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Prime 1 non-Network 2021

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Type of Medical Aid Plan: 
Hospital
Medical Aid Year: 
2021
Day to day Benefits: 

INSURED DAY-TO-DAY BENEFITS ONLY;
M = R1 250 per annum
M+= R2 500 per annum
Cover is available for GPs, specialists, acute and
self-medication and physiotherapy

In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
Unlimited at 100% of Medihelp Tariff (MT)
Hospitals: 

Any hospital for trauma or planned procedure admissions

Upfront Payments to hospitals: 

If you use a facility outside of the Day Surgery network for certain procedures, Medihelp will only cover 65% of the cost. You will be responsible for the other 35%. Procedural co-payments may apply to admissions; full details in the 2021 brochure

Casualty / Emergency Visits: 
Covered from risk for PMB emergency only. No benefit for facility fee
Specialists: 
Unlimited at 100% of MT
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Unlimited at 100% of MT
Radiology and pathology: 
Unlimited at 100% of MT
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Subject to protocols and pre-authorisation and the use of the day surgery network. Co-payment of R4 200 in a day clinic, no co-payment if procedure is done in the doctor's rooms
MRI and CT scans: 
Subject to protocols, pre-authorisation and requested by a specialist. Co-payment of R2 600 per examination, in or out of hospital
ICU and High Care: 
Unlimited at 100% of MT
Dialysis: 
Subject to pre-authorisation and clinical protocols. Unlimited at 100% of MT
Organ Transplants: 
PMB only. Subject to pre-authorisation and clinical protocols. Unlimited at 100% of MT
Oncology / Cancer: 
Subject to pre-authorisation and registration on the Medihelp Oncology Programme. Protocols and DSP's apply. Unlimited at 100% of MT for PMB's. Non-PMB's limited to R220 000
Neck and Back Operations: 
Subject to pre-authorisation,protocols and completion of a back treatment programme. Co-payment of R15 000 applies
Joint Replacements: 
PMB cover only
Prosthesis: 

Subject to pre-authorisation, protocols and case management. Internal: EVARS prosthesis R35 900 per beneficiary per annum; Vascular or cardiac prostheses R35 900 pbpa;
Health-essential functional prosthesis; R23 850 pbpa;
Intraocular lenses; 2 lenses at R4 300 per lens pbpa
Reconstructive or restorative surgery prosthesis; R4 400 per family per annum in or out of hospital

Medical and Surgical Appliances: 
No benefit
Maternity Confinements: 
Subject to pre-authorisation, protocols and case management Unlimited at 100% of MT. R27 300 available for elective caesarean section. R13500 available for home delivery
In Hospital Dentistry: 
Subject to pre-authorisation and managed care protocols. Limited to removal of wisdom teeth and extensive treatment for children younger than 7 years. Subject to a co-payment of R3 430
Take home Medicine: 
100% of MT up to R400 per admission
Rehabilitation, Hospice and Step-down facilities: 
Unlimited at 100% of MT. Subject to pre-authorisation in an approved facility and prescribed by a medical doctor
Treatment for Mental Health: 
Subject to pre-authorisation, protocols and services rendered in or out of hospital by a psychiatrist. 100% of MT. Limited to R20 050 pbpa with a max of R30 400 pfpa
HIV / AIDS: 
Subject to registration on Medihelp's HIV/AIDS programme with LifeSense. 100% of cost
Ambulance Service: 
Subject to pre-authorisation and protocols. Unlimited with Netcare 911
International Travel Benefit: 
No Benefit
Day-to-day benefits
GP consultations: 

Subject to INSURED DAY-TO-DAY BENEFITS ONLY;
M = R1 250 per annum
M+= R2 500 per annum
Cover is available for GPs, specialists, acute and self-medication and physiotherapy

Specialist consultations: 

Subject to INSURED DAY-TO-DAY BENEFITS ONLY

Acute medicine: 

Subject to INSURED DAY-TO-DAY BENEFITS ONLY. 100% of MT for generic medicine

Over-the-counter (OTC) Medicine: 

Subject to INSURED DAY-TO-DAY BENEFITS ONLY. 100% of MT for generic medicine

Optometry benefits: 
No benefit
Basic dentistry: 
No benefit
Specialised Dentistry: 
No benefit
Orthodontics: 

No benefit

MRI and CT Scans (Out of Hospital): 
Subject to pre-authorisation and requested by a specialist. Co-payment of R2 600 per examination, in or out of hospital
Radiology and Pathology: 
No benefit
Pregnancy benefits: 
Subject to registration on HealthPrint's Maternity and Baby programme, 10 ante- and postnatal consultations at GP, midwife or gynae, 2 ante- and postnatal consultations at a dietician/lactation specialist and 2 x 2D scans
Physiotherapy and Occupational Therapy day to day: 
Subject to INSURED DAY-TO-DAY BENEFITS ONLY
Chronic Conditions
Provider: 
Preferred pharmacy network
Chronic Conditions: 

Diagnosis, treatment and care costs of 26 chronic conditions that fall under the Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL), issued by the Council for Medical Schemes. Subject to pre-authorisation, protocols, and DSPs

Additional Chronic Conditions: 
None
Preventative Care Benefits
Preventative Benefits: 

Health screening, HIV testing, counselling and support, tetanus and flu vaccine at Clicks or Dischem. Oral/injectable or implantable contraceptives for woman up to 50 years: R125 per month to max of R1 500 per annum or intra-uterine device R2 000 per 60 months. Age and frequency specific tests for pneumovax vaccine and faecal occult blood test, Women: pap smear, mammogram and bone mineral density scan; Men: prostate specific antigen; Babies < 1 yr receive 2 visits to a GP or specialist. 2 x HPV vaccines for boys and girls 10-14 yrs or 3 x between 15-26 yrs. Standard child immunisations up to 7 yrs at Clicks or Dischem clinics and child flu vaccines

Total Contributions
Total Contribution Main Member: 
2202.00
Total Contribution Adult: 
1818.00
Total Contribution Child*: 
672.00
Prime 1 non-Network
Risk Contributions
Risk Contribution Main Member: 
2202.00
Risk Contribution Adult: 
1818.00
Risk Contribution Child: 
672.00
Medical Aid Plan Name Term: 
Prime 1