Medihelp MedPrime:
in-and-out of hospital benefits (2025)

This page has overview information on: Costs, In-hospital, Out of Hospital and Medicine benefits for Medihelp MedPrime. Please consult and verify with the scheme or your broker for full benefits, and an explanation of all the "fine print".

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Terminology:

• PMBs: Prescribed Minimum Benefits. You can read more about PMBs, see a list of all PMB conditions or read more what "PMB only" benefit means.
• DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
• Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
• All schemes have extensive exclusions. We've tried to list the non-common ones here, but please consult your scheme or broker to get the full list.

In-hospital Procedures (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Medihelp: MedPrime
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
GPs and Specialists:	100% scheme rate	Gap Cover: Can push payout up to 700% scheme rate (Plans coming soon)
Hospital Choice:	Any hospital Day procedure: Any Day hospital
Penalty for using other hospital:	Use of non-Day hospital for certain procedures: 35% penalty	Gap Cover: Can cover the penalty in full (Plans coming soon)
Co-payments:	Spinal Column surgery: R11,500 co-payment Endoscopic procedures, in day hospital (all scopes): R4,100 co-payment Dental procedures: R1,850 co-payment Specialized radiology: R1,700 co-payment Note: A co-payment is a fee your medical aid can insist you pay, regardless of how much the doctor/charges. It's not the same as an "excess" payment (which is when a doctor charges more than the medical aid rate). If you use a DSP (designated service provider), you never have to pay a co-payment for protocol treatment of a PMB (Prescribed Minimum Benefit). More info here There might be other co-payments if you don't use a DSP, especially if you are being treated for a PMB or when buying medicine.	Gap Cover: Can cover most co-payments (Plans coming soon)
Specialised Radiology:	MRI and CT scan: R25,000 per family with a R1,700 co-payment, in or out of hospital	Gap Cover: Can cover most co-payments and increase sublimits (Plans coming soon)
Scopes:	Endoscopic Procedures: R4,100 co-payment	Gap Cover: Can cover most co-payments and increase sublimits (Plans coming soon)
Supplementary Services: (Physio, etc)	100% scheme rate
Transplants:	PMBs only Cornea implants: R35,900 per implant
Dialysis:	Scheme rate, in and out of hospital
Exclusions:	NB: See scheme's rules for all exclusions. All schemes have plenty!	Gap Cover: Coming soon
Alternatives to hospitals:	Hospice as an alternative to hospitalisation: Covered Subacute care as an alternative to hospitalisation: Covered Private Nursing as an alternative to hospitalisation: Covered Palliative care: R28,800 per family
Casualty/ER:	From day to day benefit	Gap Cover: Can cover ER claims (Plans coming soon)
Other:	Speech therapy, OT and physio, post hospital care: R2,300 per person and R3,000 per family Wound care: R5,800 per family
PMBs= Prescribed Minimum Benefits (more info) | DSP= Designated Service Provider

Out-of-hospital Procedures (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Medihelp: MedPrime
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
Main Member: Adult: Child: Savings: R6,336 R5,400 R1,872 Extended Fund: Extra funds from the scheme for (mostly) out of hospital claims, over and above any savings account Main= R7,200 Main+1= R13,300 Other Day-to-Day Funds:
PMBs out of hospital:	All schemes must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here. This can include consults with specialists, blood or other tests, radiology and medicine PMB benefits must never be paid from your savings account Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here. See our Guide to PMBs for more information.
GP consultations:	From day to day benefit Once depleted, an additional R7,200 per person and R13,300 per family, shared with other claims
Childcare:	Conservative dentistry, for under 18yrs Paediatrician/GP/ENT: 2 consults, 0-2yrs Immunisations: Covered, up to 7yrs Flu shot: Covered	Gap Cover: Can pay for child ER visits (Plans coming soon)
Specialists consultations:	From day to day benefit Once depleted, an additional R7,200 per person and R13,300 per family, shared with other claims
Pathology:	From day to day benefit Once depleted, an additional R7,200 per person and R13,300 per family, shared with other claims
General radiology:	From day to day benefit Once depleted, an additional R7,200 per person and R13,300 per family, shared with other claims
Specialised radiology:	MRI and CT scan: R25,000 per family with a R1,200 co-payment, in or out of hospital	Gap Cover: Can pay co-payments and increase sublimits (Plans coming soon)
Scopes:	Endoscopic Procedures: R4,100 co-payment	Gap Cover: Can pay co-payments and increase sublimits (Plans coming soon)
Supplementary Services: (Physio, etc)	From day to day benefit Once depleted, an additional R7,200 per person and R13,300 per family, shared with other claims
General Appliances:	Appliances and hyperbaric oxygen : R1,600 per family Stoma components: Unlimited, paid by scheme CPAP apparatus: R11,900 per person, every 2 years paid by scheme
1.1. Hearing Aids:	R5,700 per family, every 3 years Paid by scheme
1.2. Wheelchairs:	R5,700 per family, every 3 years Paid by scheme
PMBs= Prescribed Minimum Benefits (more info) | DSP= Designated Service Provider

Medication Benefit (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Medihelp: MedPrime
Assume scheme pays all these costs, unless otherwise stated
Main Member: Adult: Child: Savings: R6,336 R5,400 R1,872 Extended Fund: Extra funds from the scheme for (mostly) out of hospital claims, over and above any savings account Main= R7,200 Main+1= R13,300 Other Day-to-Day Funds:
Chronic:	27 PMB conditions: Covered. You can see the full PMB list here.
Acute (prescribed) medication:	From day to day benefit Once depleted, an additional R7,200 per person and R13,300 per family, shared with other claims
Over-the-counter:	Care extender benefit: R510 for over the counter meds once you complete a health screening Otherwise, From day to day benefit
Birth Control:	Oral, injectable/implantable: R180 per month up to R2,350 per year IUD: R2,700 every 5 years
On Discharge:	R540 per admission
Biological:	PMBs only
View other benefits for this plan: In-hospital | Out-of-hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics You can also: Compare any two plans, side by side | View all the Medihelp plans, with costs and brief summary. Find all other open medical aid plans here.
PMBs= Prescribed Minimum Benefits (more info) | DSP= Designated Service Provider