Sizwe Platinum Enhanced B medical aid plan: 2020

View all plans in this scheme.
Always consult with your broker before making final decisions regarding your healthcare cover.

Platinum B
Total Cost pm:

Main member:

R3,675

Adult:

R3,515

Child:

R935
Savings (per year):
  • No savings option on this plan
Extended Fund: R R R
Income band:

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IN HOSPITAL PROCEDURES:
Platinum B
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 any hospital
Penalty for using other hospital:
  • n/a
  • n/a
Specialised Radiology:
  • R31,533 per family, in and out of hospital.
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: R7,525 per family
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:
  • N/A
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):
Platinum B
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
Extended Fund: R R R
General info: 2019 Benefits coming soon!
GP consultations:
  • Subject to the day-to-day limit
  • M =7 consults
  • M1 =14 consults
  • M2 =16 consults
  • M3 =18 consults
  • M4 =20 consults
  • M5 =21 consults
  • M6 =22 consults
Childcare: 2019 Benefits coming soon!
Specialists consultations:
  • Subject to the day-to-day limit
  • Must be referred by GP, except for gynaecologist and paeditrician for children up to 1 yr
  • M =4 consults
  • M1 =8 consults
  • M2 =9 consults
  • M3 =10 consults
  • M4 =11 consults
  • M5 =12 consults
  • M6 =13 consults
Pathology:
  • From day-to-day benefit
General radiology:
  • From day-to-day benefit
Specialised radiology:
  • R31,533 per family, in and out of hospital.
2019 Benefits coming soon!
Supplementary Services: (Physio, etc)
  • M =R1,673
  • M+ =R2,936
  • Limited to: speech therapy, podiatry, occupational therapy, social worker, dietics, audiology, homeopathy, educational psychologits, biokineticist and registered counsellor

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MATERNITY BENEFITS:
Platinum B
Scheme Benefits Notes and Links:
Hospital stay:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
  • 9 GP or midwife or specialist consult
  • Additional 4 specialist obstetrician consults if referred by GP
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
  • 12 x urine analysis tests
  • 1 x full blood count test
  • Vitamins worth R110

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CANCER (ONCOLOGY):
Platinum B
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • R348,851 per family, unless PMB

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DENTISTRY:
Platinum B
Scheme Benefits Notes and Links:
Standard Dentistry:
  • From day-to-day benefit, unless PMB
  • 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:
  • Crowns: 1 crown per family
  • Implants: No benefit
  • Metal dentures:2 partial frames per person, every 5 years. One per family per year
In-Hospital Dentistry:
  • R2,000 co-payment
  • General anaesthetic for children under 5yrs and removal of impacted teeth
Orthodontics:
  • 9-18yrs only, with a 35% co-payment
Maxillo Facial Surgery:

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MEDICATION:
Platinum B
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
  • An additional 13 conditions are covered
  • Other chronic: R6,147 per person. PMB medicines accumulate to this limit.
  • In addition to the per person limt, there is also a per family limit: M =R6,147
    M1 =R12,314
    M2 =R18,482
    M3 =R24,639
    M4 =R30,796
    M5 =R36,974
    M6 =R43,142
Acute (presrcibed) medication:
  • M =R3,800
    M1 =R5,789
    M2 =R6,841
    M3 =R7,357
    M4 =R8,420
    M5 =R8,683
    M6 =R8,946
  • Consider getting Primary Health Care (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
Over-the-counter:
  • Benefit shared with Acute Medicine benefit
Birth Control:
  • R2,905 per family
On Discharge:
  • 7 days supply
Biological:

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OPTOMETRY:
Platinum B
Scheme Benefits: Notes and Links:
Optometry:
Consult:1 test per person every 2 years
Frames:R884 per person
Single lensesR195 per lens
Bifocals:R421 per lens
MultifocalsR774 per lens
ContactsR1,663 with guidelines
Refractive Surgery:R7,010 per family

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MENTAL HEALTH:
Platinum B
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:
  • R9,525 per family for psychologists and psychiatrists for mental health disorders
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:
Platinum B
Scheme Benefits Notes and Links:
General Appliances:
  • M =R1,673
  • M1+ =R2,936
1.1. Hearing Aids:
  • R13,325 per family. One unit every 3 years
1.2. Wheelchairs:
  • R3,494 per family. One unit every 4 years
Dialysis:
  • PMB only
International Insurance:
Other: 2019 Benefits coming soon!

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WELLNESS/PREVENTATIVE BENEFITS:
Platinum B
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:
Platinum B
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