Affordable Care - 2018

1 Affordable Care - 2018pg 2 Affordable CAREThis care option offers generous comprehensive cover with unlimited hospitalisation at any private hospital. It also covers additional chronic conditions with specialised dentistry and preventative benefits. This option is suitable for young and healthy 2 2018 Healthcare Offeringspg 3 pg 3 2018 Healthcare OfferingsAUXILIARY SERVICES(Dietician, Speech Therapy, Occupational Therapy.)Reimbursement rate100% Sizwe rateBenefitsSubject to pre authorisa-tion and PMBsPHYSIOTHERAPY(Pre-authorisation and managed care protocols apply.)Reimbursement rate100% Sizwe rateMATERNITY(Hospitalisation [public or private hospitals] delivery, post-natal services and midwifery.)Reimbursement rate100% Sizwe rateBLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTSR eimbursement rate100% Sizwe rates; limited to PMBsPROSTHESIS(Subject to pre-authorisation, treatment protocols and PMBs.)Reimbuirsement rate100% Sizwe rateBenefits100% of costMaximum of 3 cardiac stents and 2 vascular stents per family per annumAnnual limit: R42 670 OUT OF HOSPITAL BENEFITSO ption structureMajor medical.

2 Day to day: RiskProviderAnyOVERALL DAY-TO-DAY LIMITB enefitM: R9 840M+1: R14 100M+2: R16 230M+3: R17 660M+4: R19 790M+5: R21 930M+6+: R23 930 GENERAL PRACTITIONERSR eimbursement rate100% Sizwe rateBenefitsLimited number of visitsVisitsM: 7M+1: 14M+2: 16M+3: 18M+4: 20M+5: 21M+6+: 22 SPECIALISTSR eimbursement rate100% Sizwe rateVisitsSubject to referral by a GP, with the exception of: Follow-up visits, Emergencies, Gynaecologist and Paediatrician visits for babies up to the age of 12 : 4M+1: 8M+2: 9M+3: 10M+4: 11M+5: 12M+6+:13 ACUTE MEDICINESR eimbursement rate100% Sizwe rateBenefitsWithin day-to-dayM: R3 420 M+1: R5 210 M+2: R6 160 M+3: R6 630 M+4: R7 580 M+5: R7 820 M+6+:R8 060 RADIOLOGY AND RADIOGRAPHYR eimbursement rate100% Sizwe rateBenefitsSubject to clinical protocolsSpecialised Radiology: (MRI/CAT scan/Angiogram) pre-authorisation and managed care protocolsBenefitsSubject to an overall combined in and out of hospital limit of R28 400 per familyMENTAL HEALTHR eimbursement rate100% Sizwe rateLimited to Psychiatrists, Clinical and Counselling Psychologists subject to R8 580 per familyBenefitRisk benefitPHYSIOTHERAPYR eimbursement rate100% Sizwe ratePaid from the day-to-day limitPATHOLOGYR eimbursement rate100% Sizwe rateDENTISTRY(Subject to Dental Management Programme - accessed through DENIS - 0860 109 556.)

3 Conservative DentistryReimbursement rate100% Sizwe rateBenefits2 general check-ups a year per beneficiary Motivation may be requested for extensive restorative treatment plans (fillings) Root Canal treatment Subject to managed care protocolsPlastic dentures1 set of plastic dentures, full or partial (an upper and a lower) per beneficiary in a 4-year periodSPECIALISED DENTISTRYR eimbursement rate100% Sizwe rateBenefitsSubject to pre-authorisation and managed care protocolsCrowns and bridges1 Crown per family per year Dentures metal2 partial frames (an upper and a lower) per beneficiary in a 5 year period, limited to 1 family member per annumOrthodontic treatmentPre-authorisation and clinical protocolsRestricted to beneficiary 9 years and younger than 18 years of age, 35% co-payment)OPTICAL BENEFITS ACCESSED THROUGH PPNR eimbursement rate100% Sizwe rateCycle2 yearsBenefitsLimit per beneficiaryFramesR800 Single focus lensesR175 per lensBi-focal lensesR380 per lensMulti-focal lensesR695 per lensContact lensesR1 500 AUXILIARY SERVICES (Speech therapy, Podiatry, Occupational Therapy, Social Worker, Dietetics, Audiology, Homeopathy, Biokineticist and Registered Counselor.

4 Reimbursement rate100% Sizwe rateBenefitsM: R 1 510 M+1+: R 2 640 MATERNITY (ANTENATAL)(Subject to registration on the Sizwe Baby Programme within 24 weeks of falling pregnant.)Reimbursement rate100% Sizwe rateAnte-natal consultations9 GP, Midwife or specialists visits Additional 4 Obstetrician /specialist visitsPregnancy scans and blood tests2x 2D scansBlood tests:2x Haemoglobin measurement tests, 1x Blood Grouping test, 1x VDRL test for Syphilis and 1 HIV blood testInfertilityNo benefitIN-HOSPITAL BENEFITS(All hospital admissions must be authorisedR1500 co-payment will be applied if authorisation was not obtained except in emergencies.)Annual LimitSubject to pre-authorisation and managed care protocolsProvider NetworkAnyAMBULANCE SERVICES100% cost as authorised by EUROP ASSIST SA (Telephone number: 0860 11 77 99)PRIVATE HOSPITALS AND NURSING HOMES(Subject to treatment and case management protocols and PMBs.)

