medical aid options - samwumed.org · hiv screening receive up to 1 test per pregnancy early...

BENEFITS BROCHURE

2017

HEALTH FAMILY. HEALTHY COMMUNITY.

#LET’S BRINGGOOD HEALTH HOME.

We believe everyone is entitled to quALITy HEALTHcARE.• Ourbenefitdesignisstructuredwithoutalltheunnecessarybellsandwhistlestoensurevalueformoney• SAMWUMEDhaslowmonthlycontributionsandweaimtobethelowestinthemarket,withoutcompromising

onyourbenefits• Weareinasoundfinancialposition• Ouradministrationcostsarethelowestintheindustry.

Our products are simple and will help you access essential, yet often expensive, medical treatment when you need it the most.

Nomatterwhichbenefitoptionyoutake,SAMWUMEDMedicalAidofferscoverinfullandasstipulatedbySchemeRules,forthediagnosis,treatmentandcareofanextensiverangeofmedicalconditions.

2017HIGHLIGHTS

SAMWuMED is proud to introduce its reviewed benefit offerings for the following Scheme rules:

AdvancedHIV-AIDS Programme

At SAMWUMED we keep things simple and easy by offering two amazing products:

OPTION A OPTION B

NoreductioninBenefits

IncreasedRadiologyandPathologybenefitplusManagedCare

Lowestcontributionintheentiresector

OPTION

AOPTION

B

Thisoptionissuitedforyoungermembersandyoungfamilies.Maybeyouhaveyoungchildren,recentlygotmarriedorplanningtostartafamily.Youandyourspouseareyoung,fitandhealthy.Youenjoythepreventativecarebenefitsprogrammeandtakeresponsibilityforyourhealth.Youneedmoderateday-to-daymedicalcare,butacomprehensiveMaternityBenefitProgrammeandgoodHospitalCareareessentialforyourlifestyle.

Thisoptionissuitedformiddleandolderagemembersandtheirfamilies.GettingoldermeansyouneedmoreDaytoDayBenefits,ChronicIllnessBenefitsandattimesHospitalCare.YouenjoymanagingyourhealthbytakingadvantageofEarlyDetectionTests.You’realsostillresponsibleoftakingcareofyourolderchildrenwhiletheyliveathomeaswellasyourextendedfamilywhoaredependentonyou.

Go ahead and choose the most suitable option for your family’s needs.

SAMWUMED OFFERS

TWO AFFORDABLE MEDIcAL AID OPTIONS:

IT’SSIMPLE TO BEcOME A MEMBER OF SAMWuMED

STEP 1:RequestandcompleteanapplicationformfromourSalesandServicingandBrokerConsultantsorviayourHRoffice.

STEP 2:SubmityourapplicationwithphotocopiesofSouthAfricanIdentity.

STEP 3:YouwillreceiveanSMSfromSAMWUMEDtoconfirmreceiptofyourapplication.

STEP 4:YouwillreceiveyourSAMWUMEDWelcomePackwhichincludesyourMembershipGuideandMembershipCard.

SOuTH AFRIcAN ID BOOk OR cARD/BIRTH cERTIFIcATES, BAPTISM OR cLINIc cARD

A SWORN AFFIDAvIT PROvING FINANcIAL DEPENDENcy

LEGAL DOcuMENTS OF ADOPTED/FOSTER cHILDREN

cONFIRMATION OF BANkING DETAILS

WHAT DOcuMENTS DO I NEED TO BEcOME A MEMBER?

MATERNITYBENEFITPROGRAMMEExpectingmomscanaccesstheSAMWUMEDMaternityProgrammetohelptakebettercareofthemselvesandtheirunbornbabybytakingadvantageofawiderangeofmaternitypreventativecareandearlydetectionbenefits.Simplydial0860 33 33 87 toregisterandbenefit.

