Sizwe Comparative Brochure

COMPARATIVE
G U I D E
2016
#caring4life
WHY SIZWE?
We offer a range of medical aid products, starting with a network healthcare
product ideal for lower-income earners right up to premium medical aid
products for high-income earners. To assist you in making an informed
choice on our various benefit options, have a look at what each option
offers.
DISCLAIMER:
Our 2016 benefits and contributions are subject to approval by the Registrar of Medical Schemes. This brochure is for information purposes only and does not supersede the rules of
the Fund. A full set of the rules is available on our website: www.sizwe.co.za
2016
HEALTHCARE
OFFERINGS
GOMOMO CARE
This is our entry-level option. Gomomo 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 in-hospital at selected network
hospital Covers the 27 CDL conditions.
SAVINGS CARE
This is our new generation option.
Comprehensive in-hospital benefits.
Out-of-hospital benefits paid from a 15% savings portion
available up front for the year.
No overall in-hospital limit with the freedom to go to any
private hospital.
PRIMARY CARE
Primary Care option 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, GP’s, specialists, radiology, pathology and more
to meet the needs of any family.
AFFORDABLE CARE
Our Affordable Care option offers generous comprehensive
cover with unlimited hospitalisation in any private hospital.
It also covers additional chronic conditions with specialised
dentistry and preventative benefits.
FULL BENEFIT CARE
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 offers additional chronic conditions, specialised
dentistry, GP’s, specialists, acute medication, preventative
care benefits and more rich benefits. This is the only option
which offers additional cover when in hospital up to 200% of
the Sizwe rate.
GOMOMO
SAVINGS
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
CARE
CARE
OUT OF HOSPITAL BENEFITS - Prescribed Minimum Benefits (PMB’s) are paid at Sizwe negotiated rates.
Day to Day Benefits Includes: General Practitioners (GP’s) Specialists (excluding Psychiatrists), Acute Medicine, Pathologists, Radiologists & Physiotherapists.
% Benefit
OUT OF HOSPITAL BENEFITS
Member
Member
Member
Member
Member
Member
Member
100% Sizwe Rates
+1
+2
+3
+4
+5
+6+
General Practitioners
Limited to stipulated
number of visits
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Subject to available
savings
R5 390
R7 980
R9 330
R10 670
R12 020
R13 370
R14 720
R9 330
R13 370
R15 390
R16 740
R18 760
R20 790
R15 390
R20 790
R23 370
R26 060
R28 770
R31 460
R34 150
R22 690
Additional GP visits per family on the Primary Care option only.
100% Sizwe Rates
Required benefits for
full year Subject to
Chosen GP Out of area
visits: 4 GP visits per
beneficiary. Subject to
pre-authorisation.
100% Sizwe Rates
Subject to available
savings
Member:
Member +1 :
Member +2 :
Member +3 :
Member +4 :
Member +5 :
Member +6+ :
4
9
12
14
15
16
17
Member
Member
Member
Member
Member
Member
Member
:
+1 :
+2 :
+3 :
+4 :
+5 :
+6+ :
7
14
16
18
20
21
22
Member
Member
Member
Member
Member
Member
Member
:
+1 :
+2 :
+3 :
+4 :
+5 :
+6+ :
12
20
25
29
30
31
32
Specialists (Excluding Psychiatrists) Acute Medicine, Pathologists, Radiologists & Physiotherapists.
Limited to stipulated
number of visits
All visits subject to
referral from a GP.
100% Sizwe Rates
Subject to available
savings
2
M
4
M
7
M
6
7
M+1
M+2
8
9
M+1
M+2
12
15
M+1
M+2
8
9
M+3
M+4
10
11
M+3
M+4
16
17
M+3
M+4
10
11
M+5
M+6+
12
13
M+5
M+6+
19
20
M+5
M+6+
First time specialist visits
are subject to GP referral.
First time specialist visits
are subject to GP referral.
GOMOMO
SAVINGS
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
CARE
CARE
OUT OF HOSPITAL BENEFITS - Prescribed Minimum Benefits (PMB’s) are paid at Sizwe negotiated rates.
