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MEDIHELP UNIFY 2019

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

25% medical savings account.

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 Scheme Rate
Hospitals: 

Choose any hospital

Upfront Payments to hospitals: 

Back and neck fusion: R9,950 co-payment
Gastroscopy and Colonoscopy:
in doctor's rooms: no co-payment, 
in day hospital: R2,650 co-payment
in-hospital: R3,700 co-payment
Specialised radiology (MRIs and CT Scans): R1,600 co-payment
In-hospital dentistry: R3,000 co-payment
Co-payments paid by you or your gap cover

Casualty / Emergency Visits: 
100% of the cost* Unlimited Subject to authorisation, PMB protocols and case management
Specialists: 
Up to 100% scheme rate You or gap cover pay the balance, if any
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of the MT Unlimited In hospital
Radiology and pathology: 
100% of the MT Unlimited
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
In day theatre; R2,650 co-payment, in-hospital; R3,700 co-payment
MRI and CT scans: 
R1 600 co-payment In and out of hospital
ICU and High Care: 
100% of the MT Unlimited
Dialysis: 
PMBs only 100% of the cost
Organ Transplants: 
100% of the cost. Cornea implants - R27 400 per implant per year
Oncology / Cancer: 
PMB - 100% of the MT. Non-PMB - R220 000 per family per year
Neck and Back Operations: 
Member pays the first R9 950 per admission
Joint Replacements: 
Only for PMB cases: R58 800
Prosthesis: 

Health-essential functional prosthesis: R58 800 only
Acute injuries where replacement is the only treatment option
Hospitalisation: 100% of the MT
Hip, knee and shoulder replacements (non-PMB):
(Wear and tear: no benefits)
Intra-ocular lenses – R3 950 per lens, 2 lenses per beneficiary per year, health-essential functional prosthesis benefit applies
EVARS prosthesis
- R124 000
Vascular/cardiac prosthesis
- R53 100
Prosthesis with reconstructive or restorative surgery (in and out of hospital) - R9 150 per family per year

Medical and Surgical Appliances: 
Medical Appliances, CPAP apparatus and hyperbaric oxygen: paid from day-to-day savings. Stoma products and urine bags: paid by scheme
Maternity Confinements: 
In hospital - 100% of the MT
In Hospital Dentistry: 
Member pays the first R3 000 per admission
Take home Medicine: 
100% of the MT. Savings account(PMB chronic medicine not included)
Rehabilitation, Hospice and Step-down facilities: 
100% of the MT Unlimited Subject to pre-authorisation Services rendered in an approved facility and prescribed by a medical doctor
Treatment for Mental Health: 
100% of the MT R23 200 per beneficiary per year (maximum R31 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: 
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: 

100% of the Medihelp tariff. Savings account.

Specialist consultations: 

100% of the Medihelp tariff. Savings account.

Acute medicine: 

100% of the Medihelp tariff. Savings account.

Over-the-counter (OTC) Medicine: 

100% of the Medihelp tariff. Savings account.

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).

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 MT Savings account
Basic dentistry: 
100% of the MT Savings account 2 per beneficiary per year (once every 6 months)
Specialised Dentistry: 
100% of the MT Savings account
Orthodontics: 

100% of the MT
Savings account
Once per lifetime for beneficiaries <18 years
Payment from date of authorisation, until the
patient turns 18

MRI and CT Scans (Out of Hospital): 
Member pays the first R1 600 per examination
Radiology and Pathology: 
Subject to savings
Pregnancy benefits: 
100% Medical aid tariff.
Physiotherapy and Occupational Therapy day to day: 
Subject to savings
Chronic Conditions
Provider: 
Designated service providers & specialist network apply.
Chronic Conditions: 

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).

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

IMMUNISATION

Flu vaccine (1 per beneficiary per year).

Tetanus vaccine (1 per beneficiary per 2 year cycle).

Total Contributions
Total Contribution Main Member: 
2304.00
Total Contribution Adult: 
1896.00
Total Contribution Child*: 
696.00
Medihelp Unify
Annual Medical Savings Account
Annual Medical Savings Main Member: 
6912.00
Annual Medical Savings Adult: 
5688.00
Annual Medical Savings Child*: 
2088.00
Monthly Medical Savings
Savings Child*: 
174.00
Savings Adult: 
474.00
Savings Main Member: 
576.00
Risk Contributions
Risk Contribution Main Member: 
1728.00
Risk Contribution Adult: 
1422.00
Risk Contribution Child: 
522.00
Principal Member Risk: 
1728.00
Principal Member Savings: 
576.00
Principal Member Total: 
2304.00
Per Adult Dependent Risk: 
1422.00
Per Adult Dependent Savings: 
474.00
Per Adult Dependent Total: 
1896.00
Child dependant Risk: 
522.00
Child dependant Savings: 
174.00
Child dependant Total: 
696.00
Medical Aid Plan Name Term: 
Any