Medihelp Plus 2017

Medihelp Plus - 2017

from R6 936 per month

 

Medihelp Plus offers the ultimate comprehensive cover. Over and above excellent cover for medical emergencies, private hospitalisation and preventive care, you have ample benefits for diverse day-to-day medical services to ensure that your and your loved ones’ health needs are met.

Monthly contribution

Member Subscription
Principal member R6 936 
Dependant R6 936 
Child dependant <26 years R1 728 

 

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)
  • HPV vaccine once per lifetime – administering fee at Dis-Chem or Clicks pharmacy clinics included
    • 10 to 15 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)

    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
     * These benefits are not available if you have been registered for a chronic/PMB condition, as it can no longer be considered as preventive care.

    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

    EMSEMERGENCY 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
    • Ward medicine
    • Consultations, surgery and anaesthesia
    100% of the MT
    Unlimited

    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
    Only on request of a specialist and subject to clinical protocols

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


    100% of the MT
    Unlimited for MRI, CT imaging and angiography

    R19 100 per case for PET scans (non-PMB cases)

    OXYGEN
    In hospital
    100% of the MT
    Unlimited 
    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 

    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 chronic medicine) 
    100% of the MT
    R510 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
    R36 950 per beneficiary per year to a maximum of 

    R50 350 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 MT
    Unlimited
    DSP: Icon 
    SUB-ACUTE CARE FACILITIES AND HOSPICE SERVICES 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

    ORGAN TRANSPLANTS
    Subject to pre-authorisation and clinical protocols

    100% of the MT
    Unlimited
    • Cornea implants
    100% of the MT
    R24 750 per implant per year
    ENDOSCOPIC PROCEDURES
    In hospital and performed in doctor’s rooms
    (including material)
    100% of the MT
    Unlimited
    DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA
    In hospital
    Subject to pre-authorisation and Denis managed care protocols
    100% of the MT
    Only for removal of impacted teeth and extensive dental treatment for children younger than 5 years − once per lifetime

    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
    DSP-Designated service provider
    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
     
    * 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
    R53 050 per beneficiary per year
    • Intra-ocular lenses
    Sub-limit subject to health-essential functional prosthesis benefit
    2 lenses per beneficiary per year
    R3 600 per lens
    • Prosthesis with reconstructive or restorative surgery and external breast prostheses
      In and out of hospital
    R8 300 per family per year

    • Implantable hearing devices (including devices and components)
    R90 000 per beneficiary per year
    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

    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 100 per beneficiary per year, pooled per family per year 
    PHYSIOTHERAPY
    Treatment and material
    CLINICAL PSYCHOLOGY AND PSYCHIATRIC NURSING
    Services rendered in and out of hospital
    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

    R5 350 per beneficiary per year, pooled per family per year
    • 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
    Generic medicine

    R15 600 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
    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
    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
    2 partial frames (upper and 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
      Subject to pre-authorisation and orthodontic needs analysis
      (Only one beneficiary per family may begin orthodontic treatment per calendar year)
    100% of the MT
    R13 500 per beneficiary from 9-18 years old per lifetime 
    Payment only from date of authorisation
    • Periodontal treatment
      Subject to registration on the Perio Programme
      Conservative nonsurgical therapy only
    100% of the MT
    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 
    EXTERNAL PROSTHESES, MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES
    Services in and out of hospital
    • Artificial eyes

    100% of the MT
    R13 560 per beneficiary per 3-year cycle

    • Speech and hearing aids 
    100% of the MT
    R13 560 per beneficiary per 3-year cycle
    • Artificial limbs
    100% of the MT
    R7 440 per beneficiary per 3-year cycle
     
    • Wheelchairs
    100% of the MT
    R7 440 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 650 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 650 per beneficiary per 3-year period 
    • CPAP apparatus
      Prescribed by a medical doctor and subject to pre-authorisation and protocols
    100% of the MT
    R8 400 per beneficiary per 24-month cycle 
    OXYGEN
    Out of hospital
    Subject to pre-authorisation, clinical protocols and services prescribed by a medical doctor 
    100% of the MT
    Unlimited
    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 
    PPN -Preferred Provider Negotiators 
    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-AUTHORISATIONS IS IMPORTANT
    Always pre-authorise the services listed below:
    • 100% of the MT 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
        • 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 applies.

    • 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

    Refer to the brochure for more information.

    MMAP-Maximum Medical Aid Price
    MT-Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

    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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