Sizwe Gomomo A medical aid plan: 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

Gomomo A
2018 Costs:
Total Cost pm:

Main member:

R877

Adult:

R867

Child: (Pay for all)

R365
Savings Account:
  • No savings option on this plan
2019 Costs:
Total Cost pm:

Main member:

R
(%)

Adult:

R

Child: (Pay for all)

R
Income band:
In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Gomomo A
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% scheme rate
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Choose any hospital
  • No benefit
Specialised Radiology:
  • Limited to R7,140 per family
  • In and out of hospital
  • Sublimit increased as necessary
  • Out of hospital, co-payment and sublimit increase is for MRI and CT scans only
Supplementary Services: (Physio, etc)
  • Dietician, speech therapy, occupational therapy: subject to protocols
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment approved by medical aid
  • No benefit for out-of-hospital services
Transplants:
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments: .
Alternatives to hospitals:
  • PMBs only
Casualty: 2018 benefits are coming soon!
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • Blood transfusion: PMBs only
  • No benefit
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

No phone calls!
Our quote will include the right gap cover for this plan

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Gomomo A
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • Chosen GP: No benefit, unless PMB
  • Other GP: 4 consults, PMB only
Childcare:
  • No extra benefit available
Specialists consultations:
  • Covered if referred by GP
Pathology:
  • 100% scheme rate
General radiology:
  • 100% scheme rate
Specialised radiology:
  • R7,140 per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • R2,530 per family, for PMBs only
  • Physio, speech therapist, clinical psychologist, podiatrist: 100% scheme rate

No phone calls!
Our quote will include the right gap cover for this plan

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MATERNITY BENEFITS:
Gomomo A
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
Consultations:
  • Subject to care rules and clinical protocols of DSP
Scans:
  • 2 x 2D scans

No phone calls!
Our quote will include the right gap cover for this plan

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CANCER (ONCOLOGY):
Gomomo A
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • 100% scheme tariff

No phone calls!
Our quote will include the right gap cover for this plan

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DENTISTRY:
Gomomo A
Scheme Benefits Gap benefits
Dentistry:
  • M =R2,770
    M1 =R3,190
    M2 =R3,470
    M3 =R3,750
    M4 =R4,010
    M5 =R4,290
    M6+ =R4,710
Orthodontics:
  • You pay this out of pocket
  • No extra benefit available
Maxillo Facial Surgery: 2018 benefits are coming soon!
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MEDICATION:
Gomomo A
Scheme Benefits Gap benefits
Chronic:
Acute (presrcibed) medication:
Over-the-counter:
  • R300 per family
Birth Control:
  • No benefit
On Discharge:
  • See "Acute medicine" benefit
Biological:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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OPTOMETRY:
Gomomo A
Scheme Benefits Gap benefits
Optometry:
  • M =R1,130
    M1 =R1,300
    M2 =R1,440
    M3 =R2,070
  • Benefit available every 2 years
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MENTAL HEALTH:
Gomomo A
Scheme Benefits Gap benefits
In-hospital:
  • 21 days per person
Out-of-hospital:
  • PMBs only
Trauma:

No phone calls!
Our quote will include the right gap cover for this plan

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OTHER BENEFITS:
Gomomo A
Scheme Benefits Gap benefits
General Appliances:
  • 100% scheme rate
  • No benefit
1.1. Hearing Aids:
  • No benefit
  • No benefit
1.2. Wheelchairs:
  • No benefit
  • No benefit
Dialysis:
  • PMBs only
HIV:
  • Subject to treatment protocols
  • No benefit
Emergency Transport: Europ Assist
  • No benefit
International Insurance: 2018 benefits are coming soon!
  • No benefit
Other: 2018 benefits are coming soon!

No phone calls!
Our quote will include the right gap cover for this plan

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WELLNESS/PREVENTATIVE BENEFITS:
Gomomo A
Scheme Benefits Gap benefits
Flu vaccination:
  • No benefit
  • No benefit
Pneumonia vaccines:
  • No benefit
  • No benefit
Back Rehabilitation Programme:
  • No benefit
  • No benefit
Biometric Screening:
  • No benefit
  • No benefit
Child Immunisation:
  • No benefit
  • No benefit
Pap Smear:
  • No benefit
  • No benefit
Mammogram:
  • No benefit
  • No benefit
PAS Test:
  • No benefit
  • No benefit
HIV Test:
  • No benefit
  • No benefit
Other:
  • No benefit
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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PROSTHETICS:
Gomomo A
Scheme Benefits Gap benefits
Overal Limit:
  • R28,090 per person
Sub-limits:
  • Cardiac stents: 3 per family
  • Vascular stents: 2 per family

No phone calls!
Our quote will include the right gap cover for this plan


    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised