Non-Motorised)


Family Limit R1 680 every 2 years

HEARING AIDS 1 per beneficiary every 2 years


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.


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


Limit No Limit but subject to treatment protocols. PMBs at DSP


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


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


Limit No Limit

IN-HOSPITAL BENEFITS

CHRONIC BENEFITS

PROVINCIAL HOSPITALS

% Benefit 100% Uniform Patient Fee Schedule (UPFS) Rates

Limit No Limit

PRIVATE NURSING


Limit R4 050 per family

BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS Subject to PMBs


Family Limit No Limit

GENERAL PRACTITIONERS


Limit No Limit

SPECIALISTS


Limit No Limit

RADIOLOGY AND RADIOGRAPHY


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


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


Limit R4 050 per family

BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS Subject to PMBs


Family Limit No Limit

GENERAL PRACTITIONERS


Limit No Limit

SPECIALISTS


Limit No Limit

RADIOLOGY AND RADIOGRAPHY


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


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



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


Family Limit 3 Stents per year

Vascular Stents



AUXILIARY IN HOSPITAL


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


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


Family limit R100 000 per year

PROSTHESIS Subject to pre-authorisation,Treatment Protocols and PMBs

Surgical and Non-surgical



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



Vascular Stents



AUXILIARY IN HOSPITAL


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


Limit R1 800

WELLNESS SCREENING CONSULTATIONS Blood sugar, cholesterol, blood pressure, BMI and HIV testing


Limit R240 per beneficiary per year

CONTRACEPTIVES


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

www.sizwe.co.za

[email protected]

0860 100 871

PRIMARY CARE 2016 - Sizwe · RADIOLOGY AND RADIOGRAPHY Falls within day-to-day benefit with the...

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