Member	Subscription
	*Gross monthly income of principal member
	R7,500 or less R7,501 to R11,000 R11,001 and more
Principal member	R744 R918 R1,062
Adult dependant	R588 R714 R828
Child dependant < 21 years	R318 R396 R456

* If your gross monthly income (before deductions) is more than R11,001, no proof of income is required.

• The primary care option focuses on making private healthcare services accessible to more South Africans
• Subscription for this option is based on income - proof of income must be provided in order to qualify for one of the lower income categories
• Most healthcare services are provided by specific network doctors or providers
• Formularies, protocols and a pre-authorisation or registration process apply to most services
• Benefits are subject to an overall annual limit of R800,000 per family per year, with sub-limits applicable to some services

Day-to-day benefits

Scheduled and emergency care

You may only choose a doctor for your day-to-day healthcare needs from a list of general practitioners in the Necesse network Only Medicine on the approved Necesse Medicine list (formulary) qualifies for benefits Get your Medicine from your dispensing network doctor or a Medihelp network pharmacy Pre-authorise all chronic Medicine for CDL conditions Only medicines on the Necesse chronic Medicine list (formulary) qualify for benefits Only basic dental services are covered and only if you visit a denis network dentist Get your spectacles from a PPN network optometrist

You may only visit a specialist if you are referred by your Necesse network doctor and if the visit is preauthorised Only your network doctor or a specialist may refer you for blood tests or X-rays Before you are admitted to hospital you must first obtain approval You may only be admitted to a Necesse network hospital or else you’ll be liable for a 20% co-payment Emergency ambulance services are provided by Netcare 911

Consultations at a Necesse network general practitioner

IMPORTANT TO NOTE

• Choose a specific Necesse network doctor as your general practitioner. View the list of network doctors near you or dial *120*6364# on your cell phone
• Pre-authorisation is required from the 9th consultation at your Necesse network doctor per family onwards

Description	Benefit
GENERAL PRACTITIONER SERVICES WITHIN THE NECESSE NETWORK Consultations	100% of the scheme tariff Subject to the overall annual limit

Medicine prescribed by a Necesse network doctor

Acute medicine prescribed by a Necesse network doctor

• Acute medicine must be prescribed by your Necesse network doctor.
• Medicine may only be obtained from your dispensing network doctor or at a pharmacy in the Medihelp Preferred Pharmacy Network. Visit Medihelp’s website for a list of network pharmacies. View the list of network pharmacies
• Only medicines on the Necesse medicine list (formulary) qualify for benefits.

Description	Benefit
ACUTE medicine PRESCRIBED BY A NECESSE NETWORK DOCTOR	100% of the contracted tariff Subject to the overall annual limit Co-payments may apply

Over-the-counter (OTC) medicine

IMPORTANT TO NOTE

• OTC medicine can be obtained without a prescription
• OTC medicine may only be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network
• Limits are applicable

Description	Benefit
OVER THE COUNTER (OTC) MEDICINE	100% of the scheme tariff R190 per beneficiary per year, maximum of R65 per event Subject to the overall annual limit

Chronic Diseases List (CDL) medicine

IMPORTANT TO NOTE

• Chronic medicine for CDL conditions must be prescribed by your Necesse network doctor
• Chronic medicine for CDL conditions may only be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network. Visit Medihelp’s website for a list of preferred pharmacies
• All chronic medicine for CDL conditions must fi rst be approved by Medihelp, subject to pre-authorisation and registration protocols
• Only chronic medicine used for the treatment of conditions on the CDL qualify for benefits   

Description	Benefit
OVER THE COUNTER (OTC) MEDICINE	100% of the scheme tariff R190 per beneficiary per year, maximum of R65 per event Subject to the overall annual limit

Oxygen

IMPORTANT TO NOTE

• Subject to protocols and pre-athorisation
• Must be prescribed by a Necesse network doctor. 

Description	Benefit
OXYGEN Services rendered not during hospitalisation	100% of the scheme tariff Subject to the overall annual limit 20% co-payment if not pre-authorised

IMPORTANT TO NOTE

• These services must be requested by your Necesse network doctor
• Blood tests must be performed by either Lancet or Pathcare
• Benefits will only be granted for a limited list of approved basic radiology and pathology services

Description	Benefit
BASIC RADIOLOGY (X-RAYS) Black and white X-rays and soft-tissue ultrasounds	100% of the scheme tariff Subject to the overall annual limit
BASIC PATHOLOGY (BLOOD TESTS)	100% of the contracted tariff Subject to the overall annual limit Co-payments apply if services are rendered by non-preferred providers

