Most comprehensive benefit option

Medihelp Plus 2012



Medihelp Plus brochure
Medihelp Plus is Medihelp’s most comprehensive benefit option and offers ample benefits to families and individuals with diverse day-to-day medical needs. This option also offers excellent coverage for medical emergencies and private hospitalisation. In addition, preventative care benefits in the health and benefit booster offer further peace of mind that your family’s health is protected.

monthly contribution

Member	Subscription
Principal member	R4,278
Adult dependant	R4,278
Child dependant younger than 26 years	R1,068

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major medical benefits
Medihelp Plus offers you unlimited benefits for:

Private hospitalisation (in the hospital of your choice)
The diagnosis, treatment and care costs of 270 PMB and 26 chronic conditions (CDL)
Trauma recovery

emergency medical services

Unlimited emergency medical services are provided by Netcare 911 to residents within the borders of South Africa, Lesotho, Swaziland, Mozambique and Namibia
24-hour helpline and Rape Crisis Centre (Netcare 911)

day-to-day benefits

Sufficient cover is available for your day-to-day needs, including seperate insured benefits for radiology and pathology, dental and optical services
Ample cover for chronic medicine adds further protection for you and your family

preventative care
Health and benefit booster

Benefits are provided for a selection of medical services that will contribute to protecting your good health and 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

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major medical benefits

Description	Benefit
HOSPITALISATION (government and private hospitals, day clinics and sub-acute care facilities) Subject to pre-registration, pre-authorisation and protocols – sub-acute care only as an alternative to hospitalisation 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 Unlimited 20% co-payment in case of no pre-authorisation
ORGAN TRANSPLANT
CONFINEMENT
HYSTERECTOMY
ENDOSCOPIC PROCEDURES In hospital and performed in doctor's rooms
ONCOLOGY (SAOC NETWORK – ONCOPLUS PROTOCOL) Subject to pre-authorisation Surgery and hospitalisation Chemotherapy and radiotherapy (PMB and non-PMB cases – during and not during hospitalisation)	100% of the scheme tariff/cost Unlimited
DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA Subject to Denis protocols and pre-authorisation Hospitalisation General anaesthesia	100% of the Medihelp Dental Tariff 20% co-payment in case of no pre-authorisation
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 Subject to pre-authorisation During and not during hospitalisation	100% of the scheme tariff Unlimited
TECHNOLOGIST SERVICES During and not during hospitalisation	100% of the scheme tariff Unlimited
APPLICABLE Medicine dispensed AND CHARGED BY THE HOSPITAL ON DISCHARGE FROM hospital (tto ) Excluding chronic medicine	100% of the medicine price R390 available per admission
INTERNALLY IMPLANTED PROSTHESES 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 Sublimit: 100% of the scheme tariff/cost 2 lenses per beneficiary per year R2,760 per lens
Prosthesis with reconstructive or restorative surgery Subject to pre-authorisation – during and not during hospitalisation	100% of the scheme tariff/cost R6,230 per family per year
SPECIALISED RADIOLOGY Servicesrendered during and not during hospitalisation Subject to pre-authorisation MRI and CT scanning PET scan Angiogram (not subject to preauthorisation)	100% of the scheme tariff R6,110 per case for PET scan
PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION Subject to pre-authorisation Professional psychiatric services rendered during and not during hospitalisation by a psychiatrist General ward accommodation Electroconvulsive therapy Medicine supplied during the period of treatment in the institution	100% of the contracted/scheme tariff/medicine price R27,600 per beneficiary per year (maximum R37,630 per family per year) 20% co-payment in case of no pre-authorisation
PRIVATE NURSING AS AN ALTERNATIVE TO HOSPITALISATION Subject to pre-authorisation	100% of the contracted/scheme tariff/medicine price
HOSPICE SERVICES AS AN ALTERNATIVE TO HOSPITALISATION Subject to pre-authorisation	100% of the contracted/scheme tariff/medicine price 20% co-payment in case of no pre-authorisation

