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					PROVIDER NEWS FROM SIZWE MEDICAL SERVICES                                                                    2003/2



Are you ready?                                                                          The 25 PMB chronic
                                                                                          conditions are:
                                                                                        1. Addison's disease 2. Asthma
... for the new PMB chronic conditions list                                             3. Bipolar mood disorder
                                                                                        4. Bronchiectasis 5. Cardiac
                                                                                        failure 6. Cardiomyopathy
                  rom 1 January 2004, changes      conditions.                          7. Chronic obstructive
                  to the Medical Schemes Act           Sizwe’s chronic ailment lists    pulmonary disease 8. Chronic
                  require all Medical Aid          and their PMB formularies            renal disease 9. Coronary
                  Schemes, including Sizwe, to     (copies of which are included        artery disease 10. Crohn's
                  provide their members with       with this issue of Dispenser)        disease 11. Diabetes insipidus
               reasonable access to a list of 25   are currently split into three:      12. Diabetes mellitus type 1 and
                                                   1. a basic list covering at least    type 2 13. Dysrhythmias
               chronic conditions. Schemes are
                                                                                        14. Epilepsy 15. Glaucoma
               not allowed to set limits or           the entire chronic prescribed
                                                                                        16. Haemophilia 17. Hyperlipi-
               charge co-payments for ser-            minimum benefits, for the         daemia 18. Hypertension
               vices provided by a Designated         First and Primary options;        19. Hypothyroidism 20. Multiple
               Service Provider (DSP), as long     2. a standard list for the           sclerosis 21. Parkinson's disease
                   as specific funding guide-         Affordable option; and            22. Rheumatoid arthritis
                      lines, protocols and for-    3. a comprehensive list for the      23. Schizophrenia 24. Systemic
                         mularies are followed.       Full Budget and Elite option      lupus erythematosus
                                                      members.                          25. Ulcerative colitis
                          Chronic                  These chronic ailment lists for
                            ailment lists          the various options as well as
                             In light of the new
                              regulations, Sizwe
                                                   the formularies, are also avail-
                                                   able on our website at
                                                                                       Seasons greetings
                              – along with its     www.sizwe.co.za under the           As 2003 draws to a close, Sizwe
                               newly-appointed     News link.                          Medical Services would like to
                               DSPs, Direct                                            thank you for your support dur-
                               Medicines and       Controlling costs                   ing this time and looks forward
                              Chronic Medi-        In order to keep down contribu-     to another year of working
                             cine Dispensary       tion increases as a result of the   together with you to care for
                            (CMD) – has re-        new legislation, the Trustees       the health of
                           designed the chro-      have taken steps to control the     the nation.
                         nic ailment lists for     costs relating to PMB medicine      Enjoy the
                       2004 to include a rec-      benefits and have negotiated a      festive
                      ommended list of medi-       32,5% discount (including a         season.
                   cines for these 25 chronic              Continued on page 2 …



