2016AFFORDABLEC A R E

BENEFITSGUIDE

#caring4life

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.

This option is suitable for families who require rich in-hospital and chronic cover as well as generous day–to-day benefits. Affordable Care option offers excellent value for families and individuals who want the freedom to access General Practitioners (GPs),

specialists, acute medicines and specialised dentistry.

AFFORDABLE CARE

Prescribed Minimum Benefits (PMBs) are paid at Sizwe negotiated rates 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 BENEFITS

% Benefit 100% Sizwe Rates Limit

Member R9 330

Member +1 R13 370

Member +2 R15 390

Member +3 R16 740

Member +4 R18 760

Member +5 R20 790

Member +6+ R22 690

GENERAL PRACTITIONERS Falls within day-to-day benefit with the following sub-limits

100% Sizwe Rates Number of visits

Member : 7

Member +1 : 14

Member +2 : 16

Member +3 : 18

Member +4 : 20

Member +5 : 21

Member +6+ : 22

SPECIALISTS (Excluding Psychiatrists) Subject to referral from a GP with exception of follow up visits etc. Falls within day-to-day benefit with the following sub-limits:

100% Sizwe Rates Number of visits

Member : 4

Member +1 : 8

Member +2 : 9

Member +3 : 10

Member +4 : 11

Member +5 : 12

Member +6+ : 13

ACUTE MEDICINES AND PHARMACY ADVISED THERAPY (PAT) Falls within day-to-day benefit with the following sub-limits Sub-limits

Member R3 250

Member +1 R4 940

Member +2 R5 840

Member +3 R6 290

Member +4 R7 190

Member +5 R7 420

Member +6+ R7 640

DAY-TO-DAY BENEFITS

100% Sizwe Rates

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 R25 280 per family per year

MRI/CT/Angiograms combined In and Out of Hospital)

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

Conservative Dentistry

% Benefit

Consultations/ Oral Hygiene, Extractions, Fillings 2 general check ups 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 1 crown per family per year

Once per tooth every 5 years

Pre-authorisation is required

Orthodontics (Braces) Subject to pre-authorisation and managed care protocols

Restricted to beneficiaries under the age of 18 years

35% co-payment is applicable

Implants No Benefits

Partial Metal Frame Dentures 1 per jaw per beneficiary every 5 years. Limited to 1 family member per year

2 Per family per year. Pre-authorisation is required

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. 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

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 R25 280 per family per year

MRI/CT/Angiograms combined In and Out of Hospital)

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

Conservative Dentistry

% Benefit

Consultations/ Oral Hygiene, Extractions, Fillings 2 general check ups 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 1 crown per family per year

Once per tooth every 5 years

Pre-authorisation is required

Orthodontics (Braces) Subject to pre-authorisation and managed care protocols

Restricted to beneficiaries under the age of 18 years

35% co-payment is applicable

Implants No Benefits

Partial Metal Frame Dentures 1 per jaw per beneficiary every 5 years. Limited to 1 family member per year

2 Per family per year. Pre-authorisation is required

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. 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 yearsEye Test

% Benefit 100% Sizwe Rates

Limit 1 test per beneficiary every 2 years

Combined Frames and Lenses

% Benefit 100% Sizwe Rates Sub-Limits

Member R1 570

Member +1 R1 680

Member +2 R1 900

Member +3 R2 020

Member +4 R2 080

Member +5 R2 130

Member +6+ R 2 190

Multi-focal/Varifocal Lenses

Sub-limit R680 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

Refractive Surgery, including Radial Keratotomy

% Benefit 100% Sizwe Rates

Limit R5 620 per family per year

MENTAL HEALTH

Psychiatry, Clinical and Counselling Psychology – only if related to mental health. This excludes Educational Psychologists, Social Workers and Registered Counsellors.

% Benefit 100% Sizwe Rates

Family Limit R7 640 per family per year

AUXILIARY

Audiologists, Chiropractors, Dieticians, Homeopaths, Occupational Therapists, Podiatrists, Speech Therapists, Social Workers, Educational Psychologists, Biokinetics and Registered Counsellors.

% Benefit 100% Sizwe Rates

Member R1 350

Member +1+ R2 360

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

% Benefit 100% Sizwe Rates

Member R1 350

Member+1+ R2 360

WHEELCHAIR (Non-Motorised)

% Benefit 100% Sizwe Rates

Family Limit R2 810 every 2 years

HEARING AIDS 1 per beneficiary every 2 years

% Benefit 100% Sizwe Rates

Family Limit R7 190 per year

CHRONIC MEDICINES Subject to pre-authorisation - call 0860 103 455 Subject to registration on the Chronic Medicine Programme. PMBs subject to pre-authorisation, preferred providers and treatment protocols.

