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Prime 3 Network - 2021

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

I0% savings account. After savings has run out then:
INSURED DAY-TO-DAY POOLED BENEFITS of
M = R6 000 per annum
M+ = R11 000 per annum for
• GPs & specialists
• Clinical psychology & physiotherapy
• Supplementary health services
• Acute and self-medication
` Standard radiology and Pathology
INSURED DENTISTRY BENEFITS for conservative and specialised dentistry
INSURED OPTICAL BENEFITS for spectacles or contact lenses

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
Unlimited at 100% of Medihelp Tariff (MT)
Hospitals: 

Prime network hospital only for planned procedure admissions

Upfront Payments to hospitals: 

If you choose to be admitted to an out-of-network hospital, Medihelp will only cover 65% of the cost. You will be responsible for the other 35%

Casualty / Emergency Visits: 
Covered from risk for PMB emergency only. No benefit for facility fee. Subject to Insured Day-to-Day Pooled Benefits
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. Co-pay of R3 350 in a network day clinic. There is a further 35% deductible if performed in a hospital. No co-pay if procedure is done in the doctor's rooms
MRI and CT scans: 
Subject to protocols, pre-authorisation and requested by a specialist. Co-pay of R2 000 in 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
Neck and Back Operations: 
Subject to pre-authorisation and protocols. Co-pay of R9 500
Joint Replacements: 
PMB cover only
Prosthesis: 

Subject to pre-authorisation, protocols and case management.
Internal: EVARS prosthesis; R135 600 pbpa
Vascular or cardiac prosthesis; R58 000 pbpa
Health-essential functional prosthesis; R64 300 pbpa
Intraocular lenses; 2 lenses pbpa at R4 300 per lens
Implantable hearing devices; R250 000 pbpa
Reconstructive or restorative surgery prosthesis; R9 900 pfpa in or out of hospital

Medical and Surgical Appliances: 
Subject to scheme protocols and sub-limits
Maternity Confinements: 
Subject to pre-authorisation, protocols and case management. Unlimited at 100% of MT
In Hospital Dentistry: 
Subject to pre-authorisation and DSP's managed care protocols. Limited to removal of wisdom teeth and extensive treatment for children younger than 7 years. Co-pay of R1 500
Take home Medicine: 
100% of MT up to R450 per admission
Rehabilitation, Hospice and Step-down facilities: 
Subject to pre-authorisation in an approved facility and prescribed by a medical doctor. Unlimited at 100% of MT
Treatment for Mental Health: 
Subject to pre-authorisation, protocols and services rendered in an approved facility and prescribed by a medical doctor. 100% of MT. Limited to R30 400 pbpa with a max of R40 800 pfpa
HIV / AIDS: 
Subject to registration on Medihelp's HIV/AIDS programme with LifeSense. 100% of cost
Ambulance Service: 
Netcare 911
International Travel Benefit: 
No Benefit
Day-to-day benefits
GP consultations: 

10% savings account. After savings has run out then: Insured Day-to-Day Pooled Benefits
M = R6 000 per annum
M+ = R11 000 per annum

Specialist consultations: 

10% savings account. After savings has run out then: Insured Day-to-Day Pooled Benefits
M = R6 000 per annum
M+ = R11 000 per annum

Acute medicine: 

10% savings account. After savings has run out then: Insured Day-to-Day Pooled Benefits
100% of MT for generic medicine.
M = R6 000 per annum
M+ = R11 000 per annum

Over-the-counter (OTC) Medicine: 

10% savings account. After savings has run out then: Insured Day-to-Day Pooled Benefits
100% of MT for generic medicine.
M = R6 000 per annum
M+ = R11 000 per annum

Optometry benefits: 
Subject to pre-authorization by PPN and services obtained from a PPN provider per 24 month cycle. 1 composite eye test and spectacles or contact lenses at R1 200 pbp2a
Basic dentistry: 
Insured Dentistry Benefit. Subject to DSP's managed care protocols. 100% of MT
Specialised Dentistry: 
Insured Dentistry Benefit. Subject to pre-authorization and DSP's managed care protocols. 100% of MT
Orthodontics: 

Subject to pre-authorization and orthodontic needs analysis. 100% of MT. R9 350 once per lifetime for beneficiaries <18 years

MRI and CT Scans (Out of Hospital): 
Subject to protocols, pre-authorisation and requested by a specialist. Co-pay of R1 650
Radiology and Pathology: 
10% savings account. After savings has run out then: Insured Day-to-Day Pooled Benefits. 100% of MT. M = R6 000 per annum M+ = R11 000 per annum
Pregnancy benefits: 
Subject to registration on HealthPrint's Maternity and Baby programme, 10 ante- and postnatal consultations, 2 x 2D scans, 9 months antenatal iron and folic acid supplements
Physiotherapy and Occupational Therapy day to day: 
10% savings account. After savings has run out then: Insured Day-to-Day Pooled Benefits. 100% of MT. M = R6 000 per annum M+ = R11 000 per annum
Chronic Conditions
Provider: 
MobileMeds and collection from a MediLogistics network provider
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: 

Registration on HealthPrint required to activate the benefits. Payable at 100% of MT. Health assessment screening, HIV testing, counselling and support, tetanus and flu vaccine at Clicks or Dis-chem clinics. Age and frequency specific tests for women: pap smear, mammogram and bone mineral density scan, prostate specific antigen for men and faecal occult blood test. Babies < 2 years receive 2 additional 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: 
3138.00
Total Contribution Adult: 
2388.00
Total Contribution Child*: 
822.00
Prime 3 network
Annual Medical Savings Account
Annual Medical Savings Main Member: 
3744.00
Annual Medical Savings Adult: 
3168.00
Annual Medical Savings Child*: 
1080.00
Monthly Medical Savings
Savings Child*: 
90.00
Savings Adult: 
264.00
Savings Main Member: 
312.00
Risk Contributions
Risk Contribution Main Member: 
2826.00
Risk Contribution Adult: 
2388.00
Risk Contribution Child: 
822.00
Principal Member Risk: 
2826.00
Principal Member Savings: 
312.00
Principal Member Total: 
3138.00
Per Adult Dependent Risk: 
2388.00
Per Adult Dependent Savings: 
264.00
Per Adult Dependent Total: 
3652.00
Child dependant Risk: 
822.00
Child dependant Savings: 
90.00
Child dependant Total: 
912.00
Medical Aid Plan Name Term: 
Prime 3 (Network)