 INSIDE:
NEW IN 2004                                    MEDICINE                                                 BETTER
 Look what’s                                   POLICY                                         4         DENTAL
 new at                                        Read about                                              BENEFITS
 Sizwe                                         Sizwe’s various                                         Healthy smiles
 in 2004
                2                              medicine
                                               guidelines.
                                                                    3                                       all round
                                                                                                     thanks to Denis.
… continued from cover
2,5% administration fee) with
CMD and Direct Medicines on all
chronic medication scripts.
   Members are, therefore, being
                                     See what’s new at S
encouraged to use CMD and                    s 2003 draws to a close,
Direct Medicines for their chronic           Sizwe is excited about the
medication, but are still free to            opportunities that the new
use any pharmacist or dispensing     year holds and would like to take
doctor they choose. However, if      this opportunity to inform you of
members are unable to negotiate      some of the changes and
the same 32,5% discount with         improvements that have been
their chosen provider, they will     made to the Fund.
be responsible for the differ-          As usual, contribution increas-
ence in price.                       es are an unavoidable evil at this
                                     time of the year. However,
PLEASE NOTE                          through careful management, the
q Sizwe will only pay the            Fund has been able keep the
  discounted price it has            average increase down to 12%,
  negotiated with the DSPs.          one of the lower increases in the
q In future Sizwe is planning to     market place for 2004.
  extend the network of DSPs and        The increases have mostly
  will send out communication        been influenced by the introduc-
  once they have negotiated with     tion of the chronic disease list
  other DSPs.                        portion of the prescribed mini-
q All members affected by these      mum benefits legislation intro-
  changes will, in due course, be    duced by the Registrar of Medical
  contacted by CHAMPS.               Schemes, as well as the need to
Should you have any queries          achieve the minimum solvency
regarding the new legislation        targets as set out by the Registrar.
and its implications,
please contact CHAMPS:               Disease Management                                        programmes in 2004.
(011) 353-0030.                      Programmes                                                   By helping our members to
                                     With a view to improving our                              better manage their illness, we
                                     members’ health and controlling                           will not only save on costs asso-
    Coding for PMBs                  costs where PMB chronic ailments                          ciated with chronic medication,
 Providers wanting to access         are concerned, Sizwe is introduc-                         but also ensure that Sizwe
 PMB benefits on behalf of our       ing three disease management                              remains competitive in the
 members, are kindly request-
 ed to provide Sizwe with the
 relevant diagnostic coding.
    In keeping with the current
                                               NEW EXCLUSIONS ON PRIMARY AN
 industry trend, ICD10 coding        Due to the upcoming changes to         chronic authorisation for these       Below is a list
 needs to be submitted wher-         the Medical Schemes Act with           medicines expiring on 31
 ever possible to indicate the       regard to the PMB chronic condi-       December 2003.                        Drug Name
 diagnosis related to services       tions, Sizwe has modified its med-
 rendered. Claims submitted          icine formulary to contain costs.      Members have three options ...        Seretide
 with ICD10 coding will be              Although cover in respect of        1. They can contact their doctor
                                                                                                                  Flixotide
 processed and paid                  the 25 PMB conditions will be             to change their prescription to
                                                                                                                  Amaryl
 quicker.                            unlimited, the medication is sub-         the recommended alternative if
    In the event of PMB claims       ject to a formulary. The formula-         they want to stay on the           Aprovel
 being submitted without             ries for the 25 PMBs are included         Primary or Affordable options.     Co-aprovel
 ICD10 coding, they are likely       with this issue of Dispenser.          2. They can choose not to change      Atacand
 to be processed as non-PMB             The medicines listed along             their medication and instead
 conditions. This will signifi-      side are now considered non-              upgrade to the Full Budget or      Atacand Plus
 cantly impact on the member’s       formulary medicines and will no           Elite Incentive options in which   Diovan
 benefits. Sizwe is therefore        longer be covered on the chronic          these medicines are covered.
                                                                                                                  Co-diovan
 depending on providers to           medicine benefit for the Primary       3. They can remain on the
                                                                                                                  Micardis
 help our members get the            and Affordable options.                   Primary or Affordable options      Co-micardis
 most out of their benefits by          Members on the Primary or              and pay for their preferred        Cozaar
 making use of ICD10 coding          Affordable option taking one of           medication from their acute
 at all times.                       these medicines, will see their           medicine benefit.                  Cozaar comp