IMPORTANT TO NOTE

• Services must be obtained from a PPN optometrist
• PPN must first approve the optical services
• Benefits are available in a 24-month cycle per beneficiary
• Limits are applicable on the frame and lenses

Description	Benefit
OPTICAL SERVICES (PPN) Optometric examinations	Benefits are available per 24-month cycle per beneficiary: 1 comprehensive consultation, including refraction test, tonometry and visual fields test
Spectacles or contact lenses Benefits are limited to either spectacles or contact lenses Spectacles Frame	R150 (PPN frame)
Lenses One pair of standard high-quality clear lenses	Clear single vision lenses or Clear Aquity bifocal lenses
Contact lenses	R395 (only PPN optometrists)

Pregnancy benefits

IMPORTANT TO NOTE

• Pre-and post-natal care services must be provided by your Necesse network doctor
• Midwife services must be rendered by a registered practising nurse and are subject to pre-authorisation and treatment guidelines (protocols)
• Sonars are subject to referral by a network GP or specialist
• Limits are applicable 

Description	Benefit
PREGNANCY Pre- and post-natal care Midwife services by a registered practising nurse	Subject to the overall annual limit 100% of the scheme tariff 20% co/payment if not pre-authorised
Network general practitioner services	100% of the contracted tariff
Gynaecologist services on referral by a network general practitioner	100% of the scheme tariff 2 consultations per beneficiary 20% co-payment if not on referral
Sonars (2D)	100% of the scheme tariff 2 two-dimensional sonars per beneficiary

Physiotherapy and occupational therapy

IMPORTANT TO NOTE

• These services must be requested by your Necesse network doctor
• Limits are applicable 

Description	Benefit
PHYSIOTHERAPY AND OCCUPATIONAL THERAPY	100% of the scheme tariff R1,380 per member per year or R2,120 per family per year Subject to the overall annual limit

Basic dental services

IMPORTANT TO NOTE

• You must obtain all dental services from a dentist in the Dental Information Systems (Denis) network
• Benefits are only provided for basic conservative dental services that meet specific clinical treatment guidelines (protocols)
• Some services are excluded from benefits, e.g. crowns and bridges
• All benefits are subject to Denis protocols and managed care interventions
• Acute medicine prescribed by a dentist is for your own account

Description	Benefit
BASIC CONSERVATIVE DENTAL SERVICES (DENIS) Routine check-ups (full mouth examination)	100% of the Medihelp Dental Tariff 1 consultation per beneficiary per year
Oral hygiene Fluoride treatments for children only (Item codes: 8155/8159/8161)	100% of the Medihelp Dental Tariff 1 scale and polish treatment per beneficiary per year
Fillings (Item codes: 8341/8342/8343/8344/8351/8352/8353/8354)	100% of the Medihelp Dental Tariff 4 fillings per beneficiary per year
Root canal therapy and extractions	100% of the Medihelp Dental Tariff
Plastic dentures Including associated laboratory costs	100% of the Medihelp Dental Tariff 1 set of plastic dentures (an upper and lower set) per family in a 24-month cycle for patients 21 years and older Co-payment of 20% on Medihelp Dental Tariff applies
Laughing gas in Denis network dentist’s rooms Dental procedures under conscious sedation in the Denis network dentist’s chair for extensive dental treatment only Subject to pre-authorisation	100% of the Medihelp Dental Tariff
X-rays: Intra-oral	4 per beneficiary per year
X-rays: Extra-oral	1 per beneficiary in a 3-year cycle

IMPORTANT TO NOTE

• You may only visit a specialist if you are referred by your Necesse network general practitioner, otherwise a co-payment will be applicable
• The specialist’s consultation and follow-up consultations must be pre-authorised by Medihelp
•  All medicine prescribed by a specialist must be obtained from a pharmacy in the Medihelp Preferred Pharmacy Network
• Only chronic medicine used for the treatment of CDL conditions qualify for benefits, if prescribed by a specialist on referral
• Pathology services requested by a specialist must be rendered by either Lancet or Pathcare
• Limits are applicable

Description	Benefit
SPECIALIST CARE Specialist consultations	100% of the contracted/scheme tariff R2,120 per single member or R3,000 per family per year Subject to the overall annual limit 20% co-payment if not on referral No benefits for acute medicine, basic radiology and pathology if the specialist visit is not pre-authorised
Surgical and non-surgical procedures
Diagnostic endoscopic procedures performed in the specialist’s rooms
ACUTE MEDICINE
BASIC RADIOLOGY AND PATHOLOGY
CHRONIC CDL MEDICINE PRESCRIBED BY A SPECIALIST ON REFERRAL Subject to protocols and pre-authorisation	100% of the Necesse formulary

