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medihelp plus - 2018

from R7 464 per month

Medihelp Plus offers comprehensive cover for medical emergencies, private hospitalisation and preventive care, as well as ample benefits for diverse day-to-day medical services to meet your and your loved ones’ health needs.

 Medihelp Medical Scheme top benefit option

Monthly contributions
Member Contributions
Principal member R7 464
Dependant R7 464
Child dependant <26 yearsR1 860
 

Additional insured benefits

Our additional insured benefits are designed to enhance your available day-to-day benefits, and include pregnancy, baby and preventive care benefits.

PREGNANCY AND BABY BENEFITS

  • 12 pregnancy consultations per family per year
  • Two 2D sonars per family per year
  • 2 consultations for babies <1 year old - first 2 consultations at a general practitioner or specialist

PREVENTIVE CARE
Health tests  (One test per beneficiary per year)
  • 1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose and/ or cholesterol tests (at Clicks and Dis-Chem pharmacy clinics - consultation fee included)
  • 1 dietician consultation for HealthPrint members if BMI test result at wellness provider indicates a BMI > 30 (item codes: 84200 - 84205)

Consultation fees for the tests listed below are paid from the available day-to-day benefits:

  • 1 pap smear (pathology: 4566/ 4559)
  • 1 mammogram for women >40 years (radiology: 3605/ 39175/ 34100/ 34101)
  • 1 prostate test (PSA level) >40 years (pathology: 4519)
  • 1 FOBT for beneficiaries >50 years (pathology: 4351)
  • 1 bone mineral density test for women >50 years (radiology: 3604/ 50120)
  • HIV - voluntary counselling and testing (at Clicks or Dis-Chem pharmacy clinics)

Immunisation 
  • 1 flu vaccine per beneficiary per year (administering fee at Dis-Chem or Clicks pharmacy clinics included)
  • 1 tetanus vaccine per beneficiary per year (administering fee at Dis-Chem or Clicks pharmacy clinics included)
  • HPV vaccine once per lifetime – administering fee at Dis-Chem or Clicks pharmacy clinics included
    • 10 to 14 years – 2 injections according to protocol
    • 15 to 26 years – 3 injections according to protocol
  • 1 Pneumococcal vaccination in a 5-year cycle for beneficiaries >55 years - Must be registered on Medihelp's treatment programme for asthma or COPD (NAPPI code 755826027)
  • Standard immunisation for children <7 years old, as published by the Department of Health (administering fee at Dis-Chem or Clicks pharmacy clinics included)

    Back treatment programme
    One Document-Based Care (DBC) back treatment programme per beneficiary per year at a DBC facility (subject to protocols and pre-authorisation)

    COPD-Chronic obstructive pulmonary disease
    FOBT-Faecal occult blood test
    HPV-Human papilloma virus
    * These benefits are not available if you have been registered for a chronic/PMB condition, as it can no longer be considered as additional insured benefits. 


    Core benefits

     Description Benefit
    Essential cover

    DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB AND 26 CHRONIC CONDITIONS ON THE CDL
    Subject to protocols, pre-authorisation and DSPs

    100% of the cost
    Unlimited
    Trauma

    BENEFITS FOR MAJOR TRAUMA THAT NECESSITATES HOSPITALISATION IN THE CASE OF:

    • Motor vehicle accidents
    • Stab wounds
    • Gunshot wounds
    • Head trauma
    • Burns
    • Near drowning

    Subject to authorisation, PMB protocols and case management

    100% of the cost
    Unlimited

    POST-EXPOSURE PROPHYLAXIS

    EMS

    EMERGENCY TRANSPORT SERVICES

    (Netcare 911)
    RSA, Lesotho, Swaziland, Mozambique, Namibia and Botswana
    Subject to pre-authorisation and protocols

    In beneficiary’s country of residence

    • Transport by road
    • Transport by air





    100% of the MT
    Unlimited

    Outside beneficiary’s country of residence

    • Transport by road

    100% of the MT
    R1 900 per case

    • Transport by air
    100% of the MT
    R12 400 per case

    24-HOUR HELPLINE AND TRAUMA COUNSELLING

    (Netcare 911)

    Phone 082 911

    HOSPITALISATION (state and private hospitals and day clinics)
    Subject to pre-authorisation, protocols and case management

    • Intensive and high care wards
    • Ward accommodation
    • Theatre fees
    • Treatment and ward medicine
    • Consultations, surgery and anaesthesia

