Sizwe Benefit Brochure 2017 Web A5 06122016

1 2017 BENEFITBROCHURE#caring4lifeWHY 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 :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: CAREThe Hospital Care Option offers peace of mind knowing that in the event of hospitalisation, extensive cover is available at any private hospital. In addition, the Hospital Care Option provides cover for 27 Chronic Disease List (CDL) CAREThis is our entry-level option. Gomomo Care Option provides excellent value for money.

2 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 hospitalisation at any private hospital. Covers the 27 Chronic Disease List (CDL) CAREP rimary 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, GPs, specialists, radiology, pathology and more to meet the needs of any CAREOur 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 . This option is suitable for young and healthy Benefit CAREOur Full Benefit Care Option offers comprehensive cover and generous benefits to cover families and individuals who need access to unlimited hospitalisation at any private hospital.

3 This option also offers additional chronic conditions, specialised dentistry, GPs, specialists, acute medication, preventative care benefits and more rich benefits . This is the only option which offers Top-up cover when in hospital up to 200% of the Sizwe OUT OF HOSPITAL BENEFITSP rescribed Minimum benefits (PMBs) are paid at BENEFITCAREPRIMARYCAREAFFORDABLECAREGOMO MOCAREHOSPITALCAREM ajor medical ;Day-to-dayMajor medical ;Day-to-dayMajor medical ;Day-to-dayMajor medical ; Day-to-day through networkOPTION STRUCTURE 4 Major medical onlyOVERALL DAY-TO-DAY LIMIT COVERS GENERAL PRACTITIONERS, SPECIALISTS (EXCLUDING PSYCHIATRISTS), ACUTE MEDICINES, PATHOLOGISTS, PHYSIOTHERAPISTS AND RADIOLOGISTS M: R9 330M+1: R13 370M+2: R15 390M+3: R16 740M+4: R18 760M+5: R20 790M+6+: R22 690M: R5 390M+1: R7 980M+2: R9 330M+3: R10 670M+4: R12 020M+5: R13 370M+6+: R14 720M: R15 390M+1: R20 790M+2: R23 370M+3: R26 060M+4: R28 770M+5: R31 460M+6+: R34 150 100% Sizwe Rate, subject to managed care rules, formulary and clinical protocols of the DSP (Designated Service Provider)No Benefit GENERAL PRACTITIONERS ADDITIONAL GP VISITS PER FAMILY ON THE PRIMARY CARE OPTION ONLY.

4 SPECIALISTS (EXCLUDING PSYCHIATRISTS), ACUTE MEDICINE, PATHOLOGISTS, RADIOLOGISTS AND PHYSIOTHERAPISTS 100% Sizwe Rate Limited number of visitsM: 7M+1: 14 M+2: 16M+3: 18M+4: 20M+5: 21M+6+: 22100% Sizwe RateLimited number of visits M: 4M+1: 9M+2: 12M+3: 14M+4: 15M+5: 16M+6+: 17100% Sizwe Rate Select a GP as your chosen doctor for all GP visits Out-of-area: 4 per beneficiary, subject to pre-authorisation 100% Sizwe Rate Limited number of visitsM: 12 M+1: 20 M+2: 25 M+3: 29M+4: 30M+5: 31M+6+: 32 Reimbursement RateBenefit 100% Sizwe RateAll visits are subject to mandatory referral from a GP M: 4M+1: 8M+2: 9M+3: 10M+4: 11M+5: 12M+6+: 13100% Sizwe RateAll visits are subject to mandatory referral from a GP M: 2 M+1: 6 M+2: 7 M+3: 8M+4: 9M+5: 10M+6+: 11 100% Sizwe RateM: 7 M+1: 12 M+2: 15 M+3: 16 M+4: 17 M+5: 19 M+6+.

5 20 100% Sizwe Rate All visits are subject to mandatory referral from a GP Reimbursement RateBenefit No BenefitNo BenefitOUT OF HOSPITAL benefits - Prescribed Minimum benefits (PMBs) are paid at DAY-TO-DAY LIMIT COVERS GENERAL PRACTITIONERS, SPECIALISTS (EXCLUDING PSYCHIATRISTS), ACUTE MEDICINES, PATHOLOGISTS, PHYSIOTHERAPISTS AND RADIOLOGISTS Reimbursement Rate Benefit100% Sizwe RateWithin day-to-day with sub-limits: M: R3 250M+1: R4 940M+2: R5 840M+3: R6 290 M+4: R7 190M+5: R7 420M+6: R7 640 100% Sizwe RateWithin day-to-day with sub-limits: M: R1 680 M+1: R3 030 M+2: R3 370M+3: R3 820M+4: R3 930M+5: R4 150M+6: R4 490 100% Sizwe Rate R280 over-the-countermedication per family within DSPR equired Benefit for the year. Out of area medicines: no limit, subject to Sizwe RateWithin day-to-day with sub-limits: M: R4 380M+1: R7 750 M+2: R8 990M+3: R10 230M+4: R10 890M+5: R11 460M+6.

6 R12 020 ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) - FALLS WITHIN DAY-TO-DAY Benefit WITH THE FOLLOWING SUB-LIMITS No BenefitRADIOLOGY AND RADIOGRAPHY 100% Sizwe Rate Risk Benefit , within day-to-day limitCombined limit with pathology100% Sizwe Rate Risk Benefit , within day-to-day limitCombined limit with pathology100% Sizwe Rate Risk Benefit , within day-to-day limitCombined limit with pathology 100% Sizwe Rate Risk Benefit , subject to protocols, managed care rules, pre-authorisation and basic radiology only Reimbursement Rate BenefitCombined In-Hospital and Out of HospitalR26 920 per family per annumCombined In-Hospital and Out of HospitalR17 710 per family per annumCombined In-Hospital and Out of HospitalR6 770 per family per annumBenefit PHYSIOTHERAPY 100% Sizwe Rate100% Sizwe Rate100% Sizwe Rate100% Sizwe Rate.

