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Comprehensive plans for 2019

Get insured family cover encompassing comprehensive benefits for hospitalisation, preventive care and day-to-day medical expenses, and the freedom to obtain services at any provider.

Elite product block
Elite

This all-inclusive option offers rich, insured benefits for hospitalisation, chronic medicine and other day-to-day medical expenses.

Principal member Principal member R4 698
Dependant Dependant R4 392
Child dependant <26 years Child dependant R1 278

The monthly contribution does not take any employer subsidy into account

Core benefits


Elite Chronic illness/PMB - 2019
Chronic illness/PMB
  • 100% of the cost for 270 PMB and 26 chronic conditions (DSPs, networks, protocols and pre-authorisation apply)
  • Unlimited cover for trauma that necessitates hospitalisation

Elite Emergency transport - 2019
Emergency transport (Netcare 911)

In country of residence
(RSA, Lesotho, Swaziland, Mozambique, Namibia & Botswana)
Unlimited (road and air transport)

Outside country of residence
Transport:

  • Road - R1 950 per case
  • Air - R13 000 per case

Elite Hospitalisation - 2019
Hospitalisation

100% of the MT
Any private hospital


Elite Specialised radiology- 2019
Specialised radiology

In and out of hospital

  • MRI and CT imaging
    • 100% of the MT
    • Unlimited (see deductibles)
  • Angiography
    • 100% of the MT
    • Unlimited
Elite Psychiatric treatment - 2019
Psychiatric treatment

R33 600 per beneficiary per year
(maximum R46 600 per family per year)


Elite Oncology - 2019
Oncology

In and out of hospital

  • PMB -100% of the MT
  • Non-PMB - R300 000 per family per year

Elite Confinement - 2019
Confinement (childbirth)
  • In hospital - 100% of the MT
  • Home delivery - R12 400 per event

Prostatectomy
  • Conventional/laparoscopic procedure - unlimited
  • Robotic assisted laparoscopy - hospitalisation: R105 400

Elite Organ transplants - 2019
Organ transplants

100% of the cost

  • Cornea implants - R27 400 per implant per year

Elite Other core benefits - 2019
Other core benefits

Renal dialysis, oxygen, hospice, sub-acute care and private nursing services as an alternative to hospitalisation

Elite Post hospital - 2019
Post-hospital care

Up to 30 days after discharge for speech therapy, occupational therapy and physiotherapy
Member = R1 750 per year
Member+ = R2 400 per year


Elite prosthesis - 2019
Prostheses benefits
  • Health-essential functional prosthesis: R58 800
    • Hip, knee and shoulder replacements (non-PMB):
      • Acute injuries where replacement is the only treatment option
        Hospitalisation: 100% of the MT
        Prosthesis: Health-essential functional prosthesis benefit applies
      • Wear and tear: Subject to DSP if patient qualifies in terms of clinical criteria (only hip and knee replacements)
        If not, a R18 600 benefit applies for the hospital account and prosthesis components (combined) per admission
  • Intra-ocular lenses – R3 950 per lens, 2 lenses per beneficiary per year, health-essential functional prosthesis benefit applies
  • EVARS prosthesis
    - R124 000
  • Vascular/cardiac prosthesis
    - R53 100
  • Prosthesis with reconstructive or restorative surgery and external breast prostheses (in and out of hospital)
    - R9 150 per family per year
  • Implantable hearing devices (including devices and components)
    - R99 800 per beneficiary per year

Added insured benefits

These benefits are provided in addition to other insured benefits and available annually unless otherwise indicated


Elite Women's health - 2019
Women's health
  • A pap smear requested by a medical doctor
  • A mammogram requested by a medical doctor for women 40 years and older
  • A flu vaccination at Clicks/Dis-Chem pharmacy clinics

Elite Enhanced maternity benefits - 2019
Enhanced maternity benefits
  • Free registration for and participation in the Medihelp HealthPrint pregnancy and baby programme with support and baby goodies
  • Up to 12 antenatal and postnatal consultations per family at a gynaecologist, GP or midwife
  • One amniocentesis screening per pregnancy
  • Two 2D ultrasound scans per family
  • Flu vaccination during your pregnancy at Clicks/Dis-Chem pharmacy clinics

Elite Child benefits - 2019
Child benefits
  • Child flu vaccination at Clicks/Dis-Chem pharmacy clinics
  • Babies under a year receive two additional visits to a GP or specialist
  • Full schedule of standard child immunisations covered up to 7 years at Dis-Chem/Clicks pharmacy clinics
Elite Routine screening and immunisation benefits - 2019
Routine screening and immunisation benefits

Available at Clicks/Dis-Chem pharmacy clinics per person:

  • One combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose or cholesterol test
  • HIV testing, counselling and support
  • A tetanus vaccine
  • Two HPV vaccinations for girls and boys between 10-14 years, and three between 15-26 years.

