Medihelp Prime 3 Network medical aid plan: 2020

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Prime 3 Network
2020 Costs:
Total Cost pm:

Main member:

R2,964

Adult:

R2,508

Child:

R864
Savings (per year):
  • No savings option on this plan
Extended Fund: RM = R9,450
M1 = R15,000
M2= R17,700
M3= R18,700
R R



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IN HOSPITAL PROCEDURES:
Prime 3 Network
Scheme Benefits: Notes and Links:
non-Network Specialists:
network Specialists:
  • 100% scheme rate
non-Network GPs:
  • 100% scheme rate
network GPs:
  • 100% scheme rate
Hospital Choice:
  • Choose a Network Hospital
Penalty for using other hospital:
  • 35% co-payment if you voluntarily choose another hospital
  • n/a
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: R9,100 co-payment
  • In-hospital dentistry for children younger than 5yrs and removal of impacted teeth: R960 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: R2,100 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:
  • From day-to-day benefits
  • Both the Blue Plan and Red Plan gap cover will pay up to R10,000 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 R165,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R165,000 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 3 Network
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
Extended Fund: RM = R9,450
M1 = R15,000
M2= R17,700
M3= R18,700
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:
    From day-to-day benefit
  • See Primary Health Care benefit above
Childcare:
Specialists consultations:
    From day-to-day benefit
  • See Primary Health Care benefit above
Pathology:
    From day-to-day benefit
  • See Primary Health Care benefit above
General radiology:
    From day-to-day benefit
  • See Primary Health Care benefit above
Specialised radiology:
  • R1,650 co-payment, in or out of hospital, unless PMB
Supplementary Services: (Physio, etc)
  • From day-to-day 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 3 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 3 Network
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • R263,500 per family per year



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DENTISTRY:
Prime 3 Network
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard Dentistry: paid by scheme.
  • Includes:
    • 2 annual checkups
    • X-rays. (Extra-oral 1 every 3 years)
    • 2 annual scale and polish treatments per person
    • Fissure sealants for under 16yr olds
    • Fluoride treatments for children 5-13yrs
    • One filling per tooth per year
    • Extractions and root canals
    • Removalof impacted teeth
    • Extensive treatment of children, under sedation
    • Plastic dentures, 1 set per person every 4 years
Specialised Dentistry:
  • Partial metal frame dentures: 1 frame per person every 5 years
  • Crowns and bridges: 1 crown per family per year
  • Implants: No benefit
  • Peridontal treatment
In-Hospital Dentistry:
  • Maxilo-facial surgery: 100% scheme rate
Orthodontics:
  • R9,000 per person per lifetime, Under 18 yrs only. Paid by scheme.
Maxillo Facial Surgery:
  • 100% scheme rate, paid by scheme



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MEDICATION:
Prime 3 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:
  • From day-to-day benefit
  • 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:
  • From day-to-day benefit
Birth Control:
  • From day-to-day benefits
On Discharge:
  • R350 per admission
Biological:
  • No benefit, unless PMB level of care



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OPTOMETRY:
Prime 3 Network
Scheme Benefits: Notes and Links:
Optometry:
Limit:Paid by scheme, every 2 years
Consult:1 per person
Frames:R800 per person
Single lenses1 set per person
Bifocals:1 set per person
Multifocals1 set per person
ContactsR1,185 per person
Refractive Surgery:No benefit



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MENTAL HEALTH:
Prime 3 Network
Scheme Benefits Notes and Links:
In-hospital:
  • R29,300 per person and R39,300 