PRIMARY CARE 2016 - Sizwe

1 P R I M A R Y. C A R E. 2016 . BENEFITS. GUIDE. #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. DAY-TO-DAY BENEFITS. Includes: General Practitioners, Specialists (excluding Psychiatrists), Acute Medicines, Pathologists, Radiologists and Physiotherapists.

2 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. 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.

3 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.

4 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.

5 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.

6 % 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 BENEFITS. 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. IN-HOSPITAL BENEFITS. % 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 PROVINCIAL HOSPITALS.

7 % 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.

8 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 WELLNESS BENEFITS.

9 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 PRIMARY care CONTRIBUTIONS 2016 . Income Bracket Principal Member Adult Dependant Child Dependant R0 - R500 R 376 R 376 R 376. R501 - R8 270 R 1 730 R 1 350 R 430. R8 271+ R 2 160 R 1 410 R 430. 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 or call us on 0860 10 08 71. Sizwe MEDICAL FUND.

10 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. 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. 0860 100 871.