% Benefit 100% Single Exit Price (SEP)

Member R 4 940

Member +1 R 9 880

Member +2 R 14 820

Member +3 R 19 760

Member +4 R 24 690

Member +5 R 29 640

Member +6+ R 34 580

Per beneficiary limit per year R4 940 per beneficiary

CHRONIC BENEFITS

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% of Sizwe Rates

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

IN-HOSPITAL BENEFITS

% Benefits 100% Sizwe Rates

Limit No Limit

AMBULANCE Europ Assist SA 0860 117 799 Pre-authorisation is required. Contracted Provider

PRIVATE HOSPITALS AND NURSING HOMES Subject to Treatment and Case Management Protocols and PMBs Pre-authorisation is required unless in a medical emergency

Accommodation

% Benefit 100% Sizwe Rates

Limits No Limit

Clinical Limitations and Exclusions None

Frail Care No benefits

Medicine to take home (TTO) 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 Subject to hospital limit

PROVINCIAL HOSPITALS

% Benefit 100% UPFS Rates

Limit No Limit

PRIVATE NURSING Subject to pre-authorisation

% Benefit 100% Sizwe Rates

Limit R6 040

BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS Subject to PMBs

% Benefit 100% Sizwe Rates

Family Limit Limited to PMBs

GENERAL PRACTITIONERS

% Benefit 100% Sizwe Rates

Limit No Limit

SPECIALISTS

% Benefit 100% Sizwe Rates

Limit No Limit

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% of Sizwe Rates

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

IN-HOSPITAL BENEFITS

% Benefits 100% Sizwe Rates

Limit No Limit

AMBULANCE Europ Assist SA 0860 117 799 Pre-authorisation is required. Contracted Provider

PRIVATE HOSPITALS AND NURSING HOMES Subject to Treatment and Case Management Protocols and PMBs Pre-authorisation is required unless in a medical emergency

Accommodation

% Benefit 100% Sizwe Rates

Limits No Limit

Clinical Limitations and Exclusions None

Frail Care No benefits

Medicine to take home (TTO) 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 Subject to hospital limit

PROVINCIAL HOSPITALS

% Benefit 100% UPFS Rates

Limit No Limit

PRIVATE NURSING Subject to pre-authorisation

% Benefit 100% Sizwe Rates

Limit R6 040

BLOOD TRANSFUSIONS AND BLOOD REPLACEMENT PRODUCTS Subject to PMBs

% Benefit 100% Sizwe Rates

Family Limit Limited to PMBs

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 combined In and Out of Hospital) R25 280 per family per year. 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. Subject to PMBs

ONCOLOGY Subject to pre-authorisation, treatment protocols and PMBs

% Benefit 100% Sizwe Rates

Family limit R250 000 per year

PROSTHESIS Subject to pre-authorisation, Treatment Protocols and PMBs

Surgical and Non-Surgical

% Benefit 100% of Cost

Family Limit R37 980 per year

Internal Prosthesis

Joints 1 per year

Spine 2 levels per year done in one procedure

Cardiac (Pacemaker, internal defibrillators, grafts, valves, etc) Subject to the benefit limit and PMB protocols

External Prosthesis Subject to the benefit limit and PMB protocol

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 and 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, Treatment Protocols and PMBs

% Benefit 100% Sizwe 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 year restricted to men over 40 years.

% Benefit 100% Sizwe Rates

Limit R1 800 per family per year

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

% Benefit 100% Sizwe Rates

Limit R240 per beneficiary per year

CONTRACEPTIVES

% Benefit 100% Sizwe Rates

Family Limit R2 340 per family per year

Income Bracket Principal Member Adult Dependant Child Dependant

R0 - R14 200

R14 200 - R17 400

R17 400+

R2 470

R2 570

R3 430

R2 270

R2 360

R3 050

R570

R590

R680

AFFORDABLE CARE CONTRIBUTIONS 2016

WELLNESS BENEFITS

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

SIZWE MEDICAL FUNDREGIONAL 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

www.sizwe.co.za

enquiries@sizwe.co.za

0860 100 871

www.sizwe.co.za

queries@sizwe.co.za

0860 100 871