PREvENTATIvE MATERNITy BENEFITSFolic Acid Supplementation Receive for up to 3 Months

Ante Natal consultations Receive Up To 8 Consultations Per Pregnancy

vitamin Supplements Receive for up to 9 Months

HIV Screening Receive Up To 1 Test Per Pregnancy

EARLy DETEcTION MATERNITy BENEFITSHIV Screenings Receive Up To 1 Test Per Pregnancy

PAP Smear (Papanicolaou) Receive Up To 1 Pap Smear Per Pregnancy

ultra Sounds Receive Up To 2 Scans Per Pregnancy

EMPOWER WITH kNOWLEDGE

Packed with useful information and handy tips to maintain a healthylifestyle, SAMWUMED members will receive a free print copy of theSAMWUMED Journal magazine. Our publication promises to keep theentire family informedbyoffering relevantcontent relating to thehealthneedsoftheSAMWUMEDmembers.

BENEFIT cATEGORy OPTION PROPOSEDBENEFITCHANGE

In-Hospital Radiology OPTION A 40%IncreasetoBasicRadiologyLimit

OPTION B

Out-of-Hospital Radiology and Radiography OPTION A 40%IncreasetoBasicRadiologyLimit

OPTION B

In-Hospital Pathology OPTION A40%IncreasetoPathologyLimit

OPTION B

Out-of-Hospital Pathology OPTION B 40%IncreasetoPathologyLimit

Ambulance Services, Appliances and Other Out-of-Hospital Treatment OPTION A ChildimmunisationsandscreeningscoveredatprivatepharmaciesOPTION B

chronic and HIv/AIDS Medication OPTION A RemovalofcopaymentonchronicDTPnotob-tainedfromstatefacilitiesOPTION B

Out-of-Hospital Mental Health and Substance Dependency Treatment OPTION A IncreasetheOut-of-HospitalConsultationsforMentalHealthto20perbeneficiaryperannumOPTION B

In-Hospital consultations and Procedures OPTION A In-Hospitaldentalhealthbenefitforchildrenunder7orwherethisisclinicallyappropriateOPTION B

In-Hospital consultations and Procedures OPTION A CoverforLaparoscopicSterilizationsOPTION B

BENEFIT STRucTuRE cHANGES

SAMWUMED offers comprehensive Benefit options that will cover you for your primary and secondary medical needs including but not limited to:

• ComprehensivePreventativeCareBenefitsandEarlyDetection

• DaytoDayMedicalCare

• ChronicIllnessBenefits• HospitalCare• MedicalEmergencies

cOMPREHENSIvE PREvENTATIvE cARE BENEFITS AND EARLy DETEcTION

Apartfromensuringourmembersdonotfindthemselvesinhospitals,theSAMWUMEDPreventativeHealthcareandearlydetectionbenefitprovidesmemberswithanopportunitytotakeownershipoftheirownhealthasameanstobettermanagequalityhealthoutcomeswhichwouldultimatelyresultinlowermedicalaidpremiums.OuramazingPreventativeHealthcareProgrammesincludesthefollowingscreenings:

AGEScREENING

TESTcONDITIONS 2017

Adults aged 18 years and older

Blood Pressure Limited to one screening Pbpa

Adults Type II diabetes Adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg or BMI in the overweight or obese ranges.

Limited to one screening Pbpa

25 to 64 years Total Blood Cholesterol Males between 25-64 years of age. Females between 45-64 years of age. Persons with a family history of familial hypercholesterolemia, heart attacks and cholesterol problems.


11 to 24 years,25 to 64 years, over 65 years old

Papanicolaou (Pap) test Sexually active females or beginning at age 18. Chlamydia screen is recom-mended as part of this process. Teach clinical breast examination to.>18

Limited to one screening Pbpa within a 2 year cycle

Chlamydia screening This should be done concomitantly with Pap Smear. Limited to one screening Pbpa within a 2 year cycle

Child bearing age Folic acid 1 month before pregnancy and at least first 2 months of pregnancy Limit to 1 per month for the first 3 months of pregnancy

50 years and older Faecal occult blood test

100% of Scheme rate, limited to one Pbpa age50 years and older (screening benefits for beneficiaries youngerthan 50 years subject to motivation and prior approval)


25 to 64 years , 65 years and older

Mammogram Every 1-2 years* - females between ages 50-69*. If sister or mother had/ has breast cancer start annually at 40 years of age. Every1-2 years - Females between 65-69 years of age. If normal previously: do every 2 years, if clinical examination normal and self-examination is done.

