🏥 Hospital Admissions
High Care Unit
General Ward
Theatre
Recovery Room | Covered up to 100% of the Negotiated Tariff. |
| 🧪 Medicines and consumables used in hospital and theatre | Covered up to 100% of the negotiated tariff. |
| 💊 Medicine to take home after discharge | Paid from the hospital benefit.
Limited to 7 days’ medicine. |
| 👩⚕️ Consultations and Procedures | Covered up to 100% of the negotiated tariff. |
| 1️⃣ Basic Radiology and Pathology | Covered up to 100% of the scheme tariff.
Subject to pre-authorization and the following programs:
Hospital Benefit Management
Disease Management
PMB Protocols |
| 2️⃣ Specialized Radiology | Limited to two scans per beneficiary yearly for MRI, CAT, and Angiogram scans.
Subject to the overall combined in and out-of-hospital limit of R22,654 per family per year.
Managed care protocols apply, and pre-approval is required.
Interventional Radiology falls within the hospital limit and is subject to clinical protocols and pre-approval. |
| 3️⃣ Oncology | The benefit is limited to requirements set out in PMBs covered at a DSP. |
| 4️⃣ Renal Dialysis | Covered up to 100% of the Sizwe Hosmed tariff. |
| ❤️ Organ Transplants | Covered up to 100% of the scheme tariff. |
| 🦷 Dental Hospitalisation | Covered up to 100% of the scheme tariff.
Limited to PMBs.
Children under seven can receive general anesthesia benefits once per year for intensive dental treatment.
Symptomatic wisdom tooth removal is covered solely as Day Case.
Subject to pre-approval.
Treatment protocols will apply. |
| 🥰 Maxillo-facial and Oral Surgery | Covered up to 100% of the Sizwe Hosmed tariff.
Subject to managed care protocols.
Benefits for Temporo-Mandibular Joint (TMJ) are limited to non-surgical interventions or treatments. |
| 💟 Drug and Alcohol Rehabilitation | Treatment Protocols and PMBs are subject to pre-approval.
On pre-authorization, 3 days of withdrawal treatment + 21 days of rehabilitation at an appropriate facility |
🧠 Psychiatric Treatment
Consultations
Ward Fees
Medicines
Psychiatry/psychology therapy sessions | Each beneficiary is only allowed 21 days per year.
This benefit provides six (6) in-hospital consultations with a clinical psychologist and six (6) psychiatrist consultations – subject to PMBs.
Limited to 1,785 daily per beneficiary, with a maximum value of R37,485.
Subject to managed care rules
Four (4) additional out-of-hospital visits/consultations are permitted instead of hospitalization. |
| 🚑 Hospitalisation Alternatives | Subject to PMBs
Pre-authorization required.
Subject to relevant protocols |
| ⬇️ Step-down Facilities | Subject to the Management Program and Disease Management Program.
Sizwe Hosmed prices apply to all services provided at registered step-down institutions and nursing homes.
Hospice care is covered by up to 100% of the cost.
100% of the Sizwe Hosmed rates apply for Home Care services instead of Hospitalisation. |
| 🏡 Home-Based Care | Benefits are subject to Sizwe Hosmed Private Nurse fees and Pre-Authorisation.
There is a limit of R5,505 per year per family.
Frail care is not covered under this benefit.
PMB is applicable. |
| 😮💨 Hyperbaric Oxygen Therapy | Covered up to 100% of the negotiated tariff.
Pre-authorization required.
Limited to PMBs.
Public sector protocols will apply. |
| 🅰️ Male Sterilisation/Vasectomy | Covered up to 100% of the negotiated tariff.
Sterilization is limited to R17,472 per beneficiary per year.
Subject to pre-approval and PMBs. |
| 🅱️ Female Sterilisation/Tubal Ligation | Covered up to 100% of the negotiated tariff.
Sterilization is limited to R17,472 per beneficiary per year.
Subject to pre-approval and PMBs. |
| 🧬 Back and Neck Surgery | Spinal surgery authorization for treating chronic back or neck pain is subject to managed care guidelines.
Before authorizing surgery, managed care may require adherence to conservative clinical treatment. |
| 🔴 Stereotactic Radiosurgery | Covered up to 100% of the scheme tariff.
Only covers Primary Central Nervous System tumors. |
| 🟠 Age-related Muscular Degeneration Treatment | Covered up to 100% of the negotiated tariff.
Pre-authorization required. |
| 🟡 Laparoscopic Hospitalisation and Associated Costs | Pre-authorization required.
Subject to PMBs. |
| 🟢 PMB Laparoscopic Procedures | PMBs are covered in DSP facilities.
Subject to clinical protocols. |
| 🔵 Internal and External Prostheses | Covered up to 100% of the negotiated tariff.
Subject to PMBs and pre-approval.
Overall prostheses limit of R31,043 per family per year within the hospital limit. |
| 🦾 Internal Prostheses | Subject to the benefit limit unless it is a PMB.
The following are covered:
Pacemakers
Defibrillators
Spinal Fusion – only one spine level per beneficiary, and if more is required, managed care protocols will apply.
Grafts
Joints – Hip and Knee (partial and total), limited to one joint per beneficiary yearly.
Other clinically appropriate unspecified prosthetic items |
| 🦿 External Prostheses | Subject to the benefit limit unless it is a PMB.
This benefit includes the following:
Artificial Limbs
Prosthetic Breasts
Ocular
Taylor Spatial Frame
External Fixator
Mesh
Other clinically appropriate unspecified prosthetic items. |
| 🫀 Cardiac Stents | Cardiac Stents are limited to 3 unless it is a PMB.
Vascular Stents are limited to 2 stents per family per year. |
| 🩸 Blood Transfusions | Covered up to 100% of the scheme tariff. |
| 🏈 Physiotherapy and Biokinetics | Covered up to 100% of the scheme tariff. |
| ❤️ Dietician and Occupational Therapy | Covered up to 100% of the scheme tariff. |
