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Type of Medical Aid Plan: 
Traditional
Medical Aid Year: 
2020
Day to day Benefits: 

INSURED DAY-TO-DAY BENEFITS M = R2 750 per annum M+1 = R4 700 per annum M+2 = R5 800 per annum M+3 = R7 050 per annum • GPs & specialists • Clinical psychology & physiotherapy • Supplementary health services ACUTE MEDICINE BENEFITS M = R4 250 per annum M+1 = R7 200 per annum M+2 = R8 850 per annum M+3 = R9 450 per annum CHRONIC MEDICINE BENEFITS (Non PMB) M = R4 500 per annum M+1 = R6 850 per annum M+2 = R9 150 per annum M+3 = R9 800 per annum STANDARD RADIOLOGY BENEFITS R2 750 per family per annum PATHOLOGY BENEFITS R2 750 per family per annum INSURED DENTISTRY BENEFITS Conservative and specialised INSURED OPTICAL BENEFITS Spectacles or contact lenses

In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
Unlimited at 100% of Medihelp Tariff (MT)
Hospitals: 

Any hospital for trauma and planned procedure admissions

Casualty / Emergency Visits: 
Covered from risk for PMB emergency only. No benefit for facility fee. Subject to Insured Day-to-Day Pooled Benefits
Specialists: 
Unlimited at 100% of MT
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Unlimited at 100% of MT
Radiology and pathology: 
Unlimited at 100% of MT
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Subject to protocols and pre-authorisation. Co-pay of R3 200 in hospital, R2 100 in a day clinic, no co-pay if procedure is done in the doctor's rooms
MRI and CT scans: 
Subject to protocols, pre-authorisation and requested by a specialist. Co-pay of R1 150
ICU and High Care: 
Unlimited at 100% of MT
Dialysis: 
Subject to pre-authorisation and clinical protocols. Unlimited at 100% of MT
Organ Transplants: 
PMB only. Subject to pre-authorisation and clinical protocols. Unlimited at 100% of MT
Oncology / Cancer: 
Subject to pre-authorisation and registration on the Medihelp Oncology Programme. Protocols and DSP's apply. Unlimited at 100% of MT for PMB's
Neck and Back Operations: 
Subject to pre-authorisation, protocols and case management. Co-pay of R7 750
Joint Replacements: 
Subject to pre-authorisation, protocols and case management. DSP's apply for wear and tear hip and knee replacements, if patient qualifies
Prosthesis: 

Subject to pre-authorisation, protocols and case management. Internal: EVARS prosthesis; R130 600 pbpa Vascular or cardiac prosthesis; R55 900 pbpa Health-essential functional prosthesis; R61 900 pbpa Intraocular lenses; 2 lenses pbpa at R4 150 per lens Implantable hearing devices; R105 100 pbpa Reconstructive or restorative surgery prosthesis; R9 600 pfpa in or out of hospital

Medical and Surgical Appliances: 
Subject to scheme protocols and sub-limits
Maternity Confinements: 
Subject to pre-authorisation, protocols and case management. Unlimited at 100% of MT
In Hospital Dentistry: 
Subject to pre-authorisation and DSP's managed care protocols. Limited to removal of wisdom teeth and extensive treatment for children younger than 5 years. Co-pay of R900
Take home Medicine: 
100% of MT up to R350 per admission
Rehabilitation, Hospice and Step-down facilities: 
Subject to pre-authorisation in an approved facility and prescribed by a medical doctor. Unlimited at 100% of MT
Treatment for Mental Health: 
Subject to pre-authorisation, protocols and services rendered in an approved facility and prescribed by a medical doctor. 100% of MT. Limited to R35 400 pbpa with a max of R49 100 pfpa
HIV / AIDS: 
Subject to registration on Medihelp's HIV/AIDS programme with LifeSense. 100% of cost
Ambulance Service: 
Subject to pre-authorisation and protocols. Unlimited with Netcare 911
International Travel Benefit: 
On request
Day-to-day benefits
GP consultations: 

INSURED DAY-TO-DAY BENEFITS M = R2 750 pa M+1 = R4 700 pa M+2 = R5 800 pa M+3 = R7 050 pa

Specialist consultations: 

INSURED DAY-TO-DAY BENEFITS
M = R2 750 pa
M+1 = R4 700 pa
M+2 = R5 800 pa
M+3 = R7 050 pa

Acute medicine: 

ACUTE MEDICINE BENEFITS M = R4 250 pa M+1 = R7 200 pa M+2 = R8 850 pa M+3 = R9 450 pa

Over-the-counter (OTC) Medicine: 

ACUTE MEDICINE BENEFITS M = R4 250 pa M+1 = R7 200 pa M+2 = R8 850 pa M+3 = R9 450 pa

Optometry benefits: 
INSURED OPTICAL BENEFITS. Subject to pre-authorization by PPN and services obtained from a PPN provider per 24 month cycle. 100% of MT. 1 composite eye test and spectacles or contact lenses
Basic dentistry: 
INSURED DENTISTRY BENEFITS. Subject to DSP's managed care protocols. 100% of MT
Specialised Dentistry: 
INSURED DENTISTRY BENEFITS. Subject to pre-authorization and DSP's managed care protocols. 100% of MT
Orthodontics: 

Subject to pre-authorization and orthodontic needs analysis. 100% of MT. R11 800 once per lifetime for beneficiaries <18 years

MRI and CT Scans (Out of Hospital): 
Subject to protocols, pre-authorisation and requested by a specialist. Co-pay of R1 150
Radiology and Pathology: 
STANDARD RADIOLOGY and PATHOLOGY BENEFITS R2 750 pfpa each
Pregnancy benefits: 
Free registration on HealthPrint pregnancy and baby programme, 12 ante- and postnatal consultations, 2 x 2D scans. Flu vaccine at Dis-chem or Clicks clinics
Physiotherapy and Occupational Therapy day to day: 
INSURED DAY-TO-DAY BENEFITS M = R2 750 pa M+1 = R4 700 pa M+2 = R5 800 pa M+3 = R7 050 pa
Chronic Conditions
Provider: 
Any
Chronic Conditions: 

Diagnosis, treatment and care costs of 26 chronic conditions that fall under the Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL), issued by the Council for Medical Schemes. Subject to pre-authorisation, protocols, and DSPs

Additional Chronic Conditions: 
Yes. CHRONIC MEDICINE BENEFITS (Non PMB) M = R4 500 pa M+1 = R6 850 pa M+2 = R9 150 pa M+3 = R9 800 pa
Preventative Care Benefits
Preventative Benefits: 

Payable at 100% of MT. Health assessment screening, HIV testing, counselling and support, tetanus and flu vaccine at Clicks or Dischem. Age and frequency specific tests for women: pap smear, mammogram and bone mineral density scan, prostate specific antigen for men and faecal occult blood test. Babies < 1 yr receive 2 visits to a GP or specialist. 2 x HPV vaccines for boys and girls 10-14 yrs or 3 x between 15-26 yrs. Standard child immunisations up to 7 yrs at Clicks or Dischem clinics and child flu vaccines

Total Contributions
Total Contribution Main Member: 
5304.00
Total Contribution Adult: 
4956.00
Total Contribution Child*: 
1440.00
Elite
Medical Aid Plan Name Term: 
Elite