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Benefits ⋆ SwaziMed
A medical emergency can strike at any time. The correct treatment and proper transportation of the sick or injured patient is vital to ensure the best result.
In any medical emergency, speed is vital to the survival and quick recovery of the patient. If you are involved in a motor vehicle accident or suffer a heart attack, time is of crucial essence. The first ten minutes, known as the platinum time, is the first goal in which to get the patient medical attention. The next goal is the first hour after injury, known as the golden hour. Responses in these times by qualified professionals can make all the difference between life and death.
In an emergency contact any of the following ambulance services and you will receive the best pre-hospital medical emergency care available. If necessary, we will arrange transfers to a local medical facility or evacuation to hand-picked centre of excellence for treatment.
With Swazimed your family is covered for any pre-hospital medical emergency and evacuation 24 hours a day, 365 days a year within your monthly contributions.
Emergency contact numbers:
Swazimed has introduced Medicine Management Programme to ensure that appropriate and cost effective medicines are prescribed to members.
THE MEDICINE PRICE LIST (MPL)
MPL is a reference pricing system that uses a benchmark (reference) price for generically similar products. The fundamental principle of any reference pricing system is that it does not restrict a member’s choice of medicines, but instead limits the amount that will be paid. MPL reference prices are set in such a way as to ensure availability of medicines without copayments being necessary – in other words, you will be able to afford the medicine you need without paying from your own pocket, but you may have to select certain generics over a brand name product or more expensive generics. Should you prefer one of the more expensive products, Swazimed will only pay up to the MPL reference price and you will then have to pay the difference (co payment) to the pharmacy.
If you are exposed to HIV infection through rape or needle-stick injury please ask your doctor to contact HIV/AIDS Management programme to authorise special antiretroviral medicine to help prevent possible HIV infection.
It is best to take prophylaxis treatment within 72 hours after exposure. If the incident putting you at risk occurs over the weekend, make sure you get the necessary medication on time.
WELLNESS BENEFITS
The objective is early identification of common risk factors, reduction in co-morbities and general improvement in the health status of members
Service
Clinical Criteria forAccess
Consultation with
general practictioner
Limited to one (1) long consultation per year. During this consultation, the
DR will assess blood pressure, body mass index and glucose.
Pneumococial
Vaccine
For all beneficiaries aged 65 years & older.
Pap Smear
For all female beneficiaries aged 21 years and older, limited to one test
every two years.
Total Cholesterol
For all beneficiaries aged 29 years and older, limited to one test every two
years One (1) lipogram every 5 years.
PSA
For all male beneficiaries aged 45 years & older, limited to one test every
two years.
Colo-rectal Screening
(faecal occult blood)
For all male beneficiaries aged 50 years & older, every year.
Densitometry
For all beneficiaries aged 50 years & old.
Mammogramm
For all female beneficiaries aged 50 to 74years.
Flue Vaccine
For all beneficiaries aged 6 years & older.
INTENSIVE CARE UNIT (ICU) & HIGH CARE
For Swazimed to pay for ICU and High Care facility, the Private Hospital must comply with the following:
Register with the Medical and Dental Council of Eswatini
Register with Board of Health Care Funders in SA
Evaluated and approved by the Health Service Accreditation of Southern Africa (COHSASA)
Signed memorandum of understanding with Swazimed which sets terms and conditions of operating an ICU including list of required specialist i.e ICU intensivist, ICU nurse, specialist surgeons, anaesthesiologist, neurologist, nephrologist.
Pre-authorisation approval needed before patient admission.
NB
The scheme pays negotiated rates. Limited to 2 days per admission For Swaziland hospitals. The rate per day should be agreed between SwaziMed and the hospitals at the beginning of each year.
CHRONIC MEDICINES BENEFIT
All members with their registered dependants who have accomplished a three months waiting period with the fund are entitled to a chronic medicine benefit based on the option they belong to. The cover includes; hypertension, diabetic, asthma, epileptic, ulcer, bipolar, schizophrenia, allergic rhinitis chronic obstructive pulmonary disease, cardiac failure and cardiomyopathy, coronary artery disease, hyperlipidaemia, gout and hypothyroidism, multiple sclerosis, glaucoma, chrohn’s disease, Parkinson’s disease, addison’s disease and osteoporosis
FUNERAL POLICY
All members of the scheme are automatically covered for the Swazimed funeral policy which is insured through the Eswatini Royal Insurance Corporation. The members and their registered dependants in the event of death are covered;
Member/Spouse/Parents – E20,000.00
Child: 14-21 years – E20,000 00
1-13 years – E10,000.00
Below 1 year – E5,000.00
What will the fund not pay for?
Costs above Scale of Benefits, or above your annual or category limits.
Treatment for obesity and artificial insemination.
Cosmetic surgery which includes plastic and reconstructive surgery, breast reductions or enlargements, removal of excess fat and skin grafts.
Self-inflicted injuries.
Injuries arising from professional sport or speed contests.
Conditions which were specifically excluded when you joined the fund.
Pregnancy within the first nine months of joining the fund.
Items which can be purchased from supermarkets i.e. shampoo.
More than one months’ supply of medication.
Vitamin supplements unless younger than 5 or older than 60 years.
Immunisations.
Injury on duty which is paid by Workman’s Compensation.
Heart operation (24 months)
Renal failure (24 months)
Oncology (24 months)
Organ transplant (24 months)
Any pre-existing condition before or during waiting period.
Optical benefits within the first 12 months of joining the fund.
Swazimed offers nine benefit options and each individual should choose an option according to his/her health care needs. For all the options, benefits are paid at Swazimed scale of benefit (SPL) with adequate annual limits.
Members who have completed a twelvemonth membership (calendar year; January-December) are entitled to a percentage of their contributions which is claimed before the end of March of the following year. Only High benefit, Standard benefit, Medium benefit and Savings plan members are entitled to these claims. Members are encouraged to write claims letters to Swazimed for tax purposes thus there is no automatic payments of bonuses.
Members on High, Standard and Medium option from January to December will be allowed to write a letter to claim a 30% incentive bonus for the previous year before the end of March in the following year. To qualify for the bonus members should have cleared all contribution arrears by March of the following year. Payment will be between June and October.
Swazisave members can claim a 20% savings balance only if the member has 12 months membership from the beginning of the year. If the member on the savings option leaves the fund the balance of the savings will remain with the fund and the member may claim the 20% yearly. The current year balance will be paid only if the member leaves by the end of December.
Members who have terminated their membership may claim 100% savings balance and payment will be processed after the lapse of the stale period (4 months) from the date of termination. Members may use their savings for future medical expenses/contributions if preferred not to claim back as cash.
Member’s savings will be transferred to the newly selected option and members may claim 20% of the savings balance on annual basis. Applications can be sent before the end of March the following year.
Members on high benefit, standard benefit, medium benefit and savings plan forfeit their savings or claims for the incomplete current financial period (January-December). Members may only claim for a full financial period. Members who join at the beginning of the year and terminate membership during the course of the year will not claim savings for that year. The balance from the previous years may only be claimed annually (20% balance every year)
Ex-gratia is a conditional assistance which is granted to a member who has exhausted the normal benefit and there is a clinical indication that if the treatment is not received the members life will be in danger.
Terms and conditions apply.
