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Plus Comprehensive in 2020


Medihelp’s top-of-the-range product offers the most extensive cover for medical emergencies, private hospitalisation and preventive care, as well as substantial provision for acute and chronic medicine, radiology, pathology and other day-to-day medical expenses to ensure that you and your family’s healthcare needs are always well taken care of.

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  Principal member Principal member R9 180
  Dependant Dependant R9 180
  Child dependant <26 years Child dependant R2 292

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, CT imaging and angiography
    100% of the MT – unlimited
  • PET imaging (non-PMB)
    100% of the MT – R22 200 per case
Psychiatric treatment

R43 100 per beneficiary per year (maximum R58 800 per family per year)


Oncology

In and out of hospital

100% of the MT – unlimited


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
    • 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
  • 2D ultrasound scans per family – unlimited

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 –
R3 550 per beneficiary per year, pooled per family


Optometry

PPN network applies

Spectacles or contact lenses per beneficiary per 24-month cycle

  • R1 000 for a frame/lens enhancements
  • R1 660 for contact lenses

Pathology

Unlimited

Medicine

Acute medicine
R6 200 per beneficiary per year, pooled per family

Chronic medicine (non-PMB)
R18 100 per beneficiary 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, implants and orthodontic treatment)
Radiology

Unlimited


External prostheses and medical appliances

In and out of hospital

  • Benefit per beneficiary per 3-year cycle:
    • Artificial eyes – R15 800
    • Speech and hearing aids – R15 800
    • Wheelchairs – R8 600
    • Artificial limbs – R8 600
  • CPAP apparatus – R9 700 per beneficiary per 24-month cycle
  • Medical appliances and hyperbaric oxygen treatment – R1 800 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.


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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