Emergency visits (PMB cases)

IMPORTANT TO NOTE

• Only emergencies that meet the definition:   An emergency medical condition means any sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy. An emergency medical condition must be certified as such by a medical practitioner. Emergencies qualify for PMB and must therefore also be authorised for PMB
• Emergency consultations must be reported to Medihelp and authorisation obtained within 72 hours after the visit

Description	Benefit
EMERGENCIES (PMB)	100% of the cost Unlimited – in accordance with PMB regulations

Emergency visits (non-PMB cases) and out-of-network consultations

Medicine prescribed by a non-network doctor must be obtained from a network pharmacy to qualify for benefits.

Description	Benefit
EMERGENCY VISITS AND OUT-OF-NETWORK CONSULTATIONS Outpatient and emergency consultations (non-PMB cases) Medicine and services rendered by a non-network general practitioner	80% of the scheme tarrif R740 per member per year R1,480 per family per year Subject to the overall annual limit
Facility fee	For member’s account
RADIOLOGY AND PATHOLOGY REQUESTED BY NON-NETWORK DOCTORS	Radiology is for members account. Pathology is 100% of the contracted tariff of the list of pathology codes Should you deviate from the DSP a co-payment could apply.

Emergency transport

IMPORTANT TO NOTE

• Emergency transport services are provided and must be pre-authorised by Netcare 911
• Netcare 911 also offers support through a 24-hour helpline and a Rape Crisis Centre

Description	Benefit
EMERGENCY TRANSPORT SERVICES – NETCARE 911 Pre-authorisation by Netcare 911 Emergency transport services by road within the borders of South Africa only	100% of the contracted tariff/cost
Transport of blood and blood products share a R14 300 limit with clinical technologist
24-HOUR HELPLINE (NETCARE 911)	Phone 082 911 for advice in a medical emergency
NETCARE 911 RAPE CRISIS CENTRE

IMPORTANT TO NOTE

• You may be admitted to any of the hospitals in the Necesse network. (View the list of hospitals)
• Your Necesse network doctor or the specialist to whom you’ve been referred will decide whether you should be admitted to hospital
• All hospital admissions must be pre-authorised
• In case of an emergency admission after hours the admission must be registered on the first workday after the admission
• Hospital benefits are subject to pre-registration, pre-authorisation and clinical treatment guidelines (protocols)
• A 20% co-payment will apply if your hospital admission is not pre-authorised, except for emergency admissions
• A 20% co-payment will apply if you are admitted to a hospital that is not part of the Necesse hospital network, except for emergency admissions
• Should pathology services during hospitalization not be rendered by Lancet or Pathcare, co-payments will apply

Description	Benefit
HOSPITALISATION Intensive care units and high care wards Ward accommodation Theatre costs Visits/consultations by network general practitioners or specialists Treatment and ward medicine Surgery and anaesthesia	100% of the contracted/scheme tariff/medicine price 20% co-payment per unauthorised non-emergency admission or admission to a non-network hospital Subject to the overall annual limit
APPLICABLE MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON THE DAY OF DISCHARGE FROM HOSPITAL	100% of the medicine price R250 per admission Subject to the overall annual limit
MAXILLOFACIAL SURGERY DUE TO TRAUMA-RELATED INJURIES – PMB ONLY Subject to pre-authorisation and clinical protocols	100% of the cost
PHYSIOTHERAPY AND OCCUPATIONAL THERAPY During hospitalisation	100% of the scheme tariff R6,360 per family per year Subject to the overall annual limit
PATHOLOGY AND MEDICAL TECHNOLOGY During hospitalisation Services should be rendered by Lancet or Pathcare	100% of the contracted/scheme tariff R19,610 per family per year Subject to the overall annual limit
BASIC RADIOLOGY During hospitalisation
MATERNITY (non-PMB cases) Subject to pre-authorisation and clinical protocols Hospitalisation Midwifery and confinement/delivery Gynaecologist and anaesthetist	100% of the contracted tariff R16,960 per confinement Subject to the overall annual limit 20% co-payment per unauthorised non-emergency admission or services rendered by a non-network hospital
OXYGEN Services rendered during hospitalisation	100% of the scheme tariff/cost Subject to the overall annual limit
CLINICAL TECHNOLOGIST SERVICES Services rendered during hospitalisation	100% of the scheme tariff R14,300 per family per year Subject to the overall annual limit

IMPORTANT TO NOTE

Sub-acute and private nursing as an alternative to hospitalization.

• Benefits for these services are subject to pre-authorisation and case management.
• Private nursing benefits exclude general day to day services such as bathing and general care.