5 Pre-authorisation required unless it is a medical emergency. A co-payment will apply to all unauthorised admissions unless it is an emergency.)AccommodationUnlimited at any private hospitalReimbursement rate100% Sizwe rateClinical limitations and exclusionsNoneDENTAL HOSPITALISATION(Subject to pre-authorisation, Dental Benefit Management Programme and clinical protocols subject to R1 500 co-payment.)Reimbursement rate100% Sizwe rateGeneral anaesthetic(children under the age of 5 for extensive dental treatment)Pre-authorisation is required, subject to man-aged care protocolsLaughing gas in rooms100% Sizwe rateConscious sedation in roomsSubject to pre-authorisation and managed care protocolsGENERAL PRACTITIONER AND SPECIALISTR eimbursement rate100% Sizwe rate for consultations and visits in-hospitalCHRONIC MEDICINESR eimbursement rate100% Sizwe ratePMB conditions 27 LimitR5 540 per beneficiaryNon PMBM: R5 540 M+1: R11 090 M+2: R16 640 M+3: R22 190 M+4: R27 730M+5: R33 300M+6+:R38 850 HIV/AIDS(Members are encouraged to register with the HIV/AIDS Management Programme.

6 This benefit includes relevant consultations, counselling, medication and the cost of blood tests for monitoring purposes.)Reimbursement rate100% Sizwe rateBenefitSubject to treatment protocols and PMBspg 4 pg 4 2018 Healthcare OfferingsONCOLOGYR eimbursement rate100% Sizwe rateBenefitR314 170 per familyRADIOLOGY AND RADIOGRAPHYR eimbursement rate100% Sizwe rateSpecialised Radiology (MRI/CAT scan/ Angiogram) Pre-authorisation and managed care protocolsLimited to R28 400 per family per annum, pre-authorisation and managed care protocolsInterventional radiologyPayable from the hospital limit, subject to pre-authorisation and clinical protocolsPATHOLOGYR eimbursement rate100% Sizwe rateMENTAL HEALTHP sychiatry hospitalisationLimited to 21 days per beneficiary per annumPsychiatrist consultations and 6 in-hospital Clinical Psychologists subject to PMBsAlcoholism, drug addiction, narcotism: subject to PMBs, pre-authorisation and minimum benefit package3 days withdrawal treatment and up to 21 days rehabilitationORGAN TRANSPLANT AND RENAL DIALYSISR eimbursement rate100% Sizwe rateBenefitsRestricted to PMBs, subject to pre-authorisation, minimum benefit package, treatment protocols and DSPREFRACTIVE SURGERY INCLUDING RADIAL KERATOTOMYR eimbursement rateLimited to R6 310 per familyPREVENTATIVE BENEFITSR eimbursement rate100% Sizwe rateConsultation benefitsR1 470 per familyScreening benefitsSubject to R2 020 per family for flu vaccine and pneumococcal vaccineMammogram: every 2 years for women above age 40 yearsPap smear: every 2 years for women above 21 yearsProstate-Specific Antigen (PSA): once per year for males over 40 yearsORAL CONTRACEPTIVESR eimbursement rate100% Sizwe rateBenefitsR2 620 per family per annumSubject to managed care protocols and formularyOTHER BENEFITSA ppliancesM.

7 R1 510M+1+1: R2 640 Non-motorised wheelchairLimited to R3 150 per familyOnce in every 4 yearsHearing aidsR12 000 per familyOne unit per beneficiary every 4 yearsPrivate nurseR6 780 ChiropractorsR1 300 per beneficiaryIncome BracketPrincipal MemberAdult DependantChild DependantR 0 - R 15955R 2870R 2637R 662R 15956 - R 25999R 2985R 2741R 693R 26000 + R 3840R 3414R 767 Only pay for first 3 childrenpg 5 2018 Healthcare OfferingsCONTRIBUTIONSpg 6 Hospital Pre-Authorisation, Hospital Benefit Management Programme:Tel: 0860 101 176 Dental Benefit Management:Tel: 0860 109 556 Fax: 0866 770 336 Email: Programme Helpline For Asthma, Cardiovascular Disease, Diabetes And Mental Health:Tel: 0860 103 455 Fax: 011 221 5238 Email: Management Programme:Tel: 0860 103 454 Fax: 011 221 5235/56 Europ Assistance Sa, Medical Emergencies, 24-Hour Ambulance Services And Medical Advice:Tel: 0860 117 799 Sizwe Baby Programme:Fax: 011 221 5218 Email: Anonymous Fraud Line:Tel: 0800 204 702 Fax: 0800 007 788 Email: Medication Programme:Tel: 0860 103 455 / 011 353 0030 Fax: 011 353 0352/0076 Email: 6 2018 Healthcare OfferingsIMPORTANT CONTACT 100 871