Acute Medicines & Pharmacy Advised Therapy (PAT) - falls within day-to-day benefit with the following sub-limits
Member
100% Sizwe Rates
Member +1
Member +2
Required benefits for
full year.
Member +3
Member +4
Member +5
100% Sizwe Rates
Subject to available
R1 680
R3 250
R4 380
R3 030
R3 370
R4 940
R5 840
R7 750
R8 990
Subject to Formulary
R3 820
R6 290
R10 230
Over the counter: R265
per family
R3 930
R4 150
R7 190
R7 420
R10 890
R11 460
R4 490
R7 640
R12 020
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
savings
Member +6+
% Benefit
100% Sizwe Rates
General Radiology/
Radiography Limit
Managed care protocol
pre-authorisation.
Specialised
R6 360 per family
R22 500 per family
R16 630 per family
R25 280 per family
R33 260 per family
Subject to preauthorisation and clinical
protocols
Subject to preauthorisation and clinical
protocols
Subject to preauthorisation and clinical
protocols or day to day.
Subject to preauthorisation and clinical
protocols
Subject to preauthorisation and
clinical protocols
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Radiology
(Separate Limit for
MRI/CT/Angiograms
combined In and
Out of Hospital)
Interventional
Radiology
Physiotherapy
% Benefit
100% Sizwe Rates
100% Sizwe Rates
Pathology
% Benefit
100% Sizwe Rates
At designated service
provider (DSP)
100% Sizwe Rates
100% Sizwe Rates
OUT OF HOSPITAL BENEFITS
Radiology & Radiography
GOMOMO
SAVINGS
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
CARE
CARE
OUT OF HOSPITAL BENEFITS - Prescribed Minimum Benefits (PMB’s) are paid at Sizwe negotiated rates.
Dentistry
OUT OF HOSPITAL BENEFITS
Conservative Dentistry: Subject to Dental Management Programme - 0860 109556
% Benefit
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Consultations, Oral
Hygiene, Extractions,
Filling
Consultation and Oral
hygiene treatment is
available once a year per
beneficiary.
Subject to available
savings.
Consultations and Oral
hygiene treatment is
2 annual consultations
and oral hygiene
treatment per year, once
every 6 months.
2 annual consultations
and oral hygiene
treatment per year,
once every 6 months.
available once a year,
every 6 months
Subject to managed care
protocols.
2 annual consultations
and oral hygiene
treatment per year, once
every 6 months.
Subject to managed care
protocols.
100% Sizwe Rates
Orthodontics on this
100% Sizwe Rates
Subject to managed
care protocols.
Subject to managed care
protocols.
Specialised Dentistry
% Benefit
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
option has a 35%
co-payment.
Crowns and Bridges
No Benefit
Benefit is subject to
No Benefit
Pre-authorisation is
required. 1 crown per
family per year.
Benefit is subject to
managed care protocols.
Pre-authorisation is
required. 3 crowns per
family per year.
Benefit is subject to
managed care protocols.
No Benefit
Pre-authorisation is
required. On preauthorisation cases will
be clinically assessed
and funding can be
granted up to 65% of
the Sizwe Rates.
Orthodontic treatment is
limited to beneficiaries
from age 9 and younger
than 18 years of age.
Benefit is subject to
managed care protocols.
Pre-authorisation is
required. Orthodontic
treatment is limited to
beneficiaries from
age 9 and younger than
18 years of age. Benefit
is subject to managed
care protocols.
managed care protocols.
Benefit for crowns are
limited to once per tooth
in 5 years.
Orthodontics
(Braces)
No Benefit
Benefit is subject to
managed care protocols.
Benefit for orthodontic
treatment is limited to
beneficiaries from age 9
and younger than 18
years of age.
GOMOMO
SAVINGS
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
CARE
CARE
OUT OF HOSPITAL BENEFITS - Prescribed Minimum Benefits (PMB’s) are paid at Sizwe negotiated rates.
Specialised Dentistry
Implants
No Benefit
Subject to the available
No Benefit
No Benefit
savings.