                                                             2
Sizwe in 2004                                                                    Sizwe's policy on medicines

 marketplace by keeping our
 contribution increases to a
                                           Sizwe is one of the few bigger
                                        funds in the South African med-
                                                                                  Remember ...
 minimum.                               ical aid market that still offers tra-   Generics: Where a generic equivalent is
    In addition to the HIV/AIDS         ditional fee-for-service options         available, Sizwe only pays for the cost of the
 and Respiratory Disease man-           and we believe that by extending         generic. If the member insists on using the
 agement programmes, we have            our range in this domain, while          patent medication, please remind him/her
 introduced programmes for:             keeping down costs, we have one          that they will be responsible for the difference
 1. Diabetes;                           of the best selections to offer          in price.
 2. Hypertension; and                   members.
 3. High cholesterol.                                                            To Take Out (TTO) medicines: TTO medi-
    All five programmes will be         Exclusions under Sizwe                   cines taken from hospital are paid from the
 managed by Cheiron Health              First and Primary options                acute medicine benefit and not the hospital
 Technologies from 1 January            Please note that exclusions have         account. This includes medicines taken from
 2004. Contact numbers for these        been introduced on certain pro-          casualty.
 programmes for 2004 are:               cedures on the Primary and First
 q Yebo Life (the new HIV/AIDS          options under the Private Hospi-         Medicine queries – General Practitioners:
   Management Programme):               tals and Nursing Homes benefit.          Please take note that receiving a medicine
   0860 10 34 54                           Under these exclusions, Sizwe         authorisation is not a guarantee of payment.
   Fax: (011) 221-5235                  will not cover knee, hip or shoul-       While we do have a specific phone line in
 q Respiratory, Cholesterol,            der and heart bypass surgery.            place for medicine authorisations, this is a
   Hypertension and Diabetes            However, these will be covered in        means of validating membership and not a
   programmes: 0860 10 34 55            the event of vehicle accidents           means of guaranteeing payment.
   Fax: (011) 221-5238                  and where PMBs apply.                    The medicine queries number is:
                                                                                 0800 002 447
 New addition to                        Levy dropped on
 our product range                      Full Budget option                       Discounts on Lipitor 10mg for Sizwe mem-
 We have added a new low-cost           We are happy to announce that            bers: Due to cholesterol falling within the PMB
 option to our range of products        we have dropped all levies for           ailment list as prescribed by the Registrar,
 for 2004 called Sizwe First            chronic medication on the Full           Sizwe has negotiated a special discount price
 (Option Prefix = 111). This option     Budget option.We will, however,          for Lipitor 10mg from our Designated Service
 offers the lowest contributions in     continue to charge a 10% co-             Providers, Direct Medicines and Chronic
 the traditional range with cover       payment for acute medication             Medicine Dispensary. By negotiating a good
 available on essential benefits.       on this option.                          price on this medication, the scheme is able
                                                                                 to keep down the cost of chronic medication,
                                                                                 which ultimately keeps down contribution
ND AFFORDABLE OPTIONS                                                            increases in light of the latest PMB legislation.

of the excluded drugs and their recommended alternatives:                        New Designated Service Providers (DSPs)
                                                                                 for chronic medication: Sizwe has identified
    Recommended              Drug Name                Recommended                two DSPs for next year, namely CMD
    Alternative                                       Alternative                and Direct Medicines, which have offered
    Serevent +               Fortzaar                 Pharmapress Co             a discount of more than 30% to Sizwe
    Budeflam/Beclate         Concor                   Adco-atenolol              members.
    Budeflam or Beclate      Coversyl                 Hexal-Lisinopril/-
                                                                                    Members are free to use any
    Glucomed or                                       Zetomax/Pharmapress
    Glucophage               Coversyl Plus            Zestoretic 10mg            pharmacist or dispensing doc-
    Hexal-lisinopril         Lipitor 20mg                                        tor they choose to, but should
    Zestoretic 10mg          and 40mg                 Adco-simvastatin           see if they can
    Hexal-                   Prava                    Adco-simvastatin           negotiate
    lisinopril/Zetomax       Sotacor and Sotahexal    Adco-atenolol              with them to
    Pharmapress Co           Symbicord                Serevent + Budeflam        match the
    Hexal-                   Ziak                     Tenchlor                   discount
    lisinopril/Zetomax                                                           offered by the
    Zestoretic 10mg
                                                                                 DSPs otherwise
    Pharmapress/Zetomax        Any queries relating to chronic ailments
    Zestoretic 10                or medicine, can be directed to the             they will be
    Hexal-lisinopril/-         CHAMPS Call Centre on (011) 353-0030.             responsible for the
    Pharmapress                    Fax: (011) 353-0352 or 353-0076.              difference in price.
    Zestoretic 10mg




                                                     3
                                                                                             The HIV/AIDS management
          Better                                                                                    programme