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major medical benefits - prescribed minimum benefits (PMB)

Description	Benefit
DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB CONDITIONS AND 26 CHRONIC CONDITIONS ON THE 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

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 with PMB regulations
POST-EXPOSURE PROPHYLAXIS (Optipharm)

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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

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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 special medicines used during the rendering of a service)	100% of the scheme tariff/ medicine price Unlimited
Consultations and follow-up consultations	100% of the scheme tariff/cost R2,370 per beneficiary pooled per family per year
CLINICAL PSYCHOLOGISTS AND PSYCHIATRIC NURSES Services rendered during and not during hospitalisation
PHYSIOTHERAPISTS Treatment and material
OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES
OXYGEN Subject to pre-authorisation	100% of the scheme tariff/cost Unlimited 20% co-payment in case of no pre-authorisation
MEDICINE Medicine dispensed by Medihelp's 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)	80% of the medicine price R4,020 per beneficiary, pooled per family per year
Authorised chronic medicine	80% of the medicine price R11,660 per beneficiary per year
Authorised chronic PMB medicine	100% of the medicine price 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: Frame and lens enhancements	R700
Lenses One pair of standard high-quality white lenses	Clear single vision lenses or clear Aquity bifocal lenses or clear Aquity multifocal lenses
Contact lenses	R1,660
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 period
Tooth extractions and root canal treatment in the dentist’s chair	100% of the Medihelp Dental Tariff
Laughing gas in the dentist’s rooms	100% of the Medihelp Dental Tariff
Dental procedures under conscious sedation in the dentist’s rooms (sedation cost) Subject to pre-authorisation and protocols	100% of the Medihelp Dental Tariff Extensive dental treatments only
Plastic dentures	100% of the Medihelp Dental Tariff 1 complete set (upper and lower jaw) per beneficiary in a 4-year cycle
Maxillofacial surgery and oral pathology Surgery in the dentist's chair Benefit for temporomandibular joint (TMJ) therapy are limited to non-surgical interventions/treatments	100% of the Medihelp Dental Tariff
Specialised dental services All specialised dentistry should be pre-authorised Partial metal frame dentures	100% of the Medihelp Dental Tariff 2 partial frames (upper and lower jaw) per beneficiary in a 5-year cycle
Crowns and bridges	100% of the Medihelp Dental Tariff 3 crowns per family per year, once per tooth in a 5-year cycle
Implants	100% of the Medihelp Dental Tariff 2 implants per beneficiary in a 5-year cycle R1,500 for implant components per implant
Orthodontic treatment Fixed braces – only one beneficiary per family may commence with orthodontic treatment per calenda year.	100% of the Medihelp Dental Tariff R10,000 per beneficiary younger than 18 years per lifetime
Periodontal treatment Subject to registration on the Perio Programme Conservative, non-surgical therapy only	100% of the Medihelp Dental Tariff
X-rays Intra-oral X-rays	100% of the Medihelp Dental Tariff
Extra-oral X-rays	1 per beneficiary in a 3-year cycle
PATHOLOGY Excluding services requested by naturapaths, homeaopaths and herbalists	100% of the scheme tariff Unlimited
GENERAL RADIOLOGY	100% of the scheme tariff Unlimited
MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES Services rendered during and not during hospitalisation: Artificial eyes, speech and hearing aids	100% of the scheme tariff/cost R10,700 per beneficiary in a 3-year cycle
Artificial limbs and wheelchairs	100% of the scheme tariff/cost R5,880 per beneficiary in a 3-year cycle
Other appliances, including hyperbaric oxygen treatment	100% of the scheme tariff/cost R590 per beneficiary per year
Stoma components and urine bags	100% of the scheme tariff/cost Unlimited
Wigs Subject to pre-authorisation and protocols for alopecia or cancer patients)	100% of the scheme tariff/cost Unlimited R1,500 per beneficiary in a 3-year cycle

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Medihelp Plus benefit 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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