Benefit is subject to
Pre-authorisation is
required.
2 Implants per
beneficiary per annum
managed care protocols.
over a 5 year period.
The cost of the implant
Partial Metal
Frame Dentures
Plastic Dentures
No Benefit
1 Set of plastic dentures,
an upper and a lower
per beneficiary in a 4
year period. Benefit is
subject to managed care
protocols.
Benefit is subject to
managed care protocols.
Subject to the available
savings. Managed Care
protocols apply.
X2 partial frames per
beneficiery in a 5 year
period.
Limited to X1 family
member per anumm.
X2 partial frames per
beneficiery in a 5 year
period.
Limited to X2 family
member per anumm.
Plastic Dentures and
associated laboratory
costs: 1 set of plastic
Plastic Dentures and
associated laboratory
costs: 1 set of plastic
Plastic Dentures and
associated laboratory
costs: 1 set of plastic
dentures (an upper and
a lower) per beneficiary
in a 4 year period. 1 set
dentures (an upper and
a lower) per beneficiary
in a 4 year period. 1 set
dentures (an upper and
a lower) per beneficiary
in a 4 year period. 1 set
of partial dentures
(an upper and a lower)
of partial dentures
(an upper and a lower)
of partial dentures
(an upper and a lower)
per beneficiary in a 2
year period.
per beneficiary in a 2
year period.
per beneficiary in a 2
year period.
No Benefit
Dentistry
Surgery
Benefit is subject to
managed care protocols.
Benefit is subject to
managed care protocols.
Surgery in the dental
chair: Benefit is subject to
Clinical restrictions apply
benefit is subject to
Benefit is subject to
managed care protocols.
Surgery in the dental
rooms only. Benefit is
Surgery in the dental
rooms only.
managed care protocols.
managed care protocols.
Surgery in the dental
Surgery in the dental
rooms only.
only available for the
following codes: 8931,
8935, 9011 and 9013.
rooms only.
OUT OF HOSPITAL BENEFITS
component is limited to
R2 350 per implant.
GOMOMO
SAVINGS
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
CARE
CARE
OUT OF HOSPITAL BENEFITS - Prescribed Minimum Benefits (PMB’s) are paid at Sizwe negotiated rates.
Optical
Choose either spectacles (frames and lenses) OR contact lenses once every 2 years.
OUT OF HOSPITAL BENEFITS
Eye Test
% Benefit
100% Sizwe Rates
Subject to
pre-authorisation
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Limit
1 test per beneficiary
every 2 years
Subject to available
savings
1 test per beneficiary
every 2 years
1 test per beneficiary
every 2 years
1 test per beneficiary
every 2 years
% Benefit
100% Sizwe Rates
Frames limited to R465
per beneficiary.
100% of Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Member
Member
Member
Member
Member
Member
Member
R1
R1
R1
R1
Subject to available
savings
R1
R1
R1
R1
R1
R1
R1
R1 570
R1 680
R1 900
R2 020
R2 086
R2 130
R2 190
R2
R2
R2
R2
R3
R3
R3
Subject to available
savings
R450 per lens
R680 per lens
R680 per lens
Frames & Lenses
+1
+2
+3
+4
+5
+6+
Combined Limit for frames and lenses benefit
010
160
290
850
120
240
290
350
460
570
632
360
470
810
920
030
150
200
Multi Focal Lenses
Sub limit
Contact Lenses
% Benefit
Limit
No Benefit
One pair of permanent contact lenses every 2 years or 12 pairs of monthly disposable contact lenses per beneficiary per annum.
100% Sizwe Rates
100% of Cost
Subject to available
savings
100% Sizwe Rates
Included in above
100% Sizwe Rates
Included in above
100% Sizwe Rates
Included in above
No Benefit
No Benefit
No Benefit
100% Sizwe Rates
R5 618 per family
100% Sizwe Rates
R10 791 per family
Refractive Surgery
% Benefit
Limit
GOMOMO
SAVINGS
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
CARE
CARE
OUT OF HOSPITAL BENEFITS - Prescribed Minimum Benefits (PMB’s) are paid at Sizwe negotiated rates.
