Medihelp Dimension Prime 2 Network medical aid plan: 2019

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Prime 2 Network
2019 Costs:
Total Cost pm:

Main member:

R1,974

Adult:

R1,626

Child: Pay for max 2 children under 18yrs; all children 18-26yrs

R594
Savings: R3,528 R2,952 R1080
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IN HOSPITAL PROCEDURES:
Prime 2 Network
Scheme Benefits: Notes and Links:
Specialists:
  • Up to 100% scheme rate
  • You or gap cover pay the balance, if any
Gap Cover
  • Gap cover is available for this plan. Budget about R350 for a fully comprehensive gap cover that will increase the scheme rate to 500% and pay most co-payments and increase sublimits.
Hospital Choice:
  • Choose a Network Hospital, or 35% co-payment if you voluntarily choose another hospital
Specialised Radiology:
  • You or your gap pay R1,550 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. R1,750 per person and R2,400 per family
Transplants:
  • Cornea implants: R27,400 per implant
  • Otherwise, unlimited
Co-payments:
  • Back and neck fusion: R9,950 co-payment
  • In-hospital dentistry for children younger than 5yrs and removal of impacted teeth: R3,000 co-payment, with dentist's account paid out of pocket or from savings
  • Gastroscopy and Colonoscopy:
    • in doctor's rooms: no co-payment
    • in day hospital: R2,650 co-payment
    • in-hospital: R3,700 co-payment
  • Specialised radiology (MRIs and CT Scans): R1,600 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:
  • From day-to-day benefit, unless PMB
Other:
  • Robotic assisted laparoscopic procedure for prostatectomy: R105,400 per person
  • Neurostimulators: R106,200 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 R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 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.



OUT OF HOSPITAL BENEFITS (non-PMB):
Prime 2 Network
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: R3,528 R2,952 R1080
General info: 2019 Benefits coming November 9, 2018
GP consultations:
    From day-to-day benefit , unless PMB.
Childcare:
  • Children under a year receive 2 additional GP or specialist consults
Specialists consultations:
    From day-to-day benefit , unless PMB.
Pathology:
    From day-to-day benefit , unless PMB.
General radiology:
    From day-to-day benefit , unless PMB.
Specialised radiology:
  • R1,600 co-payment, in or out of hospital, unless PMB
Supplementary Services: (Physio, etc)
  • Physiotherapy: from day-to-day benefit
  • Also, speech therapy, occupational therapy and physiotherapy for up to 30 days after discharge following hospital admission. Limited to R1,750 per person and R2,400 per family
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MATERNITY BENEFITS:
Prime 2 Network
Scheme Benefits Notes and Links:
Hospital stay:
  • Hospital delivery: 100% scheme rate
  • Home delivery: R12,400 per event
Consultations:
  • 8 consults, paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme
  • One amniocentesis
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CANCER (ONCOLOGY):
Prime 2 Network
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • R220,000 per family per year for non-PMB cases
  • PMBs covered in full
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DENTISTRY:
Prime 2 Network
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard dentistry: from day-to-day benefit
Specialised Dentistry:
  • Specialised dentistry: from day-to-day benefit
In-Hospital Dentistry:
  • Maxilo-facial surgery: No benefit, unless PMB
Orthodontics:
  • From day-to-day benefit, 9-18 yrs only
Maxillo Facial Surgery:
  • From day-to-day benefit, unless PMB
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MEDICATION:
Prime 2 Network
Scheme Benefits: Notes and Links:
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for use of non-formulary:
Acute (presrcibed) medication:
  • From day-to-day benefit
Over-the-counter:
  • From day-to-day benefit
Birth Control:
  • From day-to-day benefit, unless PMB
On Discharge:
  • From day-to-day benefit
Biological:
  • No benefit, unless PMB level of care
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OPTOMETRY:
Prime 2 Network
Scheme Benefits: Notes and Links:
Optometry:
Limit:From day-to-day benefit
Consult:n/a
Frames:n/a
Single lensesn/a
Bifocals:n/a
Multifocalsn/a
Contactsn/a
Refractive Surgery:n/a
Notes:n/a
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MENTAL HEALTH:
Prime 2 Network
Scheme Benefits Notes and Links:
In-hospital: 2019 Benefits coming November 9, 2018
Out-of-hospital:
  • Psychiatry: See above
  • Psychology: paid from day-to-day benefit
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Trauma:
  • Netcare 911 phoneline
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OTHER BENEFITS:
Prime 2 Network
Scheme Benefits Notes and Links:
General Appliances:
  • Medical Appliances and CPAP apparatus: paid from day-to-day savings
  • Hyperbaric oxygen: R600 per family
  • Stoma products and urine bags: paid by scheme
  • No benefit
1.1. Hearing Aids:
  • From day-to-day benefit, unless PMB
1.2. Wheelchairs:
  • From day-to-day benefit, unless PMB
Dialysis:
  • Unlimited
HIV:
  • Post exposure prophylaxis in the event of sexual assault or accidental exposure to HIV
  • Paid by scheme
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport:
  • Netcare 911
International Insurance:
  • Transport by road outside RSA: R1,950 per event
  • Transport by air outside RSA: R13,000 per event
Other:
  • Oxygen out-of-hospital: paid by scheme
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WELLNESS/PREVENTATIVE BENEFITS:
Prime 2 Network
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered
Pneumonia vaccines:
  • Covered, 55yrs+
Back Rehabilitation Programme:
  • Covered
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered
Mammogram:
  • Covered, 40yrs+
PAS Test:
  • Covered, 40yrs+
HIV Test:
  • Covered
Other:
  • FOBT, 50yrs+
  • Bone density, 50yrs+
  • Tetanus vaccine
  • HPV vaccine, 10-26 yrs
What next?
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PROSTHETICS:
Prime 2 Network
Scheme Benefits: Notes and Links:
Overal Limit: Most non-PMB sublimits are increased by gap cover, if authorised by medical aid
  • EVARS prosthesis: R124,000
  • Vascular/cardiac prosthesis: R53,100
  • Health-essential functional prosthesis: R58,800. This includes non-PMB hip, knee and shoulder replacements, with no benefit for wear and tear
  • Intra-ocular lenses: R3,950 per lens, 2 lenses per beneficiary per year and subject to health-essential functional prosthesis benefit (above)
  • Prosthesis with reconstructive or restorative surgery, (in and out of hospital): R9,150 per family per year
  • External breast prostheses, (in and out of hospital): from day-to-day benefit
  • Cochlear implants: No benefit
  • Artificial eyes: day-to-day benefit
  • Artificial limbs: day-to-day benefit
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