Dimension Prime 3 2017

Dimension Prime 3 - 2017

from R2 184 per month

 

Regarded as Medihelp’s flagship option, Dimension Prime 3 is the solid choice for all your family’s healthcare needs. It provides comprehensive insured cover for medical expenses incurred in and out of hospital as well as preventive care benefits. You can choose either the freedom of choice version of the option or opt for the network alternative.

Monthly contribution (network option)

Member Subscription
Principal member R2 184
Dependant R1 848
Child dependant <26 years *R636

* You only pay for two children younger than 18 years on the Dimension Prime range, 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.

Monthly contribution

Member Subscription
Principal member R2 730 
Dependant R2 316
Child dependant <26 years *R798

* You only pay for two children younger than 18 years on the Dimension Prime range, 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.

 

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)*

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)
  • 1 HPV vaccine for beneficiaries aged 10 to 26 years (3 injections in the course of one year, once per lifetime; administering fee at Dis-Chem or Clicks pharmacy clinics included)
  • 1 Pneumovax vaccine 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)

    HEALTHPRINT WELLNESS PROGRAMME 

    HealthPrint is an online wellness programme that supports you with relevant health information through every life stage.  You can also: 

    • View, update and share your health information and results of your health assessment via the site
    • Add your activity tracker and view your performance
    • Join Medihelp MultiSport, receive sports gear at a discounted price and participate as part of the Medihelp team in supported events
    • Join lifestage-specific programmes such as the pregnancy and baby programme and receive added value.

    Medihelp's wellness programme

    COPD-Chronic obstructive pulmonary disease
    FOBT-Faecal occult blood test
    HPV-Human papilloma virus
    BMI-Body mass index
     * 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 800 per case
    • Transport by air
    100% of the MT
    R11 800 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

    Dimension Prime 3 Network 
    DSP applies

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

    • Speech therapy
    • Occupational therapy
    • Physiotherapy
    100% of the MT
    M = R1 650 per year
    M+ = R2 200 per year
    Prostheses Click 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 fees
    • Equipment
    • Material and medicine
    100% of the MT
    R11 350 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

    Member pays the first R1 500 per examination

    ORGAN TRANSPLANTS (PMB only)
    Subject to pre-authorisation and clinical protocols

    100% of the cost
    Unlimited
    • Cornea implants
    100% of the MT
    R24 750 per implant per year

    PHYSIOTHERAPY, OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES
    In hospital

    100% of the MT
    Unlimited
    OXYGEN
    In hospital
    100% of the MT
    Unlimited

    NEUROSTIMULATORS
    Subject to pre-authorisation and clinical protocols

    • Device and components
    100% of the MT
    R95 750 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
    R320 per admission

    PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION
    Subject to pre-authorisation, services rendered in an approved/ network 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 institution
    • Outpatient consultations
    100% of the MT
    R25 150 per beneficiary per year
    (maximum R33 700 per family per year)

    ONCOLOGY*
    Subject to pre-authorisation and registration on the Medihelp Oncology Management Programme. Protocols and DSP (ICON) apply

    • Radiotherapy
    • Brachytherapy
    • Chemotherapy and associated adjuvant medicine (medicine subject to the MORP)
    • Bone marrow/ stem cell transplants (subject to protocols)
    100% of the cost
    DSP: ICON

    HOSPICE SERVICES AND SUB-ACUTE CARE FACILITIES AS AN ALTERNATIVE TO HOSPITALISATION
    Subject to pre-authorisation, and 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 procedure
    100% of the MT
    Unlimited
    • Laparoscopic procedure

    100% of the MT

    Hospitalisation:

    R15 000 per beneficiary

    PROSTATECTOMY
    Subject to pre-authorisation

    • Conventional or laparoscopic procedure
    100% of the MT
    Unlimited
    • Robotic assisted laparoscopic procedure

    100% of the MT

    Hospitalisation:

    R95 000 per beneficiary

    CDL-Chronic Diseases List
    CT-Computerised tomography
    EMS-Emergency medical services
    ICON-Independent Clinical Oncology Network
    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
    -Member 
     
    * 98% of all oncology cases qualify for prescribed minimum benefits (PMB), which Medihelp will cover at 100% of the cost in terms of the Act, provided that oncology is rendered by oncologists within the Independent Clinical Oncology Network (ICON) according to their protocols. Oncology outside ICON or that deviates from the protocols is subject to deductibles. 

    Internally implanted prostheses

    DescriptionBenefit
    INTERNALLY IMPLANTED PROSTHESES
    All hospital admissions and prostheses are subject to pre-authorisation, protocols and case management

    • EVARS prosthesis

    100% of the MT


    R111 800 per beneficiary per year
    • Vascular/ cardiac prosthesis
    R47 900 per beneficiary per year
    • Health-essential functional prosthesis

      • Hip, knee and shoulder replacements*
        Protocols apply
    R53 050 per beneficiary per year

    In case of acute injury where replacement is the only clinically appropriate treatment modality

    Hospitalisation:
    100% of the MT

    Prosthesis:
    Health-essential functional prosthesis benefits apply (non-PMB cases)
    • Intra-ocular lenses
    Sub-limit subject to health-essential functional prosthesis benefit
    2 lenses per beneficiary per year
    R3 600 per lens
    • Implantable hearing devices (including devices and components)
    R90 000 per beneficiary per year
    • Prosthesis with reconstructive or restorative surgery
      In and out of hospital
    R8 300 per family per year

    • External breast prostheses
      In and out of hospital
    DSP-Designated service provider
    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
     
    *Benefit not applicable to wear and tear

    Day-to-day benefits

    DescriptionBenefit
    GPs AND SPECIALISTS

    Consultations and follow-up consultations

    100% of the MT
    M = R5 700 per year
    M+1 = R9 550 per year
    M+2 = R11 700 per year
    M+3+ = R12 600 per year


    PHYSIOTHERAPY
    Treatment and material
    CLINICAL PSYCHOLOGY AND PSYCHIATRIC NURSING
    OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES
    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
    Generic medicine
    • PMB chronic medicine
      Subject to pre-authorisation and registration on Medihelp’s PMB medicine management programme
    100% of the MHRP

    Dimension Prime 3 Network
    DSP & formulary apply
    OXYGEN
    Out of hospital
    Subject to pre-authorisation, clinical protocols and services prescribed by a medical doctor
    100% of the MT
    Unlimited
    PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES
    Out of hospital
    Subject to clinical protocols and requested by a medical doctor
    100% of the MT
    M = R2 450 per year
    M+ = R3 450 per year

    STANDARD RADIOLOGY
    Out of hospital
    Subject to clinical protocols and requested by a medical doctor or chiropractor (black and white X-rays only) 
    EXTERNAL PROSTHESES, MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES
    Services in and out of hospital
    • Artificial eyes

    100% of the MT
    R4 080 per family per
    3-year cycle

    • Speech and hearing aids
    100% of the MT
    R4 080 per family per
    3-year cycle
     
    • Artificial limbs
    100% of the MT
    R4 080 per family per
    3-year cycle
    • Wheelchairs
    100% of the MT
    R4 080 per family per
    3-yearcycle
    • Medical appliances
    100% of the MT
    R1 100 per family per year
    • Hyperbaric oxygen treatment
      In and out of hospital
    • Stoma components
    • Incontinence products/ supplies
    100% of the MT
    Unlimited
    • CPAP apparatus
      Prescribed by a medical doctor
    • Subject to pre-authorisation and protocols
    100% of the MT
    R8 400 per beneficiary per
    24-month cycle
    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
    R600 per beneficiary for a frame and/ or lens enhancements per 24-month cycle
    • Lenses (one pair of standard clear Aquity lenses)
    Single vision, bifocal or multifocal (paid at the cost of bifocal lenses) lenses per beneficiary per 24-month cycle
    • Contact lenses
    R1 000 per beneficiary per 24-month cycle
    DENTAL SERVICES
    Subject to Denis 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 5-13 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)
    • 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 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 Denis managed care protocols
    • Partial metal frame dentures

    100% of the MT
    1 partial frame (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
    1 crown per family per year, once per tooth in a

    5-year period

    • 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
    R8 230 per beneficiary from 9-18 years per lifetime 
    Payment only 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
    PPN -Preferred Provider Negotiators
    PMB -Prescribed minimum benefits 
    MT-Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price
    -Member 

    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.

    DIMENSION PRIME 3 NETWORK
    • Members of the Dimension Prime 3 network option 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 network.  It is advisable for chronic medicine users to rather choose the alternative non-network option.

    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)
      • Dental procedures under conscious sedation (sedation costs) in the dentist's chair (managed care protocols apply)
      • Specialised dental services
        • Crowns and bridges
        • 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.


    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

    PROCEDURE-SPECIFIC DEDUCTIBLES
    There are a limited number of low-incidence procedures that require a procedure-specific payment.

    DescriptionBenefit
    BACK AND NECK FUSION
    Member pays the first R7 850 
    Balance paid at 100% of the MT


    ENDOSCOPIC PROCEDURES
    There are only four endoscopic procedures where a member is required to contribute to the cost. If the procedure is performed in the doctor’s rooms it will significantly reduce or eliminate that expense. These benefits apply to non-network and network options.

    DescriptionBenefit
    • In the doctor’s rooms
      • Gastroscopy
      • Colonoscopy
    Medihelp pays 100% of the MT
    • In hospital
      • Gastroscopy
      • Colonoscopy
      • Arthroscopy
      • Sigmoidoscopy
    Member pays the first R2 800 per admission
    Balance paid at 100% of the MT


    DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA
    These benefits rendered in hospital are subject to pre-authorisation and Denis managed care protocols.  Procedures are paid at 100% of the Medihelp tariff (MT).  These benefits apply to non-network and network options.

    DescriptionBenefit

    In hospital

    • Removal of impacted teeth
    • Extensive dental treatment for children younger than 5 years - once per lifetime

    Member pays the first R800 per admission
    Balance paid at 100%of the MT 


    SPECIALISED RADIOLOGY 
    Services rendered in and out of hospital must be requested by a specialist.  Benefits are subject to clinical protocols and the deductibles below.

    DescriptionBenefit
    • MRI and CT imaging (subject to pre-authorisation)
    • Angiography
    Member pays the first R1 500 per examination 
    Balance paid at 100% of the MT

    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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