Limited to one screening Pb within a 2 year period.

Women older than 60 years and men older than 70 years

Bone density Test Screening from 60 years for patients who are at risk of developing osteoporo-sis.Limited to one Pbpa

Limited to one Pbpa

55 to 70 years Screening for prostate cancer

Limited to one Pbpa Limited to one Pbpa

*Pbpa = per beneficiary per annum*

PREvENTATIvE cARE PAckAGE

cATEGORy SuB-cATEGORy 2017ALTERNATIvE HEALTH cARE

PodiatristHomeopathNaturopathChiropractor IncludedwithGPconsultationsandvisits.

PractitionerstoberegisteredwiththeHealthProfessionsCouncilofSAorAlliedHealthProfessionalsCouncilofSouthAfrica.

AMBuLANcE SERvIcES RoadandAir DesignatedServiceProvideronly:Netcare911

Unlimitedforemergencyassistanceonly–casemanaged,andprotocolsapply.

APPLIANcES MedicalSurgical

M R 2,520.00M1 R 3,540.00M2+ R 4,520.00

SubjecttothesubmissionofaclinicalmotivationwithcorrectTariffcodesandcostingforpre-authorisationbytheScheme.

LimitsandcyclesaspertheScheme’slistofapprovedappliancesapply.

DENTISTRy Basic M R 3,130.00M1 R 3,740.00M2 R 5,190.00M3+ R 6,260.00

Basicdentistryincludesfillings,rootcanaltreatments,scaling&polishing,extractions,fissuresealants,denturesandrepairs(subjecttoprescribedcycles).

GP cONSuLTATIONS, vISITS AND PROcEDuRES

Doctor’sroomsorhome Familyperannumreceivesupto:M R 3,040.00M1 R 4,850.00M2 R 6,170.00M3+ R 7,960.00

BeneficiarylimitofR 4,850.00 per annum.

Emergencytreatmentandprocedures Sub-limitofR 1,060.00 per family, per annum.Thissub-limitisincludedwiththeGPconsultations,visitsandprocedureslimit.

In-Hospital Includedwiththehospitalisationbenefitlimit.

INFERTILITy OnlyPMBconditions. SubjecttoStatehospitalsforHysterosalpingogram(HSG)andDiagnosticDilatationandCurettage(DD&C).StateProtocolsApply

MEDIcATION Prescribed,DispensedorAcute M R 1,600.00M1 R 3,150.00M2 R 4,720.00M3+ R 6,300.00

Sub-limitofR 3,150.00 per beneficiary per annum.

IncludesalternativehealthcaremedicationasprescribedandmustberegisteredwiththeMedicinesControlCouncil;injectionsandrelatedmaterials.SubjecttoMedicineFormulariesandExclusionLists.

beneFits | OPTION A

cATEGORy SuB-cATEGORy 2017MEDIcATION (continued...)

PrimaryHealthcareBenefitProgramme

Conditionspecificbenefits,sublimitsandtreatmentplansapply.

RemindyourpharmacisttoincludetheappropriateICD-10diagnosticcodeswithallclaimsforthisProgramme.Limitedtolistedconditionsandnumberofincidentsperbeneficiaryperyearasoutlinedbelow:

• Stomachpain,heartburn,indigestion(includingreflux),2• Acutegastroenteritis:vomitinganddiarrhoea,2• Upperandlowerrespiratorytractinfections,3• Oralandtopicalcandidiasis:thrush/fungaloryeastinfections,2• Helminthicinfestation:worms,2• Headache,4• Bacterialconjunctivitis:eyeinfection,2• Urinarytractinfection(acuteuncomplicatedcystitis),1• Urticarial:skinrashes,insectbitesandstings,2• Treatmentofwoundsand/orinfectionsoftheskin/subcutaneoustissues(excl.post-operativewound

care),1

ChronicMedication SubjecttoChronicDiseaseList(CDL)andChronicFormularyandprotocolsapply.

