Sizwe offers cover for numerous chronic conditions including those defined as Prescribed Minimum Benefit (PMBs). This cover is in addition to your normal day-to-day benefits to ensure that during the year you do not run out of essential medical benefits to treat these PMB conditions. The treatment covered by PMBs refers to essential treatment of your condition and is subject to clinical and funding protocols. Members and Service Providers are encouraged to use cost-effective medication (generics where available), which Sizwe pays in full without any co-payments.

What is a pmb?
Prescribed Minimum Benefits (PMBs) are a set of defined benefits that ensure all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.  PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:
• any emergency medical condition;
• a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs); and
• 26 chronic conditions (defined in the Chronic Disease List).

What is a designated service provider (DSP)?
A Designated Service Provider (DSP) is a healthcare provider (doctor, pharmacist, hospital, etc) that is a medical scheme’s first choice when its members need diagnosis, treatment or care for a PMB condition. If you choose not to use the DSP selected by Sizwe, you may have to pay a portion of the bill as a co-payment. This could either be a percentage co-payment or the difference between the DSP’s tariff and that charged by the provider you went to.

What are diagnostic and treatment pairs?
The Regulations to the Medical Schemes Act in Annexure A provide a long list of conditions identified as Prescribed Minimum Benefits. The list is in the form of Diagnosis and Treatment Pairs (DTPs).  A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated. The treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration. Should there be a disagreement about the treatment of a specific case, the standards (also called practice and protocols) in force in the public sector will be applied.  The treatment and care of some of the conditions included in the DTP may include chronic medicine, e.g. HIV-infection and menopausal management. In these cases, the public sector protocols will also apply to the chronic medication. For a full list of the DTPs, please go to the Sizwe website www.sizwe.co.za

 PMB Chronic Disease List
Respective medical formularies and chronic benefit entry criteria for the conditions
listed below are available on request from the Chronic Medicine Programme.
1. Addison’s disease
2. Asthma
3. Bipolar mood disorder
4. Bronchiectasis
5. Cardiac failure
6. Cardiomyopathy
7. Chronic obstructive pulmonary disease
8. Chronic renal disease
9. Coronary artery disease
10. Crohn’s disease
11. Diabetes insipidus
12. Diabetes mellitus type 1 and 2
13. Dysrhythmias
14. Epilepsy
15. Glaucoma
16. Haemophilia
17. Hyperlipidaemia
18. Hypertension
19. Hypothyroidism
20. Multiple sclerosis
21. Parkinson’s disease
22. Rheumatoid arthritis
23. Schizophrenia
24. Systemic lupus erythematosus
25. Ulcerative colitis
26. HIV/AIDS

What if I need, or want, a brand of medicine other than the one that Sizwe will pay for?
Sizwe has a formulary – a list of safe and effective medicines that can be prescribed to treat certain conditions. The formulary is applicable to PMB conditions.  Sizwe will only cover the cost of the drug on the formulary where available. Often the medicines on the list will be generics, which are cheaper copies of the original brand name drug. If you want to use a brand name medicine that is not on the list, Sizwe will pay up to the price of the generic and you will be liable for the difference in price.

Exclusions
NB: Kindly note that this list is not exhaustive, for details of all exclusions across all options refer to the Sizwe website on www.sizwe.co.za
1. The Fund is not liable for expenses incurred in connection with any of the following:
• Treatment of obesity.
• Operation, medicines, treatment and procedures for cosmetic purposes.
• Costs exceeding the annual maximum benefit entitlement to a member.
2. Purchase of:
• Patent medicines and proprietary preparations.
• Applicators, toiletries and beauty preparations.
• Bandages, cotton wool and similar aids.
• Tonics, slimming preparations and drugs advertised to the public.
• Household and biochemical remedies.
3. Holidays for recuperative purposes.
4. Travelling expenses incurred by a member or charged by a medical or dental practitioner.
5. Charges for appointments cancelled or which a member and or dependant fails to keep.
6. Payment of interest on arrear accounts.

Specific clinical limitations on Primary option
The following conditions will only be covered on the Primary option in terms of
Prescribed Minimum Benefits and at a Designated Service Provider:
• Advanced laparoscopic procedure
• Reconstructive surgery
• Cardiac surgery
• Joint replacements
• Spinal surgery
• Breast reconstruction surgery

Specific exclusions on Primary option:
• Keloids
• Breast reduction
• Breast augmentation