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Elite Product Block

Elite Comprehensive in 2020


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

Elite A
Elite B
Elite C
Elite D

 

 Principal memberPrincipal memberR5 304
 DependantDependantR4 956
 Child dependant <26 yearsChild dependantR1 440

 

Core benefits


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

Emergency transport

Netcare 911

In country of residence
RSA, Lesotho, Swaziland, Mozambique, Namibia & Botswana – unlimited

Outside country of residence
Transport by road R2 050 and by air
R13 700 per case


Hospitalisation

100% of the MT


Specialised radiology

In and out of hospital

  • MRI and CT imaging – 100% of the MT
    Unlimited (see deductibles)
  • Angiography – 100% of the MT
    Unlimited

Psychiatric treatment

R35 400 per beneficiary per year (maximum R49 100 per family per year)

Oncology

In and out of hospital

  • PMB – 100% of the MT
  • Non-PMB – R400 000 per family per year

Confinement (childbirth)
  • In hospital – 100% of the MT
  • Home delivery – R13 000 per event

Organ transplants

100% of the cost

Cornea implants – R28 800 per implant


Other core benefits

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


Post-hospital care

R1 800 per member and R2 500 per family per year for speech therapy, occupational therapy and physiotherapy for up to 30 days after discharge

Prostheses benefits
  • Health-essential functional prosthesis: R61 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: Subject to DSP if patient qualifies in terms of clinical criteria (only hip and knee replacements). If not, a R19 600 benefit applies for the hospital account and prosthesis components (combined) per admission
    • Intra-ocular lenses – R4 150 per lens, 2 lenses per beneficiary per year, health essential functional prosthesis benefit applies
  • EVARS prosthesis – R130 600
  • Vascular/cardiac prosthesis – R55 900
  • Prosthesis with reconstructive or restorative surgery and external breast prostheses (in and out of hospital) – R9 600 per family per year
  • Implantable hearing devices (including device and components) – R105 100 per beneficiary per year

Added insured benefits


Women's health
  • A mammogram for women 40 years and older (per 2-year cycle)
  • A pap smear (per 3-year cycle)

Enhanced maternity benefits
  • Pregnancy and baby programme
  • 12 ante- & postnatal consultations
  • Two 2D ultrasound scans per family

Child benefits
  • Two additional GP or specialist visits (babies under 1 year)
  • Standard child immunisations for children younger than 7 years
Routine screening and immunisation
  • A combo test (blood glucose, cholesterol, BMI & blood pressure measurement)/individual blood glucose or cholesterol test
  • HIV testing
  • A tetanus vaccine
  • A flu vaccination
  • Two HPV vaccinations for girls and boys between 10-14 years or three between 15-26 years

HealthPrint

Medihelp members get free access to this online health and wellness programme designed to add value based on their health profile through programmes such as a pregnancy and baby programme and discounts at selected partners

Men's health
  • A prostate test (PSA level) for men 40 years and older

Supporting wellness
  • One dietician consultation per registered HealthPrint member if a BMI test result indicates a BMI higher than 30
  • Back treatment at a Document Based Care facility
  • Chronic Care programme

Over 50s
  • One bone mineral density test for women over 50 years
  • A Pneumovax vaccine in a 5-year cycle per person over 55 years
  • An FOBT test for people over 50 years

Day-to-day benefits


Insured day-to-day benefits

GP and specialist consultations, physiotherapy, clinical psychology, psychiatric nursing and supplementary health services

Member = R2 750 per year
Member +1 = R4 700 per year
Member +2 = R5 800 per year
Member +3+ = R7 050 per year


Optometry

PPN network applies

Spectacles or contact lenses per beneficiary per 24-month cycle

  • R1 000 for a frame/lens enhancements
  • R1 635 for contact lenses

Pathology

R2 750 per family per year

Radiology

R2 750 per family per year


Medicine

Acute medicine
Member = R4 250 per year
Member +1 = R7 200 per year
Member +2 = R8 850 per year
Member +3+ = R9 450 per year

Chronic medicine (non-PMB)
Member = R4 500 per year
Member +1 = R6 850 per year
Member +2 = R9 150 per year
Member +3+ = R9 800 per year

PMB chronic medicine
100% of the MHRP

Dentistry

DRC network applies

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

External prostheses and medical appliances

In and out of hospital

  • Benefit per beneficiary per 3-year cycle:
    • Artificial eyes – R7 900
    • Speech and hearing aids – R7 900
    • Wheelchairs – R6 300
    • Artificial limbs – R6 300
  • CPAP apparatus – R9 700 per beneficiary per 24-month cycle
  • Medical appliances and hyperbaric oxygen treatment – R1 500 per beneficiary per year

Additional information

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)

  • Spinal column surgery – R7 750 per admission
  • Endoscopic procedures – gastroscopy, colonoscopy, arthroscopy and sigmoidoscopy
    In a day clinic – R2 100, in hospital – R3 200
  • Specialised radiology – R1 150 per examination
  • Dental procedures under general anaesthesia during hospitalisation
    Removal of impacted teeth (3rd molars, item codes apply on dentist’s account) and extensive dental treatment for children < 5 years – R900 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 the treatment is no longer considered as preventive care and may be linked to a specific age/gender/item code. Benefits are paid at 100% of the MT.
  • Doctors’ consultations are 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

 

Abbreviations:

AOL-Overall annual limit | BMI-Body mass index | CDL-Chronic Diseases List | CPAP-Continuous positive airway pressure | CT-Computerised tomography | DRC-Dental Risk Company | DSP-Designated service provider | EMS-Emergency medical services | 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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