7 Limited to R2 400 per family subject to PMBsCombined In-Hospital and Out of HospitalR35 420 perfamily per annum No BenefitNo BenefitNo BenefitPATHOLOGY Reimbursement Rate100% Sizwe Rate Risk Benefit , within day-to-day limit 100% Sizwe Rate Risk Benefit , withinday-to-day limit 100% Sizwe Rate Risk Benefit , withinday-to-day limit 100% Sizwe Rate Reimbursement RateFULL BENEFITCAREPRIMARYCAREAFFORDABLECAREGOMO MOCAREHOSPITALCAREOUT OF HOSPITAL benefits - Prescribed Minimum benefits (PMBs) are paid at BENEFITCAREOUT OF HOSPITAL benefits - Prescribed Minimum benefits (PMBs) are paid at (continued) BenefitCombined limit with basic radiology M: R1 300 M+1+: R2 750 Combined limit with basic radiology M: R1 100M+1+: R2 200 Combined limit withbasic radiology M: R1 000M+1+: R1 900 Subject to DSP, protocols, managed care, pre-authorisation and basic pathology only DENTISTRY Conservative Dentistry: Subject to Dental Management Programme - 0860 109 556 100% Sizwe Rate R3 200 per family per annum 2 general check-ups a year per beneficiarySubject to managed care protocols on restorative work Root canal treatment: managed care protocols apply 100% Sizwe Rate R2 800 per family per annum 2 general check-ups a year per beneficiarySubject to managed care protocols on restorative workRoot canal treatment: managed care protocolsapply 100% Sizwe Rate R3 600 per family per annum 2 general check-ups a year per beneficiary Subject to managed care protocols on restorative work Root canal treatment.

8 Managed care protocols apply 100% Sizwe Rate M: R2 630 M+1: R3 030 M+2: R3 290 M+3: R3 560 M+4: R3 810 M+5: R4 070 M+6+: R4 470 Subject to managed care rules, formulary and protocols of the DSP Reimbursement RateLimit per beneficiary or family per annumNo BenefitNo BenefitNo BenefitNo BenefitNo BenefitSpecialised Dentistry Plastic denturesMetal denturesOrthodontic treatmentCrowns1 full or partial set per beneficiary in a 4 year period2 partial metal frames per beneficiary in a 5 year period (limited to 1 family member per annum)Limited to individuals from age 9-18 years; 35% co-payment1 crown per family per annum1 full or partial set per beneficiary in a 4 year periodNo BenefitNo BenefitNo Benefit1 full or partial set per beneficiary in a 4 year period2 partial metal frames per beneficiary in a 5 year period (limited to 2 family members per annum)Limited to individuals from age 9-18 years3 crowns per family per annumNo BenefitNo BenefitNo BenefitNo Benefit PRIMARYCAREAFFORDABLECAREGOMOMOCAREHOSPI TALCAREFULL BENEFITCAREPRIMARYCAREAFFORDABLECAREGOMO MOCAREHOSPITALCAREOUT OF HOSPITAL benefits - Prescribed Minimum benefits (PMBs) are paid at Dentistry (continued)

9 ImplantsNo BenefitNo BenefitR3 500 per implant per annum, subject to 2 implants per beneficiary in a 5 year periodNo Benefit No Benefit OPTICAL benefits ACCESSED THROUGH PPN Reimbursement Rate LimitEye testFramesSingle Focus Lenses Bi-Focal Lenses Multi-Focal Lenses Contact LensesRefractive surgery incl, radial keratotomy 100% Sizwe Rate No Limit1 test per beneficiary in a 2 year period at any PPN OptometristR300 per beneficiary in a 2 year periodR165 per lens perbeneficiary in a 2 yearperiodR360 per lens perbeneficiary in a 2 yearperiodR660 per lens perbeneficiary in a 2 yearperiodR525 per beneficiaryR5 980 per familyper annum 100% Sizwe Rate No Limit1 test per beneficiary in a 2 year period at any PPN OptometristR300 per beneficiary in a 2 year periodR165 per lens per beneficiary in a 2 year periodR360 per lens per beneficiary in a 2 year periodR450 per lens per beneficiary in a 2 year periodR525 per beneficiaryNo Benefit 100% Sizwe Rate M: R1 080M+1: R1 240M+2: R1 370M+3+.

10 R1 9701 test per beneficiary in a 2 year period at any network providerLimited to R465 per beneficiary for frames in a 2 year period cycle at DSPS ubject to managed care rules, formulary and clinical protocols of the DSPS ubject to managed care rules, formulary and clinical protocols of the DSPS ubject to managed care rules, formulary and clinical protocols of the DSPS ubject to managed care rules, formulary and clinical protocols of the DSPNo Benefit100% Sizwe Rate No Limit1 test per beneficiaryin a 2 year period at anyPPN OptometristR300 per beneficiaryin a 2 year periodR165 per lens perbeneficiary in a 2 yearperiodR360 per lens perbeneficiary in a 2 yearperiodR660 per lens perbeneficiary in a 2 yearperiodR525 per beneficiaryR11 490 per familyper annum No BenefitNo BenefitNo BenefitNo BenefitNo BenefitNo BenefitNo BenefitNo BenefitFULL BENEFITCAREPRIMARYCAREAFFORDABLECAREGOMO MOCAREHOSPITALCAREOUT OF HOSPITAL benefits - Prescribed Minimum benefits (PMBs) are paid at cost.