ChronicmedicationnotontheChronicFormularywillincura25% co-payment.

PAT:Over-the-countermedicine

LimitedtoR 630.00perfamily,peryear.

Sub-limitofR 130.00 per day.

SubjecttoMedicineFormulariesandExclusionLists.Includedwithprescribed,dispensedoracutemedicationlimit.

MENTAL HEALTH SuBSTANcE DEPENDENcy

Consultations/visitsandprocedures.

100%ofcostatDSPperfamily,perannum.IncludedwithIn-Patientbenefit.LimitedtoPMBConditionsonly.

Clinicalmotivationrequiredforauthorisationofcontinuedconsultationsafterfirst20initialconsultations.

Hospitalisation ReferralfromanEmployeeAssistanceProgramme(EAP)orGPrequiredforsubstancedependency.

Referralfromspecialistrequiredformentalhealthconditions.

PMBconditionsunlimitedatStateHospitals.

OPTIcAL Frames/Lenses/ContactLenses

R 4,460.00 per family,subjecttoprescribedcycles.

Sub-limitofR 1,910.00 per beneficiary per annum.

OphthalmologistvisitsubjecttoreferralfromOptometristorGP.Exclusionsapply,includingbutnotlimitedtorepairs.Spectaclelensesandcontactlensescannotbeobtainedsimultaneously.

Frames Frames:BeneficiaryreceivesuptoR 730.00.

Lenses Whitelenses:100%ofthelowercostorOpticalAssistantTariff.Photochromiclenses:100%ofthelowercostorSchemeTariffuptoamaximumofR 350.00 per pairandsubjecttoaprescriptionof+0.50/-0.50andabove.

Fixedorgradienttintsupto35%:100%ofthelowercostsorOpticalAssociation’sTariff.

EyeTests Limitedtooneconsultationperbeneficiaryperannum.Subjecttofamilylimit.

OuT-PATIENT BENEFITS Consultations,visitsandprocedures

M R 1,360.00M1 R 1,800.00M2+ R 2,260.00

SubjecttoStateOut-Patientfacilities.

PATHOLOGy Out-of-Hospital IncludedwithSpecialistBenefit

In-Hospital R 4,100.00 per family, per annum.IncludedwithIn-Patientbenefit.

PHySIOTHERAPy Out-of-Hospital IncludedwithSpecialistbenefit.LimitedtoPMBConditionsonly.

In-Hospital Clinicalmotivationrequiredforauthorisationofcontinuedconsultationsafterfirsttwovisits.R 1,760.00 per family, per annum.IncludedwithIn-Patientbenefit.

PROSTHESES Internal R 24,300.00 per family, per annum.

IncludedwithIn-Patientbenefit.Subjecttothesubmissionofaclinicalmotivationandcostingforpre-authorisationbytheScheme.DSPistheStatefacilityforjointreplacements.

External(includingartificialeyesandlimbs)

R 12,460.00 per family, per annum.

IncludedwithIn-Patientbenefit.Subjecttothesubmissionofaclinicalmotivationandcostingforpre-authorisationbytheScheme.

RADIOLOGyRADIOGRAPHy

GENERAL(InandOut-of-hospital)

R 2,060.00 per family, per annum

Includestwoultrasoundsperpregnancy.LimitedtoPMBconditionsonly

SPECIALISED R 7,560.00 Included with In-Patient benefit.LimitedtoPMBprotocolsonly.

