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MEDIHELP PRIME 1 NON-NETWORK 2019

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Type of Medical Aid Plan: 
Hospital
Medical Aid Year: 
2019
Day to day Benefits: 

Pooled benefit for GP and specialist consultations, physiotherapy, acute medicine and self-medication.

100% of the Medihelp tariff.

Member = R1 150 per year.

Member+ = R2 300 per year. 

Co-payments: 
Co-payments may apply for specialist referral procedures, as well as back operations
In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
100% of the MediHelp Tariff. Unlimited. Subject to pre-authorisation, protocols and case management.
Hospitals: 

100% of the MediHelp Tariff.

Unlimited.

Any hospital.

Subject to pre-authorisation, protocols and case management.

Upfront Payments to hospitals: 

Back and neck fusion – member pays the first R11 100.

Endoscopic procedures – Gastroscopy, colonoscopy, arthroscopy and sigmoidoscopy:

In a day clinic – member pays the first R2 000
In hospital – member pays the first R3 050

Dental procedures under general anaesthesia during hospitalisation – Removal of impacted teeth (dentist’s account covered for item codes 8941/8943/8945) and extensive dental treatment for children < 5 years (dentist’s account for member’s account) – member pays the first R3 000 per admission.

Casualty / Emergency Visits: 
Benefits for major trauma that necessitates hospitalisation. 100% of the cost. Unlimited. Subject to authorisation, PMB protocols and case management.
Specialists: 
Specialist network apply.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of the MediHelp Tariff. Unlimited
Radiology and pathology: 
Subject to clinical protocols. 100% of the MediHelp Tariff. Unlimited.
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
100% of the MediHelp Tariff. Member pays the first R3 050 per admission.
MRI and CT scans: 
On request of a specialist and subject to clinical protocols. 100% of the Medihelp tariff, Unlimited. Member pays the first R1 600 per examination.
ICU and High Care: 
100% of the MediHelp Tariff. Unlimited. Designated service provider applies.
Dialysis: 
Subject to pre-authorisation and clinical protocols. 100% of the MediHelp Tariff. Unlimited.
Organ Transplants: 
Subject to pre-authorisation and clinical protocols. 100% of the cost. Unlimited.
Oncology / Cancer: 
Subject to pre-authorisation and registration on the Medihelp Oncology Management Programme. Prescribed minimum benefits cases, 100% of the MediHelp Tariff, Unlimited. Non-PMB cases, 100% of the MediHelp Tariff R200 000 per family per year.
Neck and Back Operations: 
Back and neck fusion. Member pays the first R11 100 Balance paid at 100% of the MediHelp Tariff.
Joint Replacements: 
100% of the MediHelp Tariff. PMB only
Prosthesis: 

INTERNALLY IMPLANTED PROSTHESES.

All hospital admissions and prostheses are subject to pre-authorisation, protocols and case management.

100% of the MediHelp Tariff.

EVARS prosthesis R32 900 per beneficiary per year.

Vascular/cardiac prosthesis R32 900 per beneficiary per year.

Health-essential functional prosthesis R21 900 per beneficiary per year.

Hip, knee and shoulder replacements (non-PMB) prosthesis:

Health-essential functional prosthesis benefits apply.

Prosthesis with reconstructive or restorative surgery, In and out of hospital, R4 050 per family per year.

External breast prostheses, In and out of hospital, R4 050 per family per year.

Medical and Surgical Appliances: 
Artificial eyes, speech and hearing aids, artificial limbs wheelchairs: 100% of the MT; R4500/family/3-year cycle. Stoma components, Incontinence products/supplies 100% of the MT, Unlimited. CPAP apparatus 100% of the MT R9 250/beneficiary/24-months.
Maternity Confinements: 
No annual limit applies
In Hospital Dentistry: 
Subject to pre-authorisation and the DSP’s managed care protocols. Member pays the first R3000 per admission, Balance paid at 100% of the MT. Removal of impacted teeth. Extensive dental treatment for children younger than 5 years – once per lifetime.
Take home Medicine: 
100% of the MediHelp Tariff. R340 per admission.
Rehabilitation, Hospice and Step-down facilities: 
Hospice services and sub-acute care facilities as an alternative to hospitalisation. 100% of the MediHelp Tariff. Unlimited.
Treatment for Mental Health: 
Subject to pre-authorisation, services rendered in an approved/ network hospital/facility and prescribed by a medical doctor. 100% of the MediHelp Tariff. R18 400 per beneficiary per year (maximum R27 800 per family per year.
HIV / AIDS: 
Halocare is the managed healthcare partner for HIV/Aids-related services and post-exposure prophylaxis while Dis-Chem Direct and Medipost are the designated service providers (DSPs) for HIV/Aids medicine.
Ambulance Service: 
Netcare 911. RSA, Lesotho, Swaziland, Mozambique, Namibia and Botswana Subject to pre-authorisation and protocols. Transport by road/air. 100% of the MediHelp Tariff. Unlimited.
International Travel Benefit: 
EMERGENCY TRANSPORT SERVICES (Netcare 911). Outside beneficiary’s country of residence, Transport by road, 100% of the MT R1 900 per case, Transport by air, 100% of the MT R12 400 per case.
Day-to-day benefits
GP consultations: 

100% of the Medihelp tariff.

Member = R1 150 per year.

Member+ = R2 300 per year.

Pooled benefit for Consultations and follow-up consultations.

Specialist consultations: 

100% of the Medihelp tariff.

Member = R1 150 per year.

Member+ = R2 300 per year.

Pooled benefit for Consultations and follow-up consultations.

Acute medicine: 

Medicine obtained in the Medihelp Preferred Pharmacy Network and prescribed/dispensed by a medical doctor.

Acute generic medicine, (including medicine dispensed at an emergency unit and self-medication, immunisations, contraceptives and homeopathic, herbal, naturopathic and osteopathic medicine),100% of the Maximum Medical Aid Price.

Member = R1 750 per year.

Member+ = R2 400 per year.

Pooled benefit.

Please note: Original medicine when no generic equivalent is available – 80% of the Medihelp tariff will apply.

Voluntary use of original medicine when generic equivalent is available – 70% of the Maximum Medical Aid Price will apply.

Over-the-counter (OTC) Medicine: 

Medicine obtained in the Medihelp Preferred Pharmacy Network and prescribed/dispensed by a medical doctor.

Acute generic medicine, (including medicine dispensed at an emergency unit and self-medication, immunisations, contraceptives and homeopathic, herbal, naturopathic and osteopathic medicine),100% of the Maximum Medical Aid Price.

Member = R1 150 per year.

Member+ = R2 300 per year.

Pooled benefit.

Please note: Original medicine when no generic equivalent is available – 80% of the Medihelp tariff will apply.

Voluntary use of original medicine when generic equivalent is available – 70% of the Maximum Medical Aid Price will apply.

Optometry benefits: 
This option does not cover these benefits.
Basic dentistry: 
This option does not cover these benefits.
Specialised Dentistry: 
This option does not cover these benefits.
Orthodontics: 

This option does not cover these benefits.

MRI and CT Scans (Out of Hospital): 
On request of a specialist and subject to clinical protocols. 100% of the Medihelp tariff, Unlimited. Member pays the first R1 600 per examination.
Radiology and Pathology: 
This option does not cover these benefits.
Pregnancy benefits: 
12 pregnancy consultations, Two 2D sonars & Two baby consultations (< 1 year).
Physiotherapy and Occupational Therapy day to day: 
Physiotherapy: Subject to pooled benefit of M=R1 150. M+=R2 300 Occupational Therapy: No benefit
Chronic Conditions
Provider: 
Designated service providers & specialist network apply.
Chronic Conditions: 

Prescribed minimum benefits chronic medicine, subject to pre-authorisation and registration on Medihelp’s PMB medicine management programme.
100% of the Medihelp Reference Price.

26 chronic conditions on the Chronic Diseases List.

1. Addison’s disease

2. Asthma

3. Bipolar mood disorder

4. Bronchiectasis

5. Cardiac failure

6. Cardiomyopathy

7. Chronic obstructive pulmonary disease (COPD)

8. Chronic renal disease

9. Coronary artery disease

10. Crohn’s disease

11. Diabetes insipidus

12. Diabetes mellitus type 1

13. Diabetes mellitus type 2

14. Dysrhythmia

15. Epilepsy

16. Glaucoma

17. Haemophilia A and B

18. Hyperlipidaemia

19. Hypertension

20. Hypothyroidism

21. Multiple sclerosis

22. Parkinson’s disease

23. Rheumatoid arthritis

24. Schizophrenia

25. Systemic lupus erythematosus (SLE)

26. Ulcerative colitis

Additional Chronic Conditions: 
None
Preventative Care Benefits
Preventative Benefits: 

HEALTH TESTS

1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose or cholesterol tests (Clicks and Dis-Chem clinics, 1 per beneficiary per year).

Dietician consultation for HealthPrint members if BMI test result at wellness provider indicates a BMI > 30 (1 consultation per registered HealthPrint beneficiary per year).

Routine tests, including mammograms, pap smears and prostate tests (1 pathology test per beneficiary per year).

Mammogram for females > 40 years & Bone mineral density test (BMD) for females > 50 years (1 radiology exam per beneficiary per year).

HIV – voluntary counselling and testing (Clicks and Dis-Chem clinics).

Faecal occult blood test.

IMMUNISATION

Flu vaccine (1 per beneficiary per year).

Tetanus vaccine (1 per beneficiary per year).

Human papilloma virus vaccine (10 – 14 years, 2 injections per beneficiary, 15 – 26 years 3 injections per beneficiary).

Pneumovax vaccine for beneficiaries registered with asthma or Chronic obstructive pulmonary disease ().1 vaccine per beneficiary in a 5-year cycle

Standard immunisations schedule as published by the Department of Health for beneficiaries < 7 years (Standard schedule per beneficiary).

Total Contributions
Total Contribution Main Member: 
1902.00
Total Contribution Adult: 
1566.00
Total Contribution Child*: 
576.00
MediHelp Prime 1 Non-network
Risk Contributions
Risk Contribution Main Member: 
1902.00
Risk Contribution Adult: 
1566.00
Risk Contribution Child: 
576.00
How many times per annum do you and your dependants visit a doctor?: 
5
How much do you spend on Acute medication per annum?: 
R1000 - R4999
How much do you spend on Chronic medication per annum?: 
R1000 - R4999
Will you or any of your dependants require specialised Dentistry: 
No
Medical Aid Plan Name Term: 
Any