Description	Benefit
SUB-ACUTE AND PRIVATE NURSING SERVICES AS AN ALTERNATIVE TO HOSPITALISATION	100% of the contracted tariff R14,300 per family per year Subject to the overall annual limit 20% co-payment per unauthorised admission to sub-acute care facilities

Specialised radiology

IMPORTANT TO NOTE

• Must be prescribed by your network general practitioner or specialist on referral
• You must obtain pre-authorisation for specialised radiology services

Description	Benefit
SPECIALISED RADIOLOGY Services rendered during and not during hospitalisation MRI and CT scans	100% of the scheme tariff R10,600 per family per year Subject to the overall annual limit

Dental surgery under general anaesthesia in a network hospital/day clinic only

IMPORTANT TO NOTE

• Benefits are subject to pre-authorisation, Denis clinical protocols, referral and services must be rendered by a Denis network dentist
• Some services are excluded from benefits, as set out in the Rules of Medihelp

Description	Benefit
DENTAL SURGERY UNDER GENERAL ANAESTHESIA IN A HOSPITAL/DAY CLINIC ONLY Trauma cases (PMB only)	100% of the cost
Extensive dental treatment for very young children	Subject to the overall annual limit 20% co-payment per unauthorised non-emergency or services rendered by a non-network hospital

IMPORTANT TO NOTE

• Prescribed Minimum Benefits (PMB) are 270 conditions for which diagnosis, care and treatment costs are covered. Medicine for the treatment of the additional 26 specific chronic conditions (CDL) qualify for benefits subject to algorithms.
• If you are diagnosed with a PMB condition by your network doctor, you must submit the doctor’s report on the PMB condition to Medihelp to have it authorised.
• PMB are subject to pre-authorisation, clinical protocols and formularies, and services must be rendered by contracted service providers. If you deviate from the formularies or protocols or are not treated by a contracted service provider, co-payments will be applicable.

Description	Benefit
DIAGNOSIS, CARE AND TREATMENT COSTS OF 270 PMB AND CHRONIC MEDICINE FOR 26 CDL CONDITIONS	100% of the cost Unlimited – in accordance with PMB regulations Co-payments may apply

Oncology (PMB cases only)

IMPORTANT TO NOTE

• Benefits are subject to protocols and pre-authorisation
• Benefits are subject to enrolment on the oncology management programme provided by ICON

Description	Benefit
ONCOLOGY –PMB ONLY Chemotherapy and radiotherapy Surgery	100% of the cost Unlimited – in accordance with PMB regulations Co-payments may apply

HIV/Aids (Optipharm)

IMPORTANT TO NOTE

• Benefits are subject to clinical protocols and treatment plans
• Benefits are subject to registration on the HIV/Aids management programme provided by Optipharm 

Description	Benefit
HIV/AIDS (Optipharm) Antiretroviral therapy and treatment by preferred provider	100% of the cost Unlimited – in accordance with PMB regulations Co-payments may apply

Trauma recovery (PMB cases)

IMPORTANT TO NOTE

Benefits are subject to pre-authorisation and case management

Description	Benefit
BENEFITS FOR TRAUMA THAT NECESSITATES HOSPITALISATION	100% of the cost Unlimited – in accordance with PMB regulations Co-payments may apply
POST-EXPOSURE PROPHYLAXIS (Optipharm)

Other services covered as PMB only  

IMPORTANT TO NOTE

• Benefits are subject to pre-authorisation and admission to a network hospital
• 20% co-payment applies for unauthorised admissions or admission to a non – network hospital.
• No benefits in respect of clinical psychology and psychiatric nursing services
• Renal dialysis is subject to pre-authorisation and enrolment on the renal management programme

Description	Benefit
TREATMENT OF A MENTAL HEALTH CONDITION – PMB ONLY Professional psychiatric services Ward accommodation Medicine and materials supplied or administered during hospitalisation	100% of the scheme/contracted tariff/medicine price Subject to the overall annual limit 20% co-payment applies to non-authorised and non-network hospital admissions
Applicable medicine dispensed and charged by the hospital on the day of discharge from hospital	100% of the medicine price R250 per admission
RENAL DIALYSIS – PMB ONLY (acute and chronic) Rendered by a designated service provider	100% of the contracted tariff
PROSTHESES – PMB ONLY Internally implanted prosthesis	100% of the scheme tariff/cost
External prosthesis	100% of the scheme tariff/cost R6,360 per family per year
SURGICAL AND ORTHOPAEDIC APPLIANCES REQUIRED DURING HOSPITALISATION – PMB ONLY