Mental Health
Psychiatrists, Clinical & Counselling Psychologists - only if related to mental health,
excludes Educational Psychologists, Social Workers and Registered Counsellors
% Benefit
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Family Limit
Included in Specialist
benefit
Subject to PMB’s
R6 750
R4 610
R7 640
R14 720
% Benefit
Audiologists, Chiropractors, Dieticians, Homeopaths, Occupational Therapists, Podiatrists, Speech Therapists,
Social Workers, Educational Psychologists, Biokinetics and Registered Counsellors.
100% Sizwe Rates
Limited to R2 250 per
family per annum
Maternity
100% Sizwe Rates
Subject to available
savings
100% Sizwe Rates
M: R900
M+1+: R1 460
100% Sizwe Rates
M: R1 350
M+1+: R2 360
100% Sizwe Rates
M: R2 470
M+1+: R4 150
Subject to registration on the maternity programme within 24 weeks of falling pregnant
% Benefit
100% Sizwe Rates
100% Sizwe Rates
Subject to available
savings
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Ante-Natal
Consultations
Within GP and Specialist
limit
9 GP/midwife visits 2
Specialist visits
9 GP/midwife visits 2
Specialist visits
9 GP/midwife visits 4
Specialist visits
9 GP/midwife visits 6
Specialist visits
Pregnancy Scans
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
.
OUT OF HOSPITAL BENEFITS
Auxiliary
GOMOMO
SAVINGS
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
CARE
CARE
CHRONIC BENEFITS: Subject to pre-authorisation. CHRONIC MEDICINES: subject to registration on the Chronic
Medicine Programme - 0860 10 34 55. PMBs subject to pre-authorisation, prefered providers and treatment protocols.
% Benefit
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Limit
R7 000 per beneficiery
Cover for 27 PMB
chronic conditions
Cover for PMB chronic
conditions
11 additional conditions
Cover for PMB Chronic
Conditions+ HRT &
Major Depression
R4 940 per beneficiary
Cover for PMB chronic
conditions.
R9 770 per beneficiary
Cover for PMB chronic
conditions.
13 additional conditions.
33 additional conditions.
% Benefit
Limit
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.
100% Sizwe Rates
100% Sizwe Rates
No limit but subject to
treatment protocols.
Subject to PMBs
No limit but subject to
treatment protocols.
Subject to PMBs
100% Sizwe Rates
No limit but subject to
treatment protocols.
Subject to PMBs
100% Sizwe Rates
No limit but subject to
treatment protocols.
Subject to PMBs
100% Sizwe Rates
No limit but subject to
treatment protocols.
Subject to PMBs
CHRONIC BENEFITS
HIV/Aids
GOMOMO
SAVINGS
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
CARE
CARE
IN-HOSPITAL BENEFITS
% Benefit
Top-up Cover
(must be applied
for within 3 months
of hospitalisation)
No Benefit
No Benefit
Ambulance
No Benefit
100% Sizwe Rates
+ 200%
EUROP ASSIST SA 0860 11 77 99
Private Hospitals & Nursing Homes
IN-HOSPITAL BENEFITS
No Benefit
Subject to Treatment and Case Management Protocols and PMBs.
Pre-authorisation required unless it is a medical emergency.
Accommodation
A co-payment will apply
to all unauthorised
admissions unless
emergency
% Benefit
Limit
100% Sizwe Rates
No Limit
100% Sizwe Rates
No Limit
100% Sizwe Rates
No Limit
100% Sizwe Rates
No Limit
100% Sizwe Rates
No Limit
Clinical Limitations
and Exclusions
Advanced Laparoscopic,
Reconstructive &
Cardiac Surgery, Joint
Replacements,
Spinal Surgery,
Breast Reconstructions
and Augmentations.
None
Advanced Laparoscopic,
Reconstructive &
Cardiac Surgery, Joint
Replacements,
Spinal Surgery, Breast
Reconstructions and
Augmentations.
