Comprehensive medal aid option

dimension Prime 3 2012



Dimension Prime 3 brochure

Your health determines your quality of life. Maintaining your health and making provision for the best care when you or your loved ones need it, is important. That's why it is essential to invest in your future by partnering with a medical scheme that offers you access to the best quality private healthcare.

what makes the Dimension Prime 3 benefit option unique?

Day-to-day benefits, pooled
Dentistry and optometry benefits
General radiology and pathology benefits
Dependant children under 26 pay subscriptions for child dependants
You pay for maximum two children
Preventative care benefits - health and benefit booster

monthly contribution

Member	Subscription
Principal member	R1,560
Adult dependant	R1,326
Child dependant younger than 26 years	R456 (you pay for maximum two children)

major medical benefits

Private hospital cover - with no overall limit
Freedom of choice of private hospital
Trauma recovery benefits
The diagnosis, treatment and care costs of 270 PMB and 26 chronic conditions on the Chronic Diseases List(CDL)

emergency medical services

Unlimited emergency medical services within the borders of the RSA

day-to-day benefits

Day-to-day benefits are available to suit different needs

preventative care
Health and benefit booster

The health and benefit booster offers a basket of preventative and additional care benefits, augmenting your insured day-to-day benefits

preventative care

health and benefit booster

*Benefits are provided at 100% of the scheme/contracted tariff and do not include the consultation fee, which will be paid from the available day-to-day benefits, where applicable

major medical benefits

Description	Benefit
HOSPITALISATION (government and private hospitals and day clinics) Subject to pre-registration, pre-authorisation, protocols and case management Intensive and high care wards Ward accommodation Theatre fees Visits, treatment and ward medicine Surgery and anaesthesia	100% of the contracted/ scheme tariff/medicine price R600 co-payment per admission where no other co-payments have been specified (non-PMB cases) Unlimited 20% co-payment if not pre-authorised
ORGAN TRANSPLANT
HYSTERECTOMY
CONFINEMENT (non-PMB cases)	100% of the contracted/ scheme tariff R600 co-payment per admission
ENDOSCOPIC PROCEDURES During hospitalisation	100% of the scheme/ contracted tariff R2,000 co-payment per admission
In the doctor’s rooms	100% of the scheme tariff Unlimited
ONCOLOGY (SAOC NETWORK ) Subject to pre-registration and pre-authorisation and OncoPrime protocol Surgery and hospitalisation Chemotherapy and radiotherapy (PMB cases)	100% of the scheme tariff/cost Unlimited
Chemotherapy and radiotherapy (non-PMB cases) During and not during hospitalisation	For member's account
DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA Subject to Denis protocols and pre-authorisation Hospitalisation General anaethesia	100% of the Medihelp Dental Tariff R600 co-payment per admission 20% co-payment if not authorised
Dentist's account
GENERAL RADIOLOGY AND PATHOLOGY During hospitalisation	100% of the scheme tariff Unlimited
PHYSIOTHERAPY, OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES During hospitalisation	100% of the scheme tariff/cost Unlimited
OXYGEN During hospitalisation	100% of the scheme tariff/cost Unlimited
DIALYSIS During and not during hospitalisation Subject to pre-authorisation	100% of the guideline tariff Unlimited
TECHNOLOGIST SERVICES During and not during hospitalisation	100% of the scheme tariff Unlimited
APPLICABLE MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON DISCHARGED FROM THE HOSPITAL (TTO) Chronic medicine excluded	100% of the medicine price R250 per admission
NECK AND BACK FUSIONS(non-PMB cases) Subject to protocols and pre- authorisation	100% of the scheme/contracted tariff Unlimited R9,970 co-payment per admission
CIRCUMCISION OR HYMENECTOMY	100% of the scheme/ contracted tariff Unlimited R1,870 co-payment per admission
INTERNALLY IMPLANTED PROSTHESES (non-PMB cases) EVARS prosthesis Subject to pre-authorisation	100% of the scheme tariff/cost R83,140 per beneficiary per year
Vascular/cardiac prosthesis	100% of the scheme tariff/cost R35,600 per beneficiary per year
Health-essential functional prosthesis Subject to pre-authorisation Intra-ocular lenses	100% of the scheme tariff/cost R39,470 per beneficiary per year Sub-limit: 100% of the scheme tariff/cost 2 lenses per beneficiary per year R2,760 per lens
Hip, knee and shoulder replacements Hospitalisation and prosthesis component	For member's account
Prosthesis with reconstructive or restorative surgery Subject to pre-authorisation – during or not during hospitalisation	100% of the scheme tariff/cost R6,230 per family per year
SPECIALISED RADIOLOGY Services rendered during and not during hospitalisation MRI and CT-scanning Subject to pre-authorisation Angiogram	100% of the scheme tariff R13,830 per family per year
PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION Subject to pre-authorisation Professional services rendered during and not during hospitalisation by a psychiatrist General ward accommodation Electroconvulsive therapy Medicine supplied during the period of the treatment in the institution	100% of the contracted/ scheme tariff/medicine price R600 co-payment per admission (non-PMB cases) R18,820 per beneficiary per year (maximum R25,170 per family per year) 20% co-payment if not pre-authorised
PRIVATE NURSING AS AN ALTERNATIVE TO HOSPITALISAITON Subject to pre-authorisation	100% of the contracted/ scheme tariff/medicine price Unlimited
HOSPICE SERVICES AND SUB-ACUTE FACILITIES AS AN ALTERNATIVE TO HOSPITALISAITON Subject to pre-authorisation	100% of the contracted/ scheme tariff/medicine price Unlimited 20% co-payment if not pre-authorised

major medical benefits - trauma recovery (PMB cases)

Description

Benefit

BENEFITS FOR TRAUMA THAT NECESSITATES HOSPITALISATION IN THE CASE OF:

Motor vehicle accidents
Stab wounds
Gunshot wounds
Head trauma
Burns
Near drowning

Subject to pre-authorisation and case management

100% of the cost

Unlimited - in accordance to PMB regulations

POST-EXPOSURE PROPHYLAXIS (Optipharm)

major medical benefits - prescribed minimum benefits (PMB)

Description	Benefit
DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB AND 26 CHRONIC CONDITIONS ON THE CHRONIC DISEASES LIST (CDL), INCLUDING OUTPATIENT TREATMENT Subject to protocols, pre-authorisation and preferred providers (where applicable)	100% of the cost Unlimited - in accordance with PMB regulations Co-payments may apply

emergency medical services

Description	Benefit
EMERGENCY TRANSPORT SERVICES (NETCARE 911) Transport by road or air within the borders of the RSA, Lesotho, Swaziland, Mozambique and Namibia (residents of these countries)	100% of the contracted tariff Unlimited
Outside these borders: Transport by road	100% of the cost R1,360 per case
Transport by air	100% of the cost R8,840 per case
BLOOD TRANSFUSION SERVICES AND THE TRANSPORT OF BLOOD AND BLOOD PRODUCTS	100% of the cost Unlimited
24-HOUR HELPLINE AND RAPE CRISIS CENTRE (NETCARE 911)	Phone 082 911 for advice in a medical emergency