    100% of the MT
    Unlimited

    POST-HOSPITAL CARE
    Professional services relating to a Medihelp authorised private hospital admission, required for up to 30 days after discharge

    • Speech therapy
    • Occupational therapy
    • Physiotherapy
    100% of the MT
    M = R1 700 per year
    M+ = R2 300 per year
    PROSTHESESClick here to see prostheses

    CONFINEMENT (childbirth)
    Subject to pre-authorisation, protocols and case management

    100% of the MT
    Unlimited

    HOME DELIVERY
    Subject to pre-authorisation

    • Professional nursing fee
    • Equipment
    • Material and medicine
    100% of the MT
    R11 900 per event

    STANDARD RADIOLOGY, PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES
    In hospital
    Subject to clinical protocols 

    100% of the MT
    Unlimited

    SPECIALISED RADIOLOGY
    In and out of hospital
    On request of a specialist and subject to clinical protocols

    • MRI and CT imaging (subject to pre-authorisation)
    • Angiography

    100% of the MT

    Unlimited for MRI, CT imaging and angiography

    • PET scan

    R20 100 per case for PET scans (non-PMB cases)

    ORGAN TRANSPLANTS  
    Subject to pre-authorisation and clinical protocols

    100% of the cost
    Unlimited
    • Cornea implants
    100% of the MT
    R26 100 per implant per year

    SUPPLEMENTARY HEALTH SERVICES
    In hospital

    • Occupational and speech therapy, dietician services, audiometry, podiatry, massage, orthoptic, chiropractic, homeopathic, herbal and naturopathic, osteopathic and biokinetic services
    100% of the MT
    Unlimited
    • Physiotherapy on referral by the attending medical doctor
    OXYGEN
    In hospital
    100% of the MT
    Unlimited

    NEUROSTIMULATORS
    Subject to pre-authorisation and clinical protocols

    • Device and components
    100% of the MT
    R101 200 per beneficiary per year

    RENAL DIALYSIS
    In and out of hospital
    Subject to pre-authorisation and clinical protocols

    100% of the MT
    Unlimited

    APPLICABLE PRESCRIPTION MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON DISCHARGE FROM THE HOSPITAL (TTO) (Excluding PMB chronic medicine) 

    100% of the MT

    R530 per admission

    PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION
    Subject to pre-authorisation, services rendered in an approved hospital/ facility and prescribed by a medical doctor

    • Professional services rendered in and out of hospital by a psychiatrist
    • General ward accommodation
    • Medicine supplied during the period of the treatment in the facility
    • Outpatient consultations


    100% of the MT
    R39 000 per beneficiary per year
    (maximum R53 200 per family per year)

    ONCOLOGY
    Subject to pre-authorisation and registration on the Medihelp Oncology Management Programme

    Protocols and DSP apply

    Hospital and associated cancer treatment and service, including:

    • Radiotherapy
    • Brachytherapy
    • Chemotheraphy and associated adjuvant therapy (medicine subject to the MORP)
    • Bone marrow/ stem cell transplants (subject to PMB legislation)
    100% of the MT
    Unlimited

    HOSPICE SERVICES AND SUB-ACUTE CARE FACILITIES AS AN ALTERNATIVE TO HOSPITALISATION
    Subject to pre-authorisation, services rendered in an approved facility and prescribed by a medical doctor

    100% of the MT
    Unlimited

    PRIVATE NURSING AS AN ALTERNATIVE TO HOSPITALISATION
    Subject to pre-authorisation
    (Excluding general day-to-day care) 

    100% of the MT

    APPENDECTOMY
    Subject to pre-authorisation

    • Conventional and laparoscopic procedures

    100% of the MT
    Unlimited

    PROSTATECTOMY
    Subject to pre-authorisation

    • Conventional or laparoscopic procedure

    100% of the MT
    Unlimited

    • Robotic assisted laparoscopic procedure

    100% of the MT
    Hospitalisation:
    R100 400 per beneficiary

    CDL-Chronic Diseases List
    CT-Computerised tomography
    DSP-Designated service provider
    EMS-Emergency medical services
    MORP-Medihelp Oncology Reference Price
    MRI-Magnetic resonance imaging
    PMB -Prescribed minimum  benefits 
    TTO -To take out (medicine) 
    MT-Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price as defined in the Medihelp Rules

