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Hospital plan for 2019

This is a summary of the Prime 1 hospital plan. On this affordable option, you only pay for two children younger than 18 years after which child dependant rates will apply from the beginning of the year following the year in which they turn 18, until they are 26 years old. Older children pay child dependant rates until they are 26 years old.

The monthly contribution does not take any employer subsidy into account

Prime 1 product block
Prime 1 network

This highly affordable hospital plan offers a network of 113 private hospitals at a discount of 22%. You get cover for hospital admissions, minor day-to-day medical expenses and added insured benefits, such as pregnancy consultations and flu immunisation.

Principal member Principal member R1 488
Dependant Dependant R1 212
Child dependant <26 years Child dependant R450
Prime 1

This hospital plan is ideal if you are healthy and want access to private healthcare at an affordable price, with hospital cover at any private facility and cover for, minor day-to-day medical expenses and added insured benefits, including pregnancy consultations and flu immunisation.

Principal member Principal member R1 902
Dependant Dependant R1 566
Child dependant <26 years Child dependant R576

Core benefits


Prime 1 Chronic illness/PMB - 2019
Chronic illness/PMB
  • 100% of the cost for 270 PMB and 26 chronic conditions (DSPs, formularies, networks, protocols and pre-authorisation apply)
  • Unlimited cover for trauma that necessitates hospitalisation

Prime 1 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

Prime 1 Hospitalisation - 2019
Hospitalisation

100% of the MT
Non-network: any private hospital
Network: 113 quality private network hospitals


Prime 1 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

Prime 1 Psychiatric treatment - 2019
Psychiatric treatment

R18 400 per beneficiary per year
(maximum R27 800 per family per year)


Prime 1 Oncology - 2019
Oncology

In and out of hospital

  • PMB - 100% of the MT
  • Non-PMB - R200 000 per family per year

Prime 1 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

Prime 1 Organ transplants - 2019
Organ transplants

100% of the cost

  • Cornea implants - R27 400 per implant per year

Prime 1 Other core benefits - 2019
Other core benefits

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

Prime 1 Post-hospital care - 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


Prime 1 Prostheses benefits - 2019
Prostheses benefits
  • Health-essential functional prosthesis: R21 900
    • 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: no benefits)
    • Intra-ocular lenses – R3 950 per lens, 2 lenses per beneficiary per year, health-essential functional prosthesis benefit applies
  • EVARS prosthesis
    - R32 900
  • Vascular/cardiac prosthesis
    - R32 900
  • Prosthesis with reconstructive or restorative surgery and external breast prostheses (in and out of hospital)
    - R4 050 per family per year

Added insured benefits

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


Prime 1 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

Prime 1 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

Prime 1 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
Prime 1 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.

Prime 1 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

Prime 1 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
Prime 1 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


Prime 1 Insured day-to-day benefits - 2019
Insured day-to-day benefits

Member = R1 150 per year
Member+ = R2 300 per year

GP and specialist consultations, physiotherapy, acute medicine and self-medication, including visits to emergency units.


Prime 1 Medicine - 2019
Medicine

PMB chronic medicine

Non-network option
- 100% of the MHRP

Network option
- 100% of the MHRP
  (DSP and formulary apply)

Prime 1 Insured dental benefits- 2019
Dental

Subject to DSP's managed care protocols

  • Dental procedures under conscious sedation in the dentist’s chair (sedation cost) for the removal of impacted teeth only (dentist’s account - item codes apply)
    100% of the MT
Prime 1 Medical, surgical, and orthopeadic appliances - 2019
External prostheses and medical appliances

In and out of hospital

  • Benefit per family per 3-year cycle:
    • Artificial eyes - R4 500
    • Speech and hearing aids - R4 500
    • Wheelchairs - R4 500
    • Artificial limbs - R4 500
  • CPAP apparatus - R9 250 per beneficiary per 24-month cycle

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 – R11 100 per admission
  • Endoscopic procedures – gastroscopy, colonoscopy, arthroscopy and sigmoidoscopy
    • In a day clinic – R2 000
    • In hospital – R3 050
  • Specialised radiology – R1 600 per examination
  • Dental procedures under general anaesthesia during hospitalisation
    • Removal of impacted teeth (item codes apply on dentist’s account) and extensive dental treatment for children <5 years (dentist’s account for member’s account) – R3 000 per admission
Prime 1 Network
  • Members of Prime 1 Network should use network hospitals for all planned admissions. A 65% benefit applies when an out-of-network hospital is used by choice.
  • 40% of the Medihelp Reference Price is paid if PMB chronic medicine is obtained outside the formulary and/or DSP on the network option. It is advisable for chronic medicine users to rather choose the alternative non-network option.
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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