Sizwe Primary Care 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.

Primary Care A
2018 Costs:
Total Cost pm:

Main member:

R419

Adult:

R419

Child: (Pay for all)

R419
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:
Primary Care 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 R18,680 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)
  • Only physiotherapists, dieticians, speech therapists, occupational therapists, and clinical technologists
  • 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:
  • 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Sublimits increased as necessary
Co-payments: .
Alternatives to hospitals:
  • Private nursing: R4,310 per family
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):
Primary Care 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:
  • M =4 consults; M1 =9 consults; M2 =12 consults; M3 =14 consults etc
  • Paid from day-to-day benefit
Childcare:
  • No extra benefit available
Specialists consultations:
  • Unlimited consults referred by GP, paid by scheme
  • Otherwise, M =2 consults; M1 =6; M2 =7; M3 =8; M4 =9; M5 =10; M6+ =11
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Subject to protocols
Specialised radiology:
  • R18,680 per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • Speech Therapists, Podiatrists, Occupational Therapists, Social Workers, Dieticians Audiologists, Chiropractors, Homeopathy, Educational Psychologists, Clinical Technologist, Biokineticist and Registered Counsellors: R1,010 per person and R1,630 per family
  • Chiropractors: R1,000 per per person
  • Physiotherapy: from day-to-day benefit

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

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MATERNITY BENEFITS:
Primary Care A
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
Consultations:
  • 9 consults with GP or midwife
  • 2 consults with OB, on referral
  • Paid by scheme
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):
Primary Care A
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R143,780 per family

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Our quote will include the right gap cover for this plan

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DENTISTRY:
Primary Care A
Scheme Benefits Gap benefits
Dentistry:
  • Standard: two consults per person, fillings and root canals if motivated
  • Plastic dentures: 1 set per jaw, every 4 years
  • Specialised: no benefit
  • In-hospital: subject to authorisation
Orthodontics:
  • You pay this out of pocket
  • No extra benefit available
Maxillo Facial Surgery:
  • PMB only
  • 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:
Primary Care A
Scheme Benefits Gap benefits
Chronic:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with following sub limits:
M =R1,770
M1 =R3,190
M2 =R3,550
M3 =R4,030
M4 =R4,140
M5 =R4,370
M6+ =R4,730
Over-the-counter:
  • See "Acute benefits", above
Birth Control:
  • R2,620 per family
On Discharge:
Biological:
  • No benefit

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

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OPTOMETRY:
Primary Care A
Scheme Benefits Gap benefits
Optometry:
  • Eye test: one per person every 2 years
  • Frames: R330 per person every 2 years
  • Lenses: R175 per lend for single, R380 for bifocal, R380 for multifocal, every 2 years
  • Contact lenses: R1,200 per person
  • 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:
Primary Care A
Scheme Benefits Gap benefits
In-hospital:
  • 21 days per person
  • Addiction: PMBs only, 3 days withdrawal treatment and 21 days rehab
Out-of-hospital:
  • R5,180 per family
Trauma:

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

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OTHER BENEFITS:
Primary Care A
Scheme Benefits Gap benefits
General Appliances:
  • M =R960 and M1+ = R1,550
  • No benefit
1.1. Hearing Aids:
  • R5,500 per family
  • No benefit
1.2. Wheelchairs:
  • R1,790 per family
  • 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:
Primary Care A
Scheme Benefits Gap benefits
Flu vaccination:
  • R2,020 per family, shared with pneumococcal vaccine benefit
  • No benefit
Pneumonia vaccines:
  • R2,020 per family, shared with flu vaccine benefit
  • No benefit
Back Rehabilitation Programme: 2018 benefits are coming soon!
  • No benefit
Biometric Screening:
  • Covered with R260 sublimit
  • No benefit
Child Immunisation: 2018 benefits are coming soon!
  • No benefit
Pap Smear:
  • Covered, every 2 years for 21yrs+
  • No benefit
Mammogram:
  • Covered, every 2 years for 40yrs+
  • No benefit
PAS Test:
  • Covered, every 2 years for 40yrs+
  • No benefit
HIV Test: 2018 benefits are coming soon!
  • No benefit
Other:
  • No benefit

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

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PROSTHETICS:
Primary Care A
Scheme Benefits Gap benefits
Overal Limit:
  • R25,600 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