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MEDIHELP PRIME 3 NETWORK 2019

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

Insured day to day benefit for GP and specialist consultations, physiotherapy, acute medicine and self-medication.

100% of the Medihelp tariff.

Member = R9 000 per year.

Member+1 = R14 300 per year. 

Member+2 = R16 800 per year.

Member+3+ = R17 800 per year.

 

Co-payments: 
R8 650 on back operation
In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
100% of the MediHelp Tariff. Unlimited. Designated service provider applies. Subject to pre-authorisation, protocols and case management.
Hospitals: 

100% of the MediHelp Tariff.

Unlimited at certain hospitals.

Designated service provider applies.

Subject to pre-authorisation, protocols and case management.

Upfront Payments to hospitals: 

Back and neck fusion – member pays the first R8 650.

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 R880 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: 
100% of the MediHelp Tariff. Unlimited
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
100% of the MediHelp Tariff. Member pays the first R2 000 per admission in day clinic, R3 050 in hospital.
MRI and CT scans: 
Co-payment of R1 600
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 R250 000 per family per year.
Neck and Back Operations: 
Back and neck fusion. Member pays the first R8 650, Balance paid at 100% of the MediHelp Tariff.
Joint Replacements: 
100% of the MediHelp Tariff.
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 R124 000 per beneficiary per year.

Vascular/cardiac prosthesis R53 100 per beneficiary per year.

Health-essential functional prosthesis R58 800 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, R3 950 per family per year.

External breast prostheses, In and out of hospital, R9 150 per family per year.

Implantable hearing devices (including devices and components), R99 800 per beneficiary 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 R9250 / beneficiary/ 24-month
Maternity Confinements: 
No annual limit applies
In Hospital Dentistry: 
Member pays the first R880 per admission. Balanced paid at 100% of the Medical Tariff. Only 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. R27 800 per beneficiary per year (maximum R37 300 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 950 per case, Transport by air, 100% of the MT R13 000 per case.
Day-to-day benefits
GP consultations: 

Consultations and follow-up consultations. 100% of the Medihelp tariff.

Member = R9 000 per year.
Member+1 = R14 300 per year.
Member+2 = R16 800 per year.
Member+3+ = R17 800 per year.

Specialist consultations: 

Consultations and follow-up consultations. 100% of the Medihelp tariff.

Member = R9 000 per year.
Member+1 = R14 300 per year.
Member+2 = R16 800 per year.
Member+3+ = R17 800 per year.

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.

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.

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: 
100% of the MediHelp Tariff. 1 composite examination, R800 per beneficiary for a frame and/or lens enhancements, single vision, bifocal or multifocal (paid at the cost of bifocal lenses) lenses, contact lenses R1 185 per beneficiary per 24-month cycle
Basic dentistry: 
Subject to DSP’s. 100% of the Medihelp tariff. Once in 6 months per beneficiary per year: 2 routine check-ups, 2 scale and polish treatments, 1 filling per tooth in 365 days. Plastic dentures 1 set (4-year period), 1 Extra-oral X-rays (3-year period)
Specialised Dentistry: 
100% of the MediHelp Tariff. 1 Partial metal frame dentures (upper or lower jaw) per beneficiary in a 5-year period. 1 crown per family per year, once per tooth in a 5-year period. Maxillofacial surgery and oral pathology.
Orthodontics: 

Orthodontic treatment (only one beneficiary per family may begin orthodontic treatment per calendar year).
Subject to pre-authorisation and orthodontic needs analysis.
100% of the Medical Tariff.
R8 650 per beneficiary > 9 and < 18 years old per lifetime
Payment from date of authorisation.

Periodontal treatment (conservative non-surgical therapy only).
Subject to pre-authorisation and a treatment plan.
100% of the Medical Tariff.

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: 
Subject to clinical protocols and requested by a medical doctor or chiropractor (black and white X-rays only). 100% of the Medical Tariff. Per year: M = R9 000, M+1 = R14 300, M+2 = R16 800, M+3+ = R17 800.
Pregnancy benefits: 
12 pregnancy consultations (before & after birth), One amniocentesis per pregnancy. Two 2D sonars & Two baby consultations (< 1 year).
Physiotherapy and Occupational Therapy day to day: 
100% of the Medihelp tariff. Member = R9 000 per year, Member+1 = R14 300 per year, Member+2 = R16 800 per year, Member+3+ = R17 800 per year.
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.

Designate Service Provider & formulary apply.

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: 
No benefit
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: 
2586.00
Total Contribution Adult: 
2184.00
Total Contribution Child*: 
750.00
MediHelp Prime 3 Network
Risk Contributions
Risk Contribution Main Member: 
2586.00
Risk Contribution Adult: 
2184.00
Risk Contribution Child: 
750.00
How many times per annum do you and your dependants visit a doctor?: 
20
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