                                                                                            “Yebo”, it’s changed
      dental benefits                                                                     Please note that as of 1 January 2004, Sizwe's
                                                                                          AIDS Management Programme will no longer
                                                                                          be administered by Lifesense Disease

        with Denis                                                                        Management, but rather by Cheiron Health
                                                                                          Technologies.
                                                                                             The new programme is called Yebo Life
                                                                                          and will continue to offer HIV-positive mem-
                                                                                          bers the same benefits offered through
     rom 1 January 2004, dental                authorisation through Denis).              Lifesense. The confidential details of these
     claims for the Elite, Full              Members are also entitled to                 members will in no way be jeopardised by
     Budget, Affordable and                  use the practitioner of their                the move, and members and their doctors
     Primary options on Sizwe                choice, keeping in mind that                 can be assured that a high level of infor-
     are to be fully administered            they will be required to pay a               mation security will continue to be
by Dental Information Systems                co-payment if their practitioner             practised when dealing with patients
(Denis) in Cape Town. As a                   charges private rates. Please                on the Yebo Life
result, Sizwe members can                    note that all dental work                    programme.
expect significant improve-                  must be approved by Denis.                      We would like to remind
ments in their dental benefits                                                            doctors that a member
for the coming year.                         Queries ...                                  diagnosed with
   Improvements include:                     Dental queries for treatment                 HIV/AIDS must be
q unlimited cover for conserva-              up to 31 December 2003, must                 referred directly to Yebo
  tive dentistry subject to                  still be directed to the Sizwe               Life from 1 January 2004, for
  accepted clinical protocols. A             Dental Query Line:                           registration on this programme.
  detailed list of these proto-              (011) 353-0192. However, from                   As a means of upholding the
  cols can be viewed at                      1 January 2004, queries and                  promise of confidentiality, these mem-
  www.denis.co.za (follow the                pre-authorisations for dental                bers must not be directed to Sizwe and
  Sizwe links); and                          treatment should be directed                 therefore Yebo Life requests that the doctor
q unlimited cover for maxillo-               to Denis on: 0860 033 647.                   takes responsibility for ensuring their patient
  facial surgery, specialised                Paper claims can be sent to:                 is registered on the programme.
  dentistry, dentures and                    Denis; Private Bag X26;                         Contact Yebo Life on: 0860 10 34 54
  orthodontics (subject to pre-              Rondebosch; 7701



                                          ADMIN UPDATE
    REPAIRS TO APPLIANCES                                       thoracotomies (motivation needed); and intractable pain
    Please be aware that while Sizwe pays up to the limit in    associated with malignancy. Sizwe will not cover the
                                                                                                                                SIZWE
    the benefit guide for appliances such as wheel chairs, it   pump in the case of maternity, tonsillectomies and hys-
                                                                                                                              CELEBRATES
    does not cover repairs to these appliances. Repairs to      terectomies, or if used in the operating theatre.
                                                                                                                               25 YEARS
    appliances are therefore for the member's account.             If the payment of the PCA pump is denied, Sizwe will
                                                                not pay for the disposable items and drugs used togeth-       Sizwe has
    PCA PUMPS                                                   er with the PCA pump. Please note, however, that              brought out its
    Sizwe will pay for Patient Controlled Analgesia (PCA)       Cyclomorph will be paid for up to four amps per case.         party hats in
    pumps according to BHF rates under the following con-                                                                     celebration of
    ditions (not applicable in Intensive Care Units and other   CLIPS AND SUTURES                                             25 years in the
    specialised units):                                         If a Sizwe member has had surgery where clips and             industry. We
    q Reusable PCA pumps (equipment fee and dispos-             sutures were used, Sizwe pays for the removal of these        would like to
       ables) – one pump per patient per day in general         up-front, which means the member and doctor need              thank you for
       ward up to a maximum of 48 hours.                        not worry about this cost at a later stage. This is to pre-   your support
    q Disposable PCA pumps – one pump per stay up to a          vent double payments by Sizwe because the doctor has          during the past
       maximum of 48 hours.                                     already been reimbursed by the Fund for the follow-up         25 years and
        PCA pumps will be covered for major joint replace-      consultation, which includes the cost to remove clips or      look forward to
    ments; open, upper abdominal surgery; severe burns;         sutures, as well as the clip remover.                         the next 25
    paediatrics in specialised cases (motivation needed);                                                                     years of busi-
                                                                                                                              ness with you.


                                                                         4

				
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