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Medihelp Prime 3 (Netwerk) 2018

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Type of Medical Aid Plan: 
Traditional
Medical Aid Year: 
2018
In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
100% of Scheme Rate
Hospitals: 

108 network facilities

Upfront Payments to hospitals: 

R8 250 for back and neck fusions. R2 950 for endoscopic procedures in hospital. R840 for dentistry. R1 550 for MRI scans

Casualty / Emergency Visits: 
No benefit
Specialists: 
Unlimited 100 % of scheme rate
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Unlimited 100 % of scheme rate
Radiology and pathology: 
Unlimited 100 % of scheme rate
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
100 % of scheme rate subject to R2 950 co-payment per admission. In doctor's rooms no co-payment
MRI and CT scans: 
Unlimited 100 % of scheme rate subject to R1 550 co-payment per admission
ICU and High Care: 
Unlimited 100 % of scheme rate
Dialysis: 
Unlimited 100 % of scheme rate
Organ Transplants: 
Subject to pre-authorisation and clinical protocols Unlimited 100 % of scheme rate
Oncology / Cancer: 
100 % of scheme rate DSP ICON
Neck and Back Operations: 
100 % of scheme rate subject to R8 250 co-payment per admission
Joint Replacements: 
PMB's only
Prosthesis: 

All hospital admissions and prostheses are subject to pre-authorisation, protocols and case management. See brochure for full details. Benefits not applicable to wear and tear. PMB's only.

Medical and Surgical Appliances: 
Sub-limits apply subject to scheme protocols
Maternity Confinements: 
Unlimited 100 % of scheme rate
In Hospital Dentistry: 
100 % of scheme rate co-payment of R840 per admission for impacted wisdom teeht, extensive dental treatment for children younger than 5 years
Take home Medicine: 
100 % of scheme rate R320 per admission
Rehabilitation, Hospice and Step-down facilities: 
Subject to pre-authorisation and presicribed by a medical doctor
Treatment for Mental Health: 
Subject to pre-authorisation and presicribed by a medical doctor
HIV / AIDS: 
100 % of scheme rate
Ambulance Service: 
Netcare 911
International Travel Benefit: 
No Benefit
Day-to-day benefits
GP consultations: 

100% of scheme rate M = R8 600 per year M+1 = R13 700 per year M+2 = R16 000 per year M+3+ = R17 000 per year

Specialist consultations: 

Paid from available medical savings account

Acute medicine: 

Paid from available medical savings account

Over-the-counter (OTC) Medicine: 

Paid from available medical savings account

Optometry benefits: 
100% of the scheme rate per beneficiary per 24-month cycle
Basic dentistry: 
100% of medical aid rate: 2 routine check-ups, fillings, extractions, scale and polish, root canal treatment and plastic dentures
Specialised Dentistry: 
Crowns, bridges, partial metal frame dentures, plastic dentures. No benefit for implants
Orthodontics: 

Yes - Limited to R8 230 per benificiary

MRI and CT Scans (Out of Hospital): 
Unlimited 100 % of scheme rate subject to R1 550 co-payment per admission
Radiology and Pathology: 
Paid from available medical savings account
Pregnancy benefits: 
12 pregnancy consultations, 2 2D sonars and 2 baby consults under 1 year
Physiotherapy and Occupational Therapy day to day: 
Paid from available medical savings account
Chronic Conditions
Provider: 
MobileMeds
Chronic Conditions: 

26 Conditions on Chronic Disease List . PMB

Additional Chronic Conditions: 
No benefit
Preventative Care Benefits
Preventative Benefits: 

One test per beneficiary per year. Blood glucose, cholesterol, BMI and HIV test at Clicks and Dis-Chem clinics Mammogram, Pap smear, and Prostate test Bone density test, Back treatment programme, Flu vaccine, Tetanus vaccine, HPV vaccine, standard kids immunisation under 7 years

Total Contributions
Total Contribution Main Member: 
2352.00
Total Contribution Adult: 
1986.00
Total Contribution Child*: 
684.00
Prime 3 network
Risk Contributions
Risk Contribution Main Member: 
2352.00
Risk Contribution Adult: 
1986.00
Risk Contribution Child: 
684.00
How many times per annum do you and your dependants visit a doctor?: 
15
How much do you spend on Acute medication per annum?: 
More than R 5000
How much do you spend on Chronic medication per annum?: 
More than R 5000
Will you or any of your dependants require specialised Dentistry: 
Yes
Medical Aid Plan Name Term: 
Any