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Prime 3 Product Block

Prime 3 comprehensive plan in 2020


With ample insured cover for day-to-day medical expenses, comprehensive hospital cover at the facility of your choice and added insured benefits, this is the ideal product for families and individuals with more extensive healthcare needs. You can choose a network of 119 quality hospitals and save 18% in monthly contributions.

Prime 3 A
Prime 3 B
Prime 3 C
Prime 3 D
Prime 3 E

   NetworkNon-network
 Principal memberPrincipal memberR2 964R3 618
 DependantDependantR2 508R3 060
 Child dependant <26 yearsChild dependantR864R1 056

Core benefits


Chronic illness/PMB

100% of the cost for 270 PMB and 26 chronic conditions (DSPs, formulary, networks, protocols and pre-authorisation apply)


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
Non-network: any hospital
Network: 119 network hospitals


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

R29 300 per beneficiary per year (maximum R39 300 per family per year)


Oncology

In and out of hospital

  • PMB – 100% of the MT
  • Non-PMB – R263 500 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: no benefits)
    • 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 benefits
  • 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, supplementary health services, medical technologist services, standard radiology, pathology, acute and self-medication

Member = R9 450 per year
Member +1 = R15 000 per year
Member +2 = R17 700 per year
Member +3+ = R18 700 per year


Optometry

PPN network applies

Spectacles or contact lenses per beneficiary per 24-month cycle

  • R800 for a frame/lens enhancements
  • R1 185 for contact lenses
Medicine

PMB chronic medicine
Non-network option – 100% of the MHRP
Network option – 100% of the MHRP (DSP and formulary apply)


Dentistry

DRC network applies

  • Conservative services (including routine check-ups, fillings, X-rays and oral hygiene)
  • Specialised services (including crowns, bridges and orthodontic treatment)
External prostheses and medical appliances

In and out of hospital

  • Benefit per family per 3-year cycle:
    • Artificial eyes – R4 700
    • Speech and hearing aids – R4 700
    • Wheelchairs – R4 700
    • Artificial limbs – R4 700
  • CPAP apparatus – R9 700 per beneficiary per 24-month cycle
  • Medical appliances and hyperbaric oxygen treatment – R1 250 per family 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 – R9 100 per admission
  • Endoscopic procedures – gastroscopy, colonoscopy, arthroscopy and sigmoidoscopy
    In a day clinic – R2 100, in hospital – R3 200
  • Specialised radiology – R1 650 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 – R960 per admission

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.

Prime 3 Network
  • Members of Prime 3 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.

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.

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


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 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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