Medihelp Prime 1 Network medical aid plan: 2020

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Prime 1 Network
2020 Costs:
Total Cost pm:

Main member:

R1,626

Adult:

R1,338

Child:

R492
Savings (per year):
  • No savings option on this plan
Extended Fund: RM = R1,200
M1 = R2,400
R R



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IN HOSPITAL PROCEDURES:
Prime 1 Network
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • The Blue Plan gap cover will increase this to 500% scheme rate
network Specialists:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
non-Network GPs:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
network GPs:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Hospital Choice:
  • Choose a Network Hospital
Penalty for using other hospital:
  • 35% co-payment if you voluntarily choose another hospital
Specialised Radiology:
  • R1,650 co-payment
  • In and out of hospital
Supplementary Services: (Physio, etc)
  • Up to 100% scheme rate
  • Professional services for up to 30 days after discharge following hospital admission: speech therapy, occupational therapy and physiotherapy. M =R1,800 and M+ =R2,500
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • Cornea implants: R28,800 per implant
  • Otherwise, unlimited
Co-payments:
  • Back and neck fusion: R11,600 co-payment
  • In-hospital dentistry for children younger than 5yrs and removal of impacted teeth: R3,300 co-payment, with dentist's account paid out of pocket
  • Gastroscopy and Colonoscopy:
    • in doctor's rooms: no co-payment
    • in day hospital: R2,100 co-payment
    • in-hospital: R3,200 co-payment
  • Specialised radiology (MRIs and CT Scans): R1,650 co-payment
  • Co-payments paid by you or your gap cover
Alternatives to hospitals:
  • Hospice and sub-acute facilities: paid by scheme, subject to authorisation
  • Private nursing: paid by scheme, subject to authorisation
Casualty:
  • No benefit, unless PMB
  • Both the Blue Plan and Red Plan gap cover will pay up to R20,000 per person for unpaid casualty costs in event of emergency
Other:
  • Robotic assisted laparoscopic procedure for prostatectomy: R111,000 per person
  • Neurostimulators: R111,900 per person
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R157,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R157,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)



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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Prime 1 Network
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
Extended Fund: RM = R1,200
M1 = R2,400
R R
General info:
  • Consider getting Primary Health Care (PHC) (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
GP consultations:
  • M= R1,200 and M+ =R2,400. Thereafter only PMBs.
  • Shared with GPs, specialists, physio, acute meds, otc meds
  • See Primary Health Care benefit above
Childcare:
Specialists consultations:
  • See GP benefit, above
  • See Primary Health Care benefit above
Pathology:
  • No benefit
  • See Primary Health Care benefit above
General radiology:
  • No benefit
  • See Primary Health Care benefit above
Specialised radiology:
  • R1,650 co-payment, in or out of hospital, unless PMB
Supplementary Services: (Physio, etc)
  • Physiotherapy: shared with GP consult benefit
  • Also, speech therapy, occupational therapy and physiotherapy for up to 30 days after discharge following hospital admission. Limited to M =R1,800 and M+ =R2,500



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MATERNITY BENEFITS:
Prime 1 Network
Scheme Benefits Notes and Links:
Hospital stay:
  • Hospital delivery: 100% scheme rate
  • Home delivery: R13,000per event
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
  • 12 consults, paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme



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CANCER (ONCOLOGY):
Prime 1 Network
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • R210,800 per family per year



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DENTISTRY:
Prime 1 Network
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Removal of impacted teeth
  • Otherwise, no benefit
  • Consider getting Primary Health Care (medical insurance) that will cover you for a lot of out of hospital claims, including standard dentistry like scaling, polishing, fillings, extractions, root canals and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Specialised Dentistry:
  • No benefit
In-Hospital Dentistry:
  • Maxilo-facial surgery: No benefit, unless PMB
Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • No benefit, unless PMB



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MEDICATION:
Prime 1 Network
Scheme Benefits: Notes and Links:
Chronic:
  • All medical aid plans pay for treatment of the 27 CDL conditions as required by law. This includes medicine as well as GP or specialist consults, tests etc. Find out more
  • If you voluntarily use medicine that is not on Medihelp's list ("formulary"), you pay a 40% co-payment
Acute (presrcibed) medication:
  • M= R1,200 and M+ =R2,400
  • Shared with GPs, specialists, physio, acute meds, otc meds, contraceptives, vacciness, herbal and homeopathic meds
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Over-the-counter:
  • M= R1,200 and M+ =R2,400
  • Shared with GPs, specialists, physio, acute meds, otc meds, contraceptives, vacciness, herbal and homeopathic meds
Birth Control:
  • M= R1,200 and M+ =R2,400
  • Shared with GPs, specialists, physio, acute meds, otc meds, contraceptives, vacciness, herbal and homeopathic meds
On Discharge:
  • R350 per admission
Biological:
  • No benefit, unless PMB level of care



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OPTOMETRY:
Prime 1 Network
Scheme Benefits: Notes and Links:
Optometry:
Limit:No benefit
Consult:n/a
Frames:n/a
Single lensesn/a
Bifocals:n/a
Multifocalsn/a
Contactsn/a
Refractive Surgery:n/a
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here



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MENTAL HEALTH:
Prime 1 Network
Scheme Benefits Notes and Links:
In-hospital:
  • R19,300 per person and R29,300 per family
Out-of-hospital:
  • See above
Trauma:
  • PMB conditions are covered for in and out of hospital treatment. For a full list see here.
  • Example of PMB condition: Acute stress disorder accompanied by recent significant trauma, including physical or sexual abuse. Treatment includes hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts



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OTHER BENEFITS:
Prime 1 Network
Scheme Benefits Notes and Links:
General Appliances:
  • Medical Appliances, hyperbaric oxygen: No benefit
  • Stoma products and urine bags: paid by scheme
  • CPAP apparatus: R9,700 per person every two years
1.1. Hearing Aids:
  • R4,700 per family every 3 years, paid by scheme
1.2. Wheelchairs:
  • R4,700 per family every 3 years, paid by scheme
Dialysis:
  • Unlimited
International Insurance:
  • Transport by road outside RSA: R2,050 per event
  • Transport by air outside RSA: R13,700 per event
Other:
  • Oxygen out-of-hospital: paid by scheme



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WELLNESS/PREVENTATIVE BENEFITS:
Prime 1 Network
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered
Pneumonia vaccines:
  • Covered, 55yrs+
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, every 3 years
Mammogram:
  • Covered, 40yrs+, every 2 years
PAS Test:
  • Covered, 40yrs+
HIV Test:
  • Covered
Other:
  • FOBT, 50yrs+
  • Bone density, women 50yrs+
  • Tetanus vaccine
  • HPV vaccine, 10-26 yrs



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PROSTHETICS:
Prime 1 Network
Scheme Benefits: Notes and Links:
Overal Limit: Most non-PMB sublimits are increased by gap cover, if authorised by medical aid
  • EVARS prosthesis: R34,600
  • Vascular/cardiac prosthesis: R34,600
  • Health-essential functional prosthesis: R23,000. This includes non-PMB hip, knee and shoulder replacements, with no benefit for wear and tear
  • Intra-ocular lenses: R4,150 per lens, 2 lenses per beneficiary per year and subject to health-essential functional prosthesis benefit (above)
  • Prosthesis with reconstructive or restorative surgery and/or external breast prostheses (in and out of hospital): R4,250 per family per year
  • Cochlear implants: No benefit
  • Artificial eyes: R4,700 per family, every 3 years
  • Artificial limbs: R4,700 per family, every 3 years
Sub-limits:
  • Up to 100% scheme rate



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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised