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Prime 3 Non-Network

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Type of Medical Aid Plan: 
Traditional
Medical Aid Year: 
2020
Day to day Benefits: 

INSURED DAY-TO-DAY POOLED BENEFITS
M = R9 450 per annum
M+1 = R15 000 per annum
M+2 = R17 700 per annum
M+3+ = R18 700 per annum
• GPs & specialists
• Clinical psychology & physiotherapy
• Supplementary health services
• Acute and self-medication
` Standard radiology and Pathology
INSURED DENTISTRY BENEFITS
Conservative and specialised
INSURED OPTICAL BENEFITS
Spectacles or contact lenses

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 and planned procedure admissions

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 200 in hospital, R2 100 in a day clinic, 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 R1 650
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 100
Joint Replacements: 
PMB cover only
Prosthesis: 

Subject to pre-authorisation, protocols and case management.
Internal: EVARS prosthesis; R130 600 pbpa
Vascular or cardiac prosthesis; R55 900 pbpa
Health-essential functional prosthesis; R61 900 pbpa
Intraocular lenses; 2 lenses pbpa at R4 150 per lens
Implantable hearing devices; R105 100 pbpa
Reconstructive or restorative surgery prosthesis; R9 600 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 5 years. Co-pay of R960
Take home Medicine: 
100% of MT up to R350 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 R29 300 pbpa with a max of R39 300 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: 

Insured Day-to-Day Pooled Benefits
M = R9 450 per annum
M+1 = R15 000 per annum
M+2 = R17 700 per annum
M+3+ = R18 700 per annum

Specialist consultations: 

Insured Day-to-Day Pooled Benefits
M = R9 450 per annum
M+1 = R15 000 per annum
M+2 = R17 700 per annum
M+3+ = R18 700 per annum

Acute medicine: 

Insured Day-to-Day Pooled Benefits
100% of MT for generic medicine.
M = R9 450 per annum
M+1 = R15 000 per annum
M+2 = R17 700 per annum
M+3+ = R18 700 per annum

Over-the-counter (OTC) Medicine: 

Insured Day-to-Day Pooled Benefits
100% of MT for generic medicine.
M = R9 450 per annum
M+1 = R15 000 per annum
M+2 = R17 700 per annum
M+3+ = R18 700 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
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 000 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: 
Insured Day-to-Day Pooled Benefits. 100% of MT. M = R9 450 per annum M+1 = R15 000 per annum M+2 = R17 700 per annum M+3+ = R18 700 per annum
Pregnancy benefits: 
Free registration on HealthPrint pregnancy and baby programme, 12 ante- and postnatal consultations, 2 x 2D scans. Flu vaccine at Dis-chem or Clicks clinics.
Physiotherapy and Occupational Therapy day to day: 
Insured Day-to-Day Pooled Benefits. 100% of MT. M = R9 450 per annum M+1 = R15 000 per annum M+2 = R17 700 per annum M+3+ = R18 700 per annum
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: 

Payable at 100% of MT. Health assessment screening, HIV testing, counselling and support, tetanus and flu vaccine at Clicks or Dis-chem. 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 < 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: 
3618.00
Total Contribution Adult: 
3060.00
Total Contribution Child*: 
1056.00
Prime 3 non-network
Medical Aid Plan Name Term: 
Prime 3