REMEDIAL THERAPy Occupational,SpeechTherapy,Audiology&Dieticians

IncludedwithSpecialistbenefitforIn-orOut-of-hospitaltreatment.

SPEcIALIST cONSuLTATIONS, vISITS AND PROcEDuRES

Out-of-Hospital Familylimit,peryear:M R 3,620.00M1 R 5,360.00M2 R 9,400.00M3+ R 10,730.00

Beneficiarylimitof R 5,360.00 per annum. SubjecttoreferralfromaGeneralPractitioner.

In-Hospital IncludedwithIn-PatientBenefit

HOSPITALISATION IN-PATIENTSubjecttopre-authorisation.

R 500,000.00 per family per annumSubjecttopre-authorisation.

UnlimitedbenefitsforPMBconditionssubjecttopre-authorisationataDSP.StateFacilityasDSPforjointreplacements,cardiacandabdominalsurgeryLaparoscopicsurgeryexcluded.“TakeHome”medicationlimitedto7days’supply.

ALTERNATIvES TOHOSPITALISATION PrivatenursingFrailcareHospiceStep-downfacility

IncludedwithIn-Patientbenefit.

BLOOD TRANSFuSIONSERvIcES


RENAL DIALySIS IncludedwithIn-Patientbenefit.SubjecttoStatehospitals.PMBonly.

ORGAN TRANSPLANT

Out-of-Hospital

In-Hospital

SchemeRulesandtreatmentplansapply.PMBConditionsonlyPreauthorisationrequired

MedicationtobeobtainedfromStatehospitals.

IncludedwithIn-PatientBenefit.SubjecttoStateHospitals.

cATEGORy SuB-cATEGORy 2017

HOSPITALISATION(continued...)

ONcOLOGy

Out-of-Hospital

In-Hospital

Subjecttopre-authorisationPMBConditionsonly

SubjecttoOverallAnnualLimitandStatehospitals.

IncludedwithIn-PatientbenefitandsubjecttoStatehospitals.

Overall Annual Limit R 500,000.00 per family per annum.


TOTAL MONTHLy PREMIuM - OPTION A –effective01January2017(Tablebelowrepresents100%contribution.Employeesonlypayupto40%.)

A]Contributionsarepaidmonthlyinarrears.

Salary Bands Principal Member Adult Dep. child Dep.

R0 - R 3 500 995 995 350

R 3 501 - R 4 500 1 176 1 176 412

R 4 501 - R 5 500 1265 1265 444

R 5 501 - R 7 000 1357 1357 476

R 7 001 - R 8 500 1454 1454 511

R 8 501 + 1558 1558 549


beneFits | OPTION B

ALTERNATIvE HEALTH cARE

PodiatristHomeopathNaturopathChiropractorIncludedwithGPandSpecialistconsultationsandvisitslimit.PractitionerstoberegisteredwiththeHealthProfessionsCouncilofSAorAlliedHealthProfessionalsCouncilofSouthAfrica.

AMBuLANcE SERvIcES RoadandAir DesignatedServiceProvideronly:Netcare911

Unlimitedforemergencyassistanceonly–casemanagedandprotocolsapply.

APPLIANcES MedicalSurgical


SubjecttothesubmissionofaclinicalmotivationwithcorrectTariffcodesandcostingforpre-authorisationbytheScheme.

LimitsandcyclesaspertheScheme’slistofapprovedappliancesapply.

DENTISTRy Basic

Advanced

Exclusions

M R 6,700.00M+1 R 7,670.00M+2 R 8,950.00M+3 R 10,040.00

Basicdentistry:Fillings,rootcanaltreatments,scaling&polishing,extractions,fissuresealants,denturesandrepairs(subjecttoprescribedcycles).

Advanceddentistry:Clinicalmotivationrequiredforpre-authorisationfromScheme.Orthodontics,crownandbridgeworkoranyprocedurethatrequiresanaesthetics.

Hospitalisationcostsforremovalofwisdomteethortreatmentforchildrenundertheageof7paidfromthehospitalisationbenefit.