None
None
Dental Hospitalisation
General
anaesthetic
in hospital
A co-payment will apply
to all unauthorised
admissions unless
emergency.
Subject to pre-authorisation and Dental Benefit Management Programme and Clinical Protocols.
Subject to R1 500 co-payment on some options.
Pre-Authorisation
required. Admission
protocols apply.
Limited to PMB
treatment only.
A co-payment of R1 500
per hospital admission
applies. Benefit is
subject to managed
care protocols. General
anaesthetic benefits are
available for beneficiaries
under the age of 5 years
for extensive dental
treatment only. General
anaesthetic treatment is
available for the removal
of impacted teeth.
A co-payment of R1 500
per hospital admission
applies. Benefit is
subject to managed
care protocols. General
anaesthetic benefits are
available for beneficiaries
under the age of 5 years
for extensive dental
treatment only. General
anaesthetic treatment is
available for the removal
of impacted teeth.
A co-payment of R1 500
per hospital admission
applies. Benefit is
subject to managed
care protocols. General
anaesthetic benefits are
available for beneficiaries
under the age of 5 years
for extensive dental
treatment only. General
anaesthetic treatment is
available for the removal
of impacted teeth.
A co-payment of R1 500
per hospital admission
applies. Benefit is
subject to managed
care protocols. General
anaesthetic benefits are
available for beneficiaries
under the age of 5 years
for extensive dental
treatment only. General
anaesthetic treatment is
available for the removal
of impacted teeth.
GOMOMO
CARE
SAVINGS
CARE
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
IN-HOSPITAL BENEFITS
% Benefit
Subject to pre-authorisation and Dental Benefit Management Programme and Clinical Protocols.
Subject to R1 500 co-payment on some options.
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Benefit is subject to
managed care protocols.
Benefit is limited to
extensive dental
treatment.
Benefit is subject to
managed care protocols.
Benefit is limited to
extensive dental
treatment.
100% Sizwe Rates
Benefit is subject to
managed care protocols.
100% Sizwe Rates
Benefit is subject to
managed care protocols.
100% Sizwe Rates
Benefit is subject to
managed care
protocols.
100% Sizwe Rates
No limit
100% Sizwe Rates
No limit
100% Sizwe Rates
No limit
100% Sizwe Rates
No limit
100% Sizwe Rates
Subject to PMB’s
100% Sizwe Rates
Subject to PMB’s
100% Sizwe Rates
Subject to PMB’s
100% Sizwe Rates
Subject to PMB’s
Conscious sedation
in rooms
Benefit is subject to
managed care protocols.
Benefit is limited to
extensive dental
treatment.
Pre-authorisation is
required. Removal of
impacted teeth only.
Laughing gas in
dental rooms
100% Sizwe Rates
Benefit is subject to
managed care protocols.
Subject to available
savings. Benefit is
subject to managed
care protocols.
100% Sizwe Rates
Required benefits for full
year
100% Sizwe Rates
Pre Authorisation
required. Subject to
PMB’s
Benefit is subject to
managed care protocols.
Benefit is limited to
extensive dental
treatment.
100% Sizwe Rates
General Practitioner
% Benefit
Limit
Auxiliary
Benefit
Dietician, Speech
Therapists &
Occupational
Therapists
Radiology & Radiography
% Benefit
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
General Radiology/
Radiography Limit
Required benefits for
full year
No Limit
No Limit
No Limit
No Limit
Specialised Radiology
(Separate Limit for
MRI/CT/Angiograms
combined
In and Out of
Hospital)
R6 360 per family
R22 500 per family
R16 630 per family
R25 280 per family
R33 260 per family
IN-HOSPITAL BENEFITS
Dental Hospitalisation
GOMOMO
SAVINGS
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
CARE
CARE
IN-HOSPITAL BENEFITS
Pathology
Benefits
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Subject to
pre-authorisation
and DSPs 21 days per
beneficiary including
psychiatric consultations
and 6 in-hospital
consultations by a
Clinical or Counselling
Psychologist.
Subject to
pre-authorisation
and DSPs 21 days per
beneficiary including
psychiatric consultations
and 6 in-hospital
consultations by a
Clinical or Counselling
Psychologist.
Subject to
pre-authorisation
and DSPs 21 days per
beneficiary including
psychiatric consultations
and 6 in-hospital
consultations by a
Clinical or Counselling
Psychologist.
Subject to
pre-authorisation
and DSPs 21 days per
beneficiary including
psychiatric consultations
and 6 in-hospital
consultations by a
Clinical or Counselling
Psychologist.
Subject to
pre-authorisation
and DSPs 21 days per
beneficiary including
psychiatric consultations
and 6 in-hospital
consultations by a
Clinical or Counselling
Psychologist.
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
100% Sizwe Rates
Psychiatric Hospitalisation
IN-HOSPITAL BENEFITS
% Benefit
Specialists
% Benefit
Maternity
Subject to registration on the maternity programme within 24 weeks of falling pregnant
Delivery
Pre-authorisation
required.
Pre-authorisation
required
Pre-authorisation
required.
Pre-authorisation
required
Pre-authorisation required
Post Natal Services
and Midwifery
Subject to
pre-authorisation
and Hospital Benefit
Management
Programme.
Subject to
pre-authorisation and
Hospital Benefit
Management
Programme.
Subject to
pre-authorisation
and Hospital Benefit
Management
Programme.
Subject to
pre-authorisation and
Hospital Benefit
Management
Programme.
Subject to
pre-authorisation and
Hospital Benefit
Management
Programme.
100% Sizwe Rates
Required benefits for
full year
100% Sizwe Rates
No Limit
100% Sizwe Rates
No Limit
100% Sizwe Rates
No Limit
100% Sizwe Rates
Limit per family
R37 980
100% Sizwe Rates
Limit per family
R50 138
Provincial Hospitals
% Benefit
Limit
Prosthesis
Surgical
% Benefit
Limit
100% Sizwe Rates
No Limit
Subject to Pre-authorisation and PMBs
100% of Sizwe Rates
PMBs apply
Pre-authorisation
required
100% Sizwe Rates
R33 765
100% Sizwe Rates
Limit per family
R 22 790
GOMOMO
SAVINGS
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
CARE
CARE
IN-HOSPITAL BENEFITS
Alcoholism/Drug Addiction/Narcotism
Benefit
3 days withdrawal
treatment plus 21 days
Rehabilitation
at an appropriate facility
Subject to Pre-authorisation and PMBs
3 days withdrawal
treatment plus 21 days
Rehabilitation
at an appropriate facility
3 days withdrawal
treatment plus 21 days
Rehabilitation
at an appropriate facility
3 days withdrawal
treatment plus 21 days
Rehabilitation
at an appropriate facility
3 days withdrawal
treatment plus 21 days
Rehabilitation
at an appropriate facility
100% Sizwe Rates
R178 796
100% Sizwe Rates
PMBs at DSPs
100% Sizwe Rates
PMBs at DSPs
100% Sizwe Rates
PMBs at DSPs
Organ Transplants & Renal Dialysis
100% Sizwe Rates
PMBs at DSPs
Stents
Subject to PMB’s
CARDIAC STENTS
%Benefit
Limit
100% Sizwe Rates
3 per family
100% Sizwe Rates
3 per family
100% Sizwe Rates
3 per family
100% Sizwe Rates
3 per family
VASCULAR STENTS
%Benefit
Limit
100% Sizwe Rates
2 per family
100% Sizwe Rates
2 per family
100% Sizwe Rates
2 per family
100% Sizwe Rates
2 per family
100% Sizwe Rates
R 250 000
100% Sizwe Rates