day-to-day benefits

Description	Benefit
GENERAL MEDICAL PRACTITIONERS, MEDICAL SPECIALISTS AND EMERGENCY UNITS Treatment (medical and surgical services, anaesthesia as well as material and medicines used during the rendering of a service)	100% of the guideline/ scheme tariff/cost 80% of the medicine price M = R3,920 per year or M +1 = R6,470 per year or M +2 = R8,050 per year or M +3+ = R8,690 per year
Consultations and follow-up consultations
CLINICAL PSYCHOLOGISTS AND PSYCHIATRIC NURSES Services rendered during and not during hospitalisation
PHYSIOTHERAPY Treatment and material
OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES
MEDICINE Medicine dispensed by the Medihelp Preferred Pharmacy Network not during hospitalisation: Acute medicine (including medicine dispensed at an emergency unit and self-medication, oral contraceptives, intra-uterine devices and homeopathic, herbal, naturopathic and osteopathic medicine)
Chronic medicine	For member's account
Authorised chronic PMB medicine CDL conditions only	100% of the cost Unlimited Co-payments may apply
OPTOMETRY Benefits are subject to pre-authorisation by PPN and services should be obtained from a PPN provider Optometric examinations	Benefits are available per 24-month cycle per beneficiary: 1 comprehensive consultation, including refraction test, tonometry and visual fields test
Spectacles and contact lenses Benefits are limited to either spectacles or contact lenses: Spectacles: Frames and lens enhancements	R550
Lenses One pair of standard high-quality clear lenses	Clear single vision lenses or Clear Aquity bifocal lenses
Contact lenses	R1,000
OXYGEN Subject to pre-authorisation	100% of the scheme tariff/cost 20% co-payment in case of no pre-authorisation
DENTAL SERVICES All benefits are subject to clinical protocols determined by Denis Routine check-ups	100% of the Medihelp Dental Tariff 2 per beneficiary per year
Oral hygiene Fluoride treatment for children only	100% of the Medihelp Dental Tariff 2 scale and polish treatments per beneficiary per year
Fillings A treatment plan and X-rays may be requested for multiple fillings	100% of the Medihelp Dental Tariff 1 filling per tooth per 365-day cycle
Tooth extractions and root canal treatment in the dentist's chair Subject to protocols	100% of the Medihelp Dental Tariff
Laughing gas (in the dentist's chair)	100% of the Medihelp Dental Tariff
Dental procedures under conscious sedation in the dentist’s chair (sedation cost) Subject to pre-authorisation	100% of the Medihelp Dental Tariff Extensive dental treatment only
Plastic dentures	100% of the Medihelp Dental Tariff 1 set (upper and lower jaw) per beneficiary per 4-year cycle
Specialised dental services All specialised dentistry should be pre-authorised Partial metal frame dentures	100% of the Medihelp Dental Tariff 1 partial frame (upper or lower jaw) per beneficiary per 5-year cycle
Maxillofacial surgery and oral pathology Surgery in the dentist's chair Benefit for temporomandibular joint (TMJ) therapy is limited to non-surgical interventions/treatments	100% of the Medihelp Dental Tariff
Crowns and bridges	100% of the Medihelp Dental Tariff 1 crown per family per year, once per tooth per 5-year cycle
Implants	For member’s account
Orthodontic treatment Fixed braces – only one beneficiary per family may begin orthodontic treatment per calendar year	100% of the Medihelp Dental Tariff R6,000 per beneficiary younger than 18 years per lifetime
Periodontal treatment Subject to registration on the Perio Programme	100% of the Medihelp Dental Tariff Conservative non-surgical therapy only
X-rays Intra-oral X-rays	100% of the Medihelp Dental Tariff
Extra-oral X-rays	1 in a 3-year cycle
PATHOLOGY Excluding services requested by homeopaths, herbalists and naturopaths	100% of the scheme tariff M = R1,930 per year M+ = R2,610 per year
GENERAL RADIOLOGY
MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES Services rendered during and not during hospitalisation: Artificial eyes, speech and hearing aids	100% of the scheme tariff/cost R3,210 per family per 3-year cycle
Artificial limbs and wheelchairs	100% of the scheme tariff/cost R3,210 per family per 3-year cycle
Other appliances, including hyperbaric oxygen treatment	100% of the scheme tariff/cost R280 per family per year
Stoma components and urine bags	100% of the scheme tariff/cost Unlimited

Dimension Prime 3 exclusions

This is a summary of the available benefits. In the event of a dispute the registered Rules of Medihelp wil apply, subject to approval by the Registrar of Medical Schemes. If a beneficiary joins during the course of a financial year, the benefits (limits) are calculated pro rata according to the remaining number of months per year.

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