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MediPhila 2019

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Medical Aid Year: 
2019
In Hospital Benefits
Hospital Rate of Payment: 
100% of Scheme Rate
Hospitals: 

services must be obtained from the MediPhila
Hospital Network.

Upfront Payments to hospitals: 

Non-PMB Specialised Radiology 10% upfront co-payment
Voluntary use of a non-MedPhila Network Hospital 25% upfront co-payment
Voluntary use of a non-MedPhila Network Hospital - Organ, Tissue and Haemopoietic 25% upfront co-payment
stem cell (Bone marrow) transplant 40% upfront co-payment
Voluntary use of a non-DSP for Chronic Medication  40% upfront co-payment
Non-Network Emergency GP consultations (once the two allocated visits have been
depleted) 40% upfront co-payment
Voluntarily obtained out of formulary medication 40% upfront co-payment
Voluntary use of a non-DSP for HIV & AIDS related medication 40% upfront co-payment
Voluntary use of a non-ICON provider - Oncology 40% upfront co-payment
Voluntary use of a non-MedPhila Network Hospital - Mental Health 40% upfront co-payment
Voluntary use of a non-DSP or a non-Medshield Pharmacy Network 40% upfront co-payment

 

In-Hospital Procedural upfront co-payments
Endoscopic Procedures (refer to Addendum B for a list) R2 000 upfront co-payment
Arthroscopic procedures R4 000 upfront co-payment
Wisdom Teeth R4 000 upfront co-payment
Nissen Fundoplication R5 000 upfront co-payment
Hysterectomy R5 000 upfront co-payment

Casualty / Emergency Visits: 
the account for the Casualty will be paid from your available Day-to-Day Limit and the doctor attending to you will be paid from your out of network GP benefit.
Specialists: 
Specialist services from treating/attending Specialists are subject to pre-authorisation.
Radiology and pathology: 
Subject to In-Hospital Limit. The MediPhila GP Provider will refer you to the appropriate pathology and radiology healthcare provider.
MRI and CT scans: 
Subject to In-Hospital Limit. R6 000 per family. 10% upfront co-payment for non-PMB.
Dialysis: 
Unlimited subject to PMB and PMB level of care. 40% upfront co-payment for the use of a non-DSP. Use of a DSP applicable from Rand one for PMB and non-PMB.
Organ Transplants: 
Unlimited subject to PMB and PMB level of care. 25% upfront co-payment for the use of a non-MediPhila Hospital Network. Organ harvesting is limited to the Republic of South Africa.
Oncology / Cancer: 
(40% upfront co-payment for the use of a non-DSP) Unlimited subject to PMB and PMB level of care.
Prosthesis: 

PROSTHESIS AND DEVICES INTERNAL
Subject to pre-authorisation by the relevant Managed Healthcare Programme on
086 000 0376 (+27 10 597 4703) and services must be obtained from the MediPhila
Hospital Network. Preferred Provider Network will apply.
Surgically Implanted Devices.
Clinical Protocols apply.

Unlimited subject to PMB and PMB level of care.
Sub-limit for hips and knees: R30 000 per beneficiary
- subject to Prosthesis and Devices Internal Limit

(global fee).

PROSTHESIS EXTERNAL
Services must be pre-approved or pre-authorised by the Scheme on
086 000 0376 (+27 10 597 4703) and must be obtained from the DSP, Network
Provider or Preferred Provider.
Clinical Protocols apply.

Unlimited subject to PMB and PMB level of care.
Subject to referral by a Network GP and authorisation.

Medical and Surgical Appliances: 
Unlimited subject to PMB and PMB level of care. Unlimited subject to PMB and PMB level of care.
Maternity Confinements: 
Unlimited.
Take home Medicine: 
Limited to R160 per admission. According to the Maximum Generic Pricing or Medicine Price List and Formularies.
Rehabilitation, Hospice and Step-down facilities: 
Unlimited subject to PMB and PMB level of care. R11 100 per family per annum. Subject to the Alternatives to Hospitalisation Limit.
Treatment for Mental Health: 
Unlimited subject to PMB and PMB level of care. 40% upfront co-payment for the use of a non- DSP Facility. DSP applicable from Rand one for PMB admissions.
HIV / AIDS: 
As per Managed Healthcare Protocols.
Day-to-day benefits
GP consultations: 

Unlimited

Access to the following without pre-authorisation:

M0 = 8 visits
M+1 = 9 visits
M2+ = 11 visits

Thereafter unlimited - subject to pre-authorisation.
2 visits per family, thereafter a 40% co-payment
will apply. Subject to GP Network Limit.

Specialist consultations: 

1 visit per family per annum, thereafter subject to Day-to-
Day Limit and subject to Network GP referral.

Acute medicine: 

Subject to Day-to-Day Limit.
Further limited to: R1 200 per family
The use of MediPhila Pharmacy Network and the
Basic Acute formulary applies from Rand one.

Optometry benefits: 
Limited to R710 per beneficiary every 24 month Determined by an Optical Service Date Cycle. Starting 1 January 2019. Subject to the use of a DSP.
Basic dentistry: 
R1 270 per family per annum. Subject to the Specialised Dentistry Limit.
Specialised Dentistry: 
R5 300 per family per annum.
Radiology and Pathology: 
Subject to the Medshield MediPhila Basic Radiology formulary. Only on referral from a Network GP.
Pregnancy benefits: 
6 Antenatal consultations per pregnancy. Two 2D Scans per pregnancy.
Preventative Care Benefits
Preventative Benefits: 

Flu Vaccination 1 per beneficiary 18+ years old to a maximum of R95.
Pap Smear 1 per female beneficiary.
Health Risk Assessment (Pharmacy or GP) 1 per beneficiary 18+ years old per annum.
TB Test 1 test per beneficiary.
National HIV Counselling Testing (HCT) 1 test per beneficiary.
Birth Control (Oral Contraceptive Medication) Restricted to 1 month’s supply to a maximum of
12 prescriptions per annum per female beneficiary,
with a script limit of R105.
Limited to the Scheme’s Contraceptive formularies

and protocols.

HPV Vaccination (Human Papillomavirus) 1 course of 2 injections per female beneficiary. Subject to qualifying criteria.

Medical Aid Plan Name Term: 
Any