R 300 000
Oncology
%Benefit
Limit
Subject to PMB’s
100% Sizwe Rates
Subject to PMBs
100% Sizwe Rates
R114 480
100% Sizwe Rates
R 100 000
IN-HOSPITAL BENEFITS
% Benefit
Limit
#caring4life
GOMOMO
CARE
SAVINGS
CARE
PRIMARY
AFFORDABLE
FULL BENEFIT
CARE
CARE
CARE
WELLNESS BENEFITS
% Benefit
Limit
100% Sizwe Rates
Within GP, Pathology
limit
Wellness Screening Consultation
% Benefit
Limit
100% Sizwe Rates
R1 802
100% Sizwe Rates
R1 802
100% Sizwe Rates
R1 802
100% Sizwe Rates
R1 802
Blood sugar, cholesterol, blood pressure, BMI & HIV
100% Sizwe Rates
Within GP, Pathology
limit
100% Sizwe Rates
R286
100% Sizwe Rates
R244
100% Sizwe Rates
R244
100% Sizwe Rates
R244
No Benefit
100% Sizwe Rates
Subject to available
savings
100% Sizwe Rates
R2 364 per family per
annum
100% Sizwe Rates
R2 364 per family per
annum
100% Sizwe Rates
R2 364 per family per
annum
% Benefit
Limit
WELLNESS BENEFITS
Oral Contraceptives
CONTRIBUTIONS 2016
GOMOMO CARE
Income Bracket
Income Category
Principal Member
Adult Dependant
Child Dependant
R0 - R6 360
R6 361 - R7 420
R7 421 - R9 540
R9 541 +
460
470
480
490
R700
R1 030
R1 530
R1 890
R690
R1 020
R1 420
R1 490
R290
R370
R370
R380
Income Bracket
Income Category
Principal Member
Adult Dependant
Child Dependant
R0 – R14 200
R14 201 +
580
590
R1 850
R2 570
R1 600
R2 060
R450
R510
15 % of total contribution paid to savings account.
PRIMARY CARE
Income Bracket
Income Category
Principal Member
Adult Dependant
Child Dependant
R0 - R500
R500 - R8 270
R8 271 +
170
180
R376
R1 730
R2 160
R376
R1 350
R1 410
R376
R430
R430
Income Bracket
Income Category
Principal Member
Adult Dependant
Child Dependant
R0 - R14 200
R14 201 +
280
290
R2 470
R3 430
R2 270
R3 050
R570
R680
Income Bracket
Income Category
Principal Member
Adult Dependant
Child Dependant
R0 - R17 810
380
R3 830
R3 480
R780
R17 811 +
390
R4 530
R4 120
R890
AFFORDABLE CARE
FULL BENEFIT CARE
CONTRIBUTIONS 2016
SAVINGS CARE
#caring4life
IMPORTANT CONTACT DETAILS
CHRONIC MEDICATION PROGRAMME:
Tel: 0860 10 34 55 | 011 353 0030
Fax: 011 353 0352/0076
chronic@sizwemedfund.co.za
HOSPITAL PRE-AUTHORISATION, HOSPITAL
BENEFIT MANAGEMENT PROGRAMME:
Tel: Tel: 0860 10 11 76
DENTAL BENEFIT MANAGEMENT:
Tel: 0860 10 95 56 | Fax: 0866 77 03 36
sizweenq@denis.co.za
WELLNESS PROGRAMME–HELPLINE FOR
ASTHMA, CARDIOVASCULAR DISEASE,
DIABETES AND MENTAL HEALTH:
Tel: 0860 10 34 55 | Fax: 011 221 5238
wellnessqueries@sizwemedfund.co.za
HIV/AIDS MANAGEMENT PROGRAMME:
Tel: 0860 10 34 54 | Fax: 011 221 5235/56
EUROP ASSISTANCE SA, MEDICAL
EMERGENCIES, 24-HOUR AMBULANCE
SERVICES AND MEDICAL ADVICE:
Tel: 0860 11 77 99
MATERNITY
Fax: 011 221 5218
Email: maternity@sizwemedfund.co.za
TIP-OFFS ANONYMOUS FRAUD LINE:
Tel: 0800 20 47 02 | Fax: 0800 00 77 88
Email: sizwemedical@tip-offs.com
CHRONIC MEDICATION PROGRAMME:
Tel: 0860 10 34 55 | 011 353 0030
Fax: 011 353 0352/0076
chronic@sizwemedfund.co.za
www.sizwe.co.za
queries@sizwe.co.za
0860 100 871