Elite Men's health - 2019
Men's health
  • A prostate test (PSA level) requested by a medical doctor for men 40 years and older
  • A flu vaccination at Clicks/Dis-Chem pharmacy clinics

Elite Additional screenings and immunisation for over 50s - 2019
Additional screenings and immunisation for over 50s
  • An FOBT test for people over 50 years
  • Women over 50 years have access to one bone mineral density test requested by a medical doctor
  • A Pneumovax vaccine in a 5-year cycle per person older than 55 years and registered on Medihelp’s asthma/COPD programme
  • A flu vaccination at Clicks/Dis-Chem pharmacy clinics
Elite Supporting wellness - 2019
Supporting wellness

Maintain a healthy weight

  • Free registration for and participation in Medihelp’s HealthPrint BMI programme
  • One dietician consultation per registered HealthPrint member if a BMI test result done at Clicks/Dis-Chem indicates a BMI higher than 30

An alternative to surgery

  • Back treatment at a Document-Based Care facility for patients who qualify for this benefit

Chronic Care programme

  • People who suffer from high blood pressure, high cholesterol and diabetes simultaneously have access to Medihelp's Chronic Care programme which will provide personal support through a care coordinator to assist in maintaining and optimising their well-being

Day-to-day benefits


Elite Insured day-to-day benefits - 2019
Insured day-to-day benefits

Member = R2 650 per year
Member +1 = R4 500 per year
Member +2 = R5 550 per year
Member +3+ = R6 700 per year

GP and specialist consultations, physiotherapy, clinical psychology and supplementary health services.

Pathology

R2 650 per family per year

Radiology

R2 650 per family per year

Elite Medicine - 2019
Medicine

Acute medicine
Member = R4 050 per year
Member +1 = R6 850 per year
Member +2 = R8 400 per year
Member +3+ = R9 000 per year

Chronic medicine (non-PMB)
Member = R4 300 per year
Member +1 = R6 500 per year
Member +2 = R8 700 per year
Member +3+ = R9 300 per year

PMB chronic medicine
100% of the MHRP


Elite Optometry- 2019
Optometry

PPN network applies

Spectacles or contact lenses per beneficiary per 24-month cycle

  • R1 000 for a frame
  • R1 635 for contact lenses
Elite Medical, surgical, and orthopeadic appliances - 2019
External prostheses and medical appliances

In and out of hospital

  • Benefit per beneficiary per 3-year cycle:
    • Artificial eyes - R7 500
    • Speech and hearing aids - R7 500
    • Wheelchairs - R6 000
    • Artificial limbs - R6 000
  • Medical appliances, hyperbaric oxygen treatment, insulin pumps (per 5-year cycle), glucometer (per 5-year cycle) - R1 450 per year
  • CPAP apparatus - R9 250 per beneficiary per 24-month cycle

Elite Insured dental benefits- 2019
Insured dental benefits
  • Conservative services (including routine check-ups, fillings, X-rays and oral hygiene)
  • Specialised services (including crowns, bridges and orthodontic treatments)

Deductibles

Visiting network service providers, following the correct pre-authorisation process and negotiating tariffs with your doctor are just some of the ways you can manage or reduce out-of-pocket medical expenses.


Procedure-specific deductibles

Payable by the member

  • Back and neck fusion – R7 400 per admission
  • Endoscopic procedures – gastroscopy, colonoscopy, arthroscopy and sigmoidoscopy
    • In a day clinic – R2 000
    • In hospital – R3 050
  • Specialised radiology – R1 100 per examination
  • Dental procedures under general anaesthesia during hospitalisation
    • Removal of impacted teeth and extensive dental treatment for children <5 years – R820 per admission
Pre-authorisation is important

The following services and procedures are paid at 100% of the Medihelp tariff if pre-authorised:

  • All planned hospital admissions (protocols and case management apply)
  • Oxygen for out-of-hospital use (protocols and case management apply)
  • Dental procedures under conscious sedation (sedation cost) in the dentist’s chair (managed care protocols apply)
  • Specialised dental services
    • Crowns and bridges
    • Periodontal treatment (conservative non-surgical therapy only)
      Subject to pre-authorisation and treatment plan

Should these services not be pre-authorised, an 80% benefit will apply.

Emergency transport services (Netcare 911)

In and outside the country of residence (air and road transport) should be pre-authorised to qualify for the applicable benefit. If not pre-authorised, 50% of the benefit applies except in the case of emergency medical conditions.

Oncology

Subject to pre-authorisation and registration on the Medihelp Oncology Programme, use of the designated service provider and treatment protocols to avoid deductibles. The Medihelp Oncology Reference Price applies to oncology medicine.


Important:

This is only a summary of the available benefits. Please consult the registered Medihelp Rules for more information and details of services that are excluded from benefits. In case of a dispute, the Rules of Medihelp will apply (subject to approval by the Council for Medical Schemes).

  • Certain added insured benefits are not available if you have been registered for a chronic/PMB condition as it is no longer considered as preventive care and may be linked to a specific age/gender/item code/clinical validity criteria. Benefits are paid at 100% of the MT.
  • Doctor’s consultation paid from available day-to-day benefits.
  • Subject to pre-authorisation and/or protocols
  • Generic medicine = 100% of MMAP | Original medicine - no generic available = 80% of MT | Choose original medicine - generic is available = 70% of MMAP

BMI-Body mass index | COPD-Chronic obstructive pulmonary disease | CPAP-Continuous positive airway pressure | CT-Computerised tomography | DSP-Designated service provider | EVARS-Endovascular aortic replacement surgery | FOBT-Faecal occult blood test | GP-General practitioner | HPV-Human papilloma virus | MHRP - Medihelp Reference Price | MMAP - Maximum Medical Aid Price | MRI-Magnetic resonance imaging | MT-Medihelp tariff paid by Medihelp for benefits which can include a contracted tariff or the single exit price | PMB-Prescribed minimum benefits | PPN-Preferred Provider Negotiators

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