Sizwe Copper Core A medical aid plan: 2020

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Always consult with your broker before making final decisions regarding your healthcare cover.

Copper Core A
Total Cost pm:

Main member:

R1,060

Adult:

R1,060

Child:

R430
Savings (per year):
  • No savings option on this plan
Income band:

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IN HOSPITAL PROCEDURES:
Copper Core A
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • 100% specific scheme tariff
network Specialists:
  • 100% specific scheme tariff
non-Network GPs:
  • 100% specific scheme tariff
network GPs:
  • 100% specific scheme tariff
Hospital Choice:
  • Choose a Network (DSP) Hospital
Penalty for using other hospital:
  • R12,000 co-payment if you voluntarily choose another hospital
  • The Blue Plan gap cover will pay one "penalty co-payment" up to R10,000 per policy per year
Specialised Radiology:
  • R7,925 per family, in and out of hospital. Limited to PMB level of care
Supplementary Services: (Physio, etc)
  • 100% scheme rate, limited to physiotherapist, dietician, speech therapy and occupational therapy. Subject to PMB protocols.
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • 100% scheme rate, at DSP and subject to protocols
Co-payments:
  • N/A
Alternatives to hospitals:
  • Private nurse: PMB only
Casualty: 2019 Benefits coming soon!
  • Both the Blue Plan and Red Plan gap cover will pay up to R10,000 per person for unpaid casualty costs in event of emergency
Other: Exclusions:
  • Refractive surgery including radial keratotomy, breast reduction, breast augmantation, keloids and frail care
PMB only:
  • Advanced laparoscopic surgery
  • Re-constructive surgery
  • Joint replacements
  • Cardiac surgery incl cardiac stents
  • Spinal surgery
  • Breast re-constructive surgery
  • Minor procedures are only paid in full if done in network doctor's rooms
  • Only one joint replacement per person per year
  • Surgery for only one spinal level per person per year, unless PMB
  • Only one cardiac stent covered per vessel per year
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R165,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R165,000 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)

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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):
Copper Core A
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
General info:
  • Consider getting Primary Health Care (PHC) (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
GP consultations:
  • 4 visits per person, with DSP doctor
  • See Primary Health Care benefit above
Childcare: 2019 Benefits coming soon!
Specialists consultations:
  • Must be referred by GP, and with a network specialist managed care rules
  • See Primary Health Care benefit above
Pathology:
  • Subject to formulary nad protocols
  • See Primary Health Care benefit above
General radiology:
  • Subject to formulary nad protocols
  • See Primary Health Care benefit above
Specialised radiology:
  • R7,925 per family, in and out of hospital. Limited to PMB level of care
Supplementary Services: (Physio, etc)
  • R2,810 per family, unless PMB
  • Limited to: physiotherapy, speech therapists, podiatrist, clinical psychologists, equipment and external prosthesis

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MATERNITY BENEFITS:
Copper Core A
Scheme Benefits Notes and Links:
Hospital stay:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
  • Part of GP and Specialist benefit
Scans:
  • 2 x 2D scans, paid by scheme
  • 2 x haemoglobin tests
  • 1 x blood group test
  • 1 x VDRL test for syphillis
  • 1 x HIV Elisa test

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CANCER (ONCOLOGY):
Copper Core A
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • PMB only

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DENTISTRY:
Copper Core A
Scheme Benefits Notes and Links:
Standard Dentistry:
  • For consults, oral hygiene, extractions and fillings: M =R3,073
    M1 =R3,547
    M2 =R3,852
    M3 =R4,168
    M4 =R4,452
    M5 =R4,768
    M6 =R5,231
  • Root canal: from network provider, subject to limit and rules
  • Plastic dentures: one set per beneficiary every 4 years
  • Consider getting Primary Health Care (medical insurance) that will cover you for a lot of out of hospital claims, including standard dentistry like scaling, polishing, fillings, extractions, root canals and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Specialised Dentistry:
  • No benefit
In-Hospital Dentistry:
  • PMB only
Orthodontics:
  • No benefit
Maxillo Facial Surgery:

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MEDICATION:
Copper Core A
Scheme Benefits: Notes and Links:
Chronic:
  • All medical aid plans pay for treatment of the 27 CDL conditions as required by law. This includes medicine as well as GP or specialist consults, tests etc. Find out more
  • Other chronic: R8,736 per person. PMB medicines accumulate to this limit.
Acute (presrcibed) medication:
  • As per network provider
Over-the-counter:
  • R337 per family
Birth Control:
  • No benefit
On Discharge:
  • 7 days supply
Biological:

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OPTOMETRY:
Copper Core A
Scheme Benefits: Notes and Links:
Optometry:
Limit(per family)
M =R1,252
M1 =R1,442
M2 =R1,600
M3 =R2,294
Consult:1 test per person every 2 years
Frames:R520 per person, part of above limit
Single lensesAs per limit
Bifocals:As per limit
MultifocalsAs per limit
ContactsAs per limit
Refractive Surgery:No benefit

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MENTAL HEALTH:
Copper Core A
Scheme Benefits Notes and Links:
In-hospital:
  • 21 days per person, including 6 in-hospital consults with psychologist.
  • Can be substituted with 4 additional consults in lieu of hospitalisation
  • Subject to PMBs and Designated Service Providers
  • Alcoholism/Drug Addiction: 3 days withdrawal treatment plus 21 days rehab at an appropriate facility
Out-of-hospital:
  • Shared with Supplementary Out-of-hospital benfit
  • R2,810 per family, unless PMB. Shared with: physiotherapy, speech therapists, podiatrist, clinical psychologists, equipment and external prosthesis
Trauma:
  • PMB conditions are covered for in and out of hospital treatment. For a full list see here.
  • Example of PMB condition: Acute stress disorder accompanied by recent significant trauma, including physical or sexual abuse. Treatment includes hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts

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OTHER BENEFITS:
Copper Core A
Scheme Benefits Notes and Links:
General Appliances:
  • Clinically appropriate devices and appliances subject to clinical protocol
1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
  • PMB only
International Insurance:
Other: 2019 Benefits coming soon!

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WELLNESS/PREVENTATIVE BENEFITS:
Copper Core A
Scheme Benefits: Notes and Links:
Flu vaccination:
Pneumonia vaccines:
Biometric Screening:
Child Immunisation:
Pap Smear:
Mammogram:
PAS Test:
HIV Test:
Other:

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PROSTHETICS:
Copper Core A
Scheme Benefits: Notes and Links:
Overal Limit: 2019 Benefits coming soon!
Sub-limits: 2019 Benefits coming soon!

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    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