Dentalprocedurecostspaidfromdentistrybenefit.

Exclusions:cosmeticdentistrysuchasveneersandimplantsisexcluded.

GP AND SPEcIALIST cONSuLTATIONS & vISITS

Roomsorhome Familylimit,peryear.M R 3,510.00M+1 R 5,650.00M+2 R 7,730.00M+3 R 9,630.00

BeneficiarylimitofR 5,650.00 per annum.

In-hospital SubjecttoIn-PatientBenefit

GP AND SPEcIALIST PROcEDuRES & TESTS

Roomsorhome R 7,310.00 per family, per annum.

INFERTILITy PMBconditionsonly SubjecttoStatehospitalsforHysterosalpingogram(HSG)andDiagnosticDilatationandCurettage(DD&C).Stateprotocolsapply.

cATEGORy SuB-cATEGORy 2017MEDIcATION Prescribed,dispensedoracute M R 3,150.00

M+1 R 4,130.00M+2 R 6,300.00M+3 R 8,280.00

Sub-limitofR 4,130.00 per beneficiary, per annum.IncludesalternativehealthcaremedicationasprescribedandmustberegisteredwiththeMedicinesControlCouncil;injectionsandrelatedmaterials.

SubjecttoMedicineFormulariesandExclusionLists.=

PrimaryHealthcareBenefitProgramme

Conditionspecificbenefits,sublimitsandtreatmentplansapply.

RemindyourpharmacisttoincludetheappropriateICD-10diagnosticcodeswithallclaimsforthisProgramme.

• Limitedtolistedconditionsandnumberofincidentsperbeneficiaryperyearasoutlinedbelow:

• Stomachpain,heartburn,indigestion(includingreflux),3• Acutegastroenteritis:vomitinganddiarrhoea,3• Upperandlowerrespiratorytract• infections,4• Oralandtopicalcandidiasis:thrush/fungaloryeastinfections,3• Helminthicinfestation:worms,2• Headache,6• Bacterialconjunctivitis:• eyeinfection,2• Urinarytractinfection(acuteuncomplicatedcystitis),2• Urticarial:skinrashes,insectbitesandstings,2• Treatmentofwoundsand/orinfectionsoftheskin/subcutaneous• tissues(excl.post-operativewoundcare),2

ChronicMedication SubjecttoChronicDiseaseList(CDL)andChronicFormularyandprotocolsapply.

ChronicmedicationnotontheChronicFormularywillincura25%co-payment.

PAT:Over-the-countermedicine

ReceiveuptoR 1,260.00 per family, per annum.

Sub-limitofR 160.00 per day.

SubjecttoMedicineFormulariesandExclusionLists.Includedwithprescribed,dispensedoracutemedicationlimit.

MENTAL HEALTH SuB-STANcE DEPENDENcy

Consultations,visitsandprocedures. IncludedwithIn-Patientbenefit.Clinicalmotivationrequiredforauthorisationofcontinuedconsultationsafterfirsttwentyinitialconsultations.

LimitedtoPMBonly.

Hospitalisation ReferralfromanEmployee

AssistanceProgramme(EAP)orGPrequiredforsubstancedependency.Referralfromspecialistrequiredformentalhealthconditions.

PMBunlimitedatStatehospitals.

cATEGORy SuB-cATEGORy 2017OPTIcAL Frames/Lenses/ContactLenses R 5,350.00 per family,subjecttoprescribedcycles.Ophthalmologistconsultationsubject

toReferralfromOptometrist.

Sub-limitofR 2,250.00 per beneficiary, per annum.

Exclusionsapply,includingbutnotlimitedtorepairs.Spectaclelensesandcontactlensescannotbeobtainedsimultaneously

Frames Frames:R 900.00 limit per beneficiary.

Lenses Whitelenses:100%ofthelowerofcostorOpticalAssistantTariff.Photochromiclenses:100%ofthelowerofcostorOpticalAssistantTariff,uptoamaximumofR 350.00 per pair andsubjecttoaprescriptionof+0.50/-0.50andabove.

