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MEDSHIELD Medicore 2019

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Medical Aid Year: 
2019
Day to day Benefits: 

DAY-TO-DAY LIMIT Limited to the following:
M = R7 550
M+1 = R10 530
M+2 = R11 850
M+3 = R13 320
M4+ = R14 590

In Hospital Benefits
Hospital Rate of Payment: 
100% of Scheme Rate
Hospitals: 

services must be obtained from the Medshield
Hospital Network.

Upfront Payments to hospitals: 

Non-PMB Specialised Radiology including PET and PET-CT scan 10% upfront co-payment
Specialised Drugs for Oncology, non-Oncology and Biological Drugs 15% upfront co-payment
Non-PMB Internal Prosthesis and Devices 20% upfront co-payment
Voluntary use of a non-Medshield Network Hospital 25% upfront co-payment
Voluntary use of a non-Medshield Network Hospital - Mental Health 25% upfront co-payment
Voluntary use of a non-Medshield Network Hospital - Organ, Tissue and Haemopoietic
stem cell (Bone marrow) transplant 25% upfront co-payment
Voluntary use of a non-DSP for HIV & AIDS related medication 40% upfront co-payment
Voluntary use of a non-DSP or a non-Medshield Pharmacy Network 40% upfront co-payment
Voluntarily obtained out of formulary medication  40% upfront co-payment
Voluntary use of a non-ICON provider - Oncology 40% upfront co-payment
Voluntary use of a non-DSP provider - Chronic Renal Dialysis 40% upfront co-payment

 

In-Hospital Procedural upfront co-payments
Endoscopic procedures (refer to Addendum B for list of services) R1 500 upfront co-payment
Functional Nasal surgery R1 500 upfront co-payment
Hernia Repair (except in infants) R3 000 upfront co-payment
Laparoscopic procedures R3 500 upfront co-payment
Arthroscopic procedures R3 500 upfront co-payment
Wisdom Teeth R3 500 upfront co-payment
Nissen Fundoplication R5 000 upfront co-payment
Hysterectomy R5 000 upfront co-payment
Back and Neck surgery R5 000 upfront co-payment

Casualty / Emergency Visits: 
Subject to Day-to-Day Limit.
Specialists: 
Unlimited.
Radiology and pathology: 
Unlimited.
MRI and CT scans: 
Subject to Specialised Radiology Limit. No co-payment applies to CT Colonography. Unlimited.
Dialysis: 
R175 000 per family per annum. 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: 
R140 000 per family per annum. 25% upfront co-payment for the use of a non-Medshield Network Hospital.
Oncology / Cancer: 
(40% upfront co-payment for the use of a non-DSP) R230 000 per family per annum.
Prosthesis: 

PROSTHESIS AND DEVICES INTERNAL
Subject to pre-authorisation by the relevant Managed Healthcare Programme on
086 000 2121 (+27 11 671 2011) and services must be obtained from the Medshield
Hospital Network. Preferred Provider Network will apply.
Surgically Implanted Devices.
Clinical Protocols apply.

R32 860 per family per annum.
20% upfront co-payment for non-PMB.
Sub-limit for hips and knees: R30 000 per beneficiary
- subject to Prosthesis and Devices Internal Limit

(global fee).

PROSTHESIS EXTERNAL
Service must be pre-approved or pre-authorised by the Scheme on
086 000 2120 (+27 10 597 4701) and must be obtained from the DSP, Network
Provider or Preferred Provider.
Including Ocular Prosthesis.

Subject to Prosthesis and Devices Internal Limit.
No co-payment applies to External Prosthesis.

Medical and Surgical Appliances: 
R8 350 per family per annum.
Maternity Confinements: 
Unlimited.
In Hospital Dentistry: 
Unlimited.
Take home Medicine: 
Limited to R500 per admission. According to the Maximum Generic Pricing or Medicine Price List and Formularies.
Rehabilitation, Hospice and Step-down facilities: 
R57 000 per family per annum.
Treatment for Mental Health: 
R28 000 per family per annum. 25% upfront co-payment for the use of a non- Medshield Network Hospital. DSP applicable from Rand one for PMB and non-PMB admissions.
HIV / AIDS: 
As per Managed Healthcare Protocols.
Day-to-day benefits
GP consultations: 

Unlimited.

Specialist consultations: 

Unlimited.

Acute medicine: 

Subject to Day-to-Day Limit.

Over-the-counter (OTC) Medicine: 

Subject to Day-to-Day Limit.
Further limited to: Single member R600
Family R1 100
Limited to R210 per script.

Optometry benefits: 
1 pair of Optical Lenses and a frame, or Contact Lenses per beneficiary every 24 months. Determined by an Optical Service Date Cycle. Starting 1 January 2019. Subject to Overall Annual Limit.
Basic dentistry: 
Unlimited.
Specialised Dentistry: 
R11 180 per family per annum.
MRI and CT Scans (Out of Hospital): 
Subject to Specialised Radiology Limit. No co-payment applies to CT Colonography. Unlimited.
Radiology and Pathology: 
R11 400 per family per annum. 10% upfront co-payment for non-PMB.
Pregnancy benefits: 
12 Antenatal consultations per pregnancy. Limited to the following: Two 2D Scans per pregnancy. 1 Amniocentesis 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.
Bone Density (for Osteoporosis and bone fragmentation) 1 per beneficiary 50+ years old every 3 years.
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.
Mammogram (Breast Screening) 1 per female beneficiary 40+ years old every 2 years.
Pneumococcal Vaccination 1 per annum for high risk individuals and for beneficiaries 60+ years old.
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 R160.
Limited to the Scheme’s Contraceptive formularies and protocols.

Adult Vaccination R360 per family per annum.
HPV Vaccination (Human Papillomavirus) 1 course of 2 injections per female beneficiary. Subject to qualifying criteria.
Child Immunisations Immunisation programme as per the Department of Health Protocol and specific

age groups.

At Birth: Tuberculosis (BCG) and Polio (OPV).
At 6 Weeks: Polio (OPV), Diptheria, Tetanus, Whooping Cough (DTP), Hepatitis B, Hemophilus Influenza B (HIB), Rotavirus, Pneumococcal.
At 10 Weeks: Polio, Diptheria, Tetanus, Whooping Cough (DTP), Hepatitis B, Hemophilus Influenza B (HIB), Rotavirus, Pneumococcal.
At 14 Weeks: Polio, Diptheria, Tetanus, Whooping Cough (DTP), Hepatitis B, Hemophilus Influenza B (HIB), Pneumococcal.
At 9 Months: Measles, Pneumococcal.
At 18 Months: Polio, Diptheria, Tetanus, Whooping Cough (DTP), Measles OR Measles, Mumps and Rubella (MMR).
At 6 Years: Polio, Diptheria and Tetanus (DT).
At 12 Years: Diptheria and Tetanus

Medical Aid Plan Name Term: 
Any