    Internally implanted prostheses

    DescriptionBenefit
    INTERNALLY IMPLANTED PROSTHESES
    All hospital admissions and prostheses are subject to pre-authorisation, protocols and case management
    100% of the MT
    • EVARS prosthesis
    R118 100 per beneficiary per year 
    • Vascular/ cardiac prosthesis
    R50 600 per beneficiary per year
    • Health-essential functional prosthesis
    R56 000 per beneficiary per year
    • Intra-ocular lenses
    Sub-limit of health-essential functional prosthesis:
    2 lenses per beneficiary per year
    R3 800 per lens
    • Prosthesis with reconstructive or restorative surgery and external breast prostheses (in and out of hospital)
    R8 750 per family per year
    • Implantable hearing devices (including devices and components)
    R95 100 per beneficiary per year
    EVARS-Endovascular aortic replacement surgery
    PMB -Prescribed minimum benefits 
    MT-Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

    Day-to-day benefits

    DescriptionBenefit
    GPs, SPECIALISTS AND EMERGENCY UNITS
    • Treatment (medical and surgical services, anaesthesia as well as material and medicines used during the service)
    100% of the MT
    Unlimited
    • Consultations and follow-up consultations
    100% of the MT
    R3 250 per beneficiary per year, pooled per family
    PHYSIOTHERAPY
    Treatment and material
    CLINICAL PSYCHOLOGY AND PSYCHIATRIC NURSING
    In and out of hospital
    SUPPLEMENTARY HEALTH SERVICES
    Occupational and speech therapy, dietician services, audiometry, podiatry, massage, orthoptic, chiropractic, homeopathic, herbal and naturopathic, osteopathic and biokinetic services

    PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES
    Out of hospital

    Subject to clinical protocols and requested by a medical doctor

    100% of the MT
    Unlimited

    STANDARD RADIOLOGY
    Out of hospital

    Subject to clinical protocols and requested by a medical doctor or chiropractor (black and white X-rays only)

    100% of the MT
    Unlimited

    MEDICINE

    Medicine obtained in the Medihelp Preferred Pharmacy Network and prescribed/ dispensed by a medical doctor

    • Acute generic medicine (including medicine dispensed at an emergency unit and self-medication, immunisations, contraceptives and homeopathic, herbal, naturopathic and osteopathic medicine)
    • Please note:
      • Original medicine when no generic equivalent is available – 80% of the MT will apply
      • Voluntary use of original medicine when generic equivalent is available – 70% of the MMAP will apply
    100% of the MMAP if generic medicine is used
    R5 650 per beneficiary per year, pooled per family
    • Non-PMB generic chronic medicine
      Subject to pre-authorisation and registration on Medihelp’s chronic medicine management programme
      • Original medicine when no generic equivalent is available – 80% of the MT will apply
      • Voluntary use of original medicine when generic equivalent is available –70% of the MMAP will apply
    100% of the MMAP if generic medicine is used
    R16 400 per beneficiary per year
    • PMB chronic medicine
      Subject to pre-authorisation and registration on Medihelp’s PMB medicine management programme
    100% of the MHRP
    Unlimited
    OXYGEN
    Out of hospital
    Subject to pre-authorisation, clinical protocols and services prescribed by a medical doctor
    100% of the MT
    Unlimited
    OPTOMETRY
    Subject to pre-authorisation by PPN and services should be obtained from a PPN provider
    • Optometric examinations
      1 composite consultation, including refraction test, tonometry and visual field test
    100% of the MT
    1 composite examination per beneficiary per  24-month cycle
    • Spectacles or contact lenses
      Benefits are limited to either spectacles or contact lenses
      • Spectacles
        • Frames and/ or lens enhancements
    R750 per beneficiary per 24-month cycle
    • Lenses (one pair of standard clear Aquity lenses)
    Single vision, bifocal or multifocal lenses per beneficiary per 24-month cycle
    • Contact lenses
    R1 660 per beneficiary per 24-month cycle
    EXTERNAL PROSTHESES, MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES
    Services in and out of hospital

    • Artificial eyes
    100% of the MT
    R14 300 per beneficiary per 3-year cycle
    • Speech and hearing aids
    100% of the MT
    R14 300 per beneficiary per 3-year cycle
    • Artificial limbs
    100% of the MT
    R7 850 per beneficiary per 3-year cycle
    • Wheelchairs
    100% of the MT
    R7 850 per beneficiary per 3-year cycle
    • Insulin pumps (per 5-year cycle)
    • Glucometers (per 5-year cycle)
    • Medical appliances
    • Hyperbaric oxygen treatment
    100% of the MT
    R1 700 per beneficiary per year
    • Stoma components
    • Incontinence products/ supplies
    100% of the MT
    Unlimited
    • Wigs (for alopecia totalis or cancer patients)
      Subject to pre-authorisation and protocols
    100% of the MT
    R1 700 per beneficiary per 3-year period
    • CPAP apparatus
      Prescribed by a medical doctor
    100% of the MT
    R8 850 per beneficiary per 24-month cycle
    DENTAL SERVICES 
    Subject to DSP's managed care protocols 


    Conservative dental services

    • Routine check-ups
    100% of the MT
    2 per beneficiary per year (once in 6 months) 
    • Oral hygiene
      • Fluoride treatment for children > 5 and < 13 years
      • Fissure sealants for children younger than 16 years only
    100% of the MT
    2 scale and polish treatments per beneficiary per year (once in 6 months)
    • Fillings (treatment plans and X-rays may be requested for multiple fillings)
    100% of the MT
    1 filling per tooth in 365 days
    • Tooth extractions and root canal treatment in the dentist’s chair

    100% of the MT

    • Laughing gas (in the dentist’s chair)

    100% of the MT

    • Dental procedures under conscious sedation in the dentist’s chair (sedation cost)
      Subject to pre-authorisation and managed care protocols
    100% of the MT
    Extensive dental treatment and the removal of impacted teeth only
    • Plastic dentures
    100% of the MT
    1 set (upper and lower jaw) per beneficiary in a 4-year period
    • X-rays
      • Intra-oral X-rays
    100% of the MT
    • Extra-oral X-rays
    100% of the MT
    1 per beneficiary in a 3-year period
    Specialised dental services
    Subject to pre-authorisation and DSP's managed care protocols
    • Partial metal frame dentures
    100% of the MT
    2 partial frames (upper or lower jaw) per beneficiary in a 5-year period
    • Maxillofacial surgery and oral pathology
      • Surgery in the dentist’s chair
        Benefits for temporomandibular joint (TMJ) therapy are limited to non-surgical interventions/ treatment
    100% of the MT
    • Crowns and bridges
      Subject to pre-authorisation
    100% of the MT
    3 crowns per family per year, once per tooth in a 5-year period
    • Implants
      Subject to pre-authorisation

    100% of the MT
    2 implants per beneficiary in a 5-year period

    R2 270 for implant components per implant

    • Orthodontic treatment (only one beneficiary per family may begin orthodontic treatment per calendar year)
      Subject to pre-authorisation and orthodontic needs analysis
    100% of the MT
    R13 500 per beneficiary > 9 and < 18 years old per lifetime
    Payment from date of authorisation
    • Periodontal treatment (conservative non-surgical therapy only)
      Subject to pre-authorisation and registration on the Perio Programme
    100% of the MT
    CPAP-Continuous positive airway pressure
    DSP-Designated service provider
    GP-General practitioner
    MHRP-Medihelp Reference Price
    MMAP-Maximum Medical Aid Price
    PMB -Prescribed minimum benefits 
    MT-Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

    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
    Always pre-authorise the services listed below:
    • 100% of the Medihelp tariff applies if these services or procedures are pre-authorised:
      • All planned hospital admissions (protocols and case management apply)
      • Oxygen for out of hospital use (protocols and case management apply)
      • Specialised dental services
      • Crowns and bridges
      • Implants
      • Periodontal treatment (conservative non-surgical therapy only and subject to registration on the Perio Programme)
    • 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 is subject to pre-authorisation and registration on the Medihelp Oncology Management Programme, use of the designated service provider and treatment protocols to avoid deductibles.  The Medihelp Oncology Reference Price applies to oncology medicine.

    MEDICINE BENEFITS
    Ask your pharmacist for the generic equivalent of prescribed medicine to avoid unnecessary out-of-pocket expenses. The only difference between an original medicine item and its generic equivalent is the price.

    Medicine benefits are applied as follows:
    • Generic medicine – 100% of the MMAP
    • Original medicine if no generic equivalent is available – 80% of the MT
    • Original medicine if a generic equivalent is available – 70% of the MMAP

    MMAP-Maximum Medical Aid Price
    PMB -Prescribed minimum benefits 
    MT-Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price
    CT-Computerised tomography
    MRI-Magnetic resonance imaging

    Important notes:

    • If a beneficiary joins during the course of a financial year, the medical aid benefits are calculated pro rata according to the remaining number of months per year.
    • This is a summary of the available benefits. In the event of a dispute the registered Rules of Medihelp will apply, subject to approval by the Registrar of Medical Schemes. Phone Medihelp on 086 0100 678 if you have any enquiries about the Rules of Medihelp Medical Scheme.

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