Fixedorgradienttintsupto35%:100%ofthelowerofcostsorOpticalAssistantTariff.

ContactLenses Contactlenseswithaprescriptionreadingof-0.75or+1.00andabove:100%ofthelowerofcostsorOpticalAssistantTariffuptoamaximumofR 2,210.00 per beneficiary,subjecttoatwoyearcycle.

EyeTests Beneficiaryperannumreceivesuptooneconsultation.Subjecttofamilylimit.

PATHOLOGy In-and-Out-of-Hospital R 8,260.00 per family, per annum.

PHySIOTHERAPy In-and-Out-of-Hospital R 4,130.00 per family, per annum.Sub-limitofR 1,690.00 per beneficiary, perannum.Clinicalmotivationrequiredforauthorisationofcontinuedconsultationsaftertwovisits.

PROSTHESES Internal R 24,790.00 per family, per annum.


External(includingartificialeyesandlimbs) R 14,540.00 per family, per annum.


RADIOLOGyRADIOGRAPHy

GENERALIn-and-OutofHospital


SPECIALISEDIn-and-OutofHospital

R 12,420.00 per family, per annumMRI/CATorsimilar.Scanslimited.Subjecttopre-authorisationfromtheScheme.Limitedto2scansperfamilyperannum.

REMEDIAL THERAPy Occupational,SpeechTherapy,Audiology&Dieticians.

R 4,130.00 per family, per annum.In-and-OutofHospital.

HOSPITALISATION IN-PATIENTSubjecttopre-authorisation.

R 1,000,000.00 per family, per annum.

Subjecttopre-authorisationandregistrationwithClinicalDiseaseManagementProgrammeforasthma,cardiovasculardisease,diabetes,andcancer,whereapplicable.StateFacilityasDSPforjointreplacements,cardiacandabdominalsurgery.

UnlimitedbenefitsforPMBconditionssubjecttopre-authorisationataDSP.“TakeHome”medicationlimitedto7days’supply.

cATEGORy SuB-cATEGORy 2017HOSPITALISATION(continued...)

ALTERNATIvES TOHOSPITALISATION PrivatenursingFrailcareHospiceStep-downfacility


BLOOD TRANSFuSIONSERvIcES


RENAL DIALySIS IncludedwithIn-Patientbenefit.SubjecttoStatehospitals.PMBonly.

ORGAN TRANSPLANT

Out-of-Hospital

In-Hospital

SchemeRulesandtreatmentplansapply.PMBconditionsonly.

Pre-authorisationrequired.SubjecttoOverallAnnualLimitandStatehospitals.MedicationtobeobtainedfromStatehospitals.

IncludedwithIn-Patientbenefit.SubjecttoStatehospitals.

ONcOLOGy

Out-of-Hospital

In-Hospital

Subjecttopre-authorisationandregistrationwithDiseaseManagementProgramme.PMBconditionsonly.Non-PMBsubjecttoR100,000.00

SubjecttoOverallAnnualLimitandStatehospitals.

IncludedwithIn-PatientbenefitandsubjecttoStatehospitals.

Overall Annual Limit uNLIMITED

TOTAL MONTHLy PREMIuM - OPTION B –effective01January2017(Tablebelowrepresents100%contribution.Employeesonlypayupto40%.)

B]Contributionsarepaidmonthlyinarrears.

Salary Bands Principal Member Adult Dep. child Dep.

R0 - R 5 000 1598 1598 560

R 5 001 - R 6 000 1785 1785 626

R 6 001 - R 7 000 1820 1820 638

R 7 001 - R 10 000 1858 1858 652

R 10 001 - R 13 000 1958 1958 665

R 13 001 + 2 061 2 061 679

ADDITIONAL vALuE

SAMWuMED PRIMARy HEALTHcARE BENEFIT PROGRAMMEThisuniquebenefitoffersSAMWUMEDmemberspeaceofmindshouldamemberdepletehis/herannualmedicinebenefit.Inpartnershipwithourpharmacynetwork,SAMWUMEDhascreatedaformulary(aspecificlistofmostcosteffectivemedicines)availableoverthecounterforthe10mostcommonailments.

1.Stomachpain:Heartburn,indigestionsandreflux2.Headache3.Acutegastroenteritis:vomitinganddiarrhoea4.BacterialConjunctivitisandeyeinfections5.Upperandlowerrespiratorytractinfections6.Urinarytractinfectionsincludingacuteuncomplicatedcystitis7.Oralandtopicalcandidiasis:thrushandfungaloryearinfections8.Urticarial:Skinrashes,usuallyduetoanallergicreaction,insectbitesandstings9.Helminthicinfestations:tapeworm10.Woundcareandskininfections(excludingpost-operativecare)

SubjecttoSchemetariffs,memberscanaccessthesefromyourapprovedpharmacistwithoutpayingextramoney.

PHARMAcy BENEFIT MANAGEMENTcHRONIc MEDIcINE BENEFITS

Achronicconditionisapersistentorotherwiselong-lastingillnessthatmaybelongerthanthreemonthsorlifelong.SAMWUMEDwillcoverforthediagnosis,treatmentandcareof26chronicconditions.

SAMWUMEDworkswithMedschemetogivemembersthebestadviceontheuseoftheirchronicmedication,aswellastoensurethattheirchronicbenefitsarecorrectlyallocated.

YourtreatingdoctorwillneedtocallourManagedCareProvider,Medscheme on 0860 33 33 87toregisteryourChronicMedication.

HIv MANAGEMENT HIVisachronicconditionwheretreatmentisavailableandmustbetakenforlife.SAMWUMEDwillcoverthetreatment,pathologymonitoringanddoctorconsultationsinordertokeepallHIVpositivebeneficiarieshealthy.

SAMWUMEDworkswithAidforAIDStogivemembersthebestadviceonhowtomanagetheirHIVstatusandtheuseoftheirHIVmedication,bloodmonitoringtestsandotherassociatedmedication.

YourtreatingdoctorwillneedtofaxtheHIVapplicationformtoourHIVManagedCareProvider,AidforAIDSon0800 600 773 or call 0800 227 700toregisteryouontheHIVManagementProgramme.

HOSPITAL & ONcOLOGy BENEFIT MANAGEMENT

Whenyouneedhospitaltreatmentoranoperation,SAMWUMEDwillcoveryouforapprovedmedicalexpenseswhenyouareinhospital.Thecomprehensivehospitalbenefitcoverensuresyouaretakencareofshouldyouoryourlovedoneslandupinahospital.

WehavepartneredwithMedschemeasourHospital,HIV-AIDS,PharmacyandOncologyBenefitManagementServiceProvidertomanageyourcare.Forallhospitalpre-authorisationsmembers

cancall 0860 33 33 87.

Unless an emergency, members will need to contact

Medscheme no less than 72 Hours before the procedure

to get authorisation for their admission to hospital.

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talk to saMWUMed today

Tel:0860104117(ShareCall)Tel:0216979000

OPERATING HOuRS:ContactCentre08h30-16h00Mon-Fri

PostalAddress:P.O.Box134,Athlone,7760CnrTremation&LascellesStreets,Athlone,CapeTown

Website:Visitwww.samwumed.orgFacebook:Followandlikeourpageatwww.facebook.com/Samwumed

MEDScHEME

Hospital & Pharmacy Benefit Management Enquiries–0860333387Email:[email protected]

Oncology Management–0860333387Email:[email protected]

HIv MANAGEMENT - AID FOR AIDS

Member Enquiries–0860100646email:[email protected]

NETcARE 911

Tel:082911

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medical aid options - samwumed.org · hiv screening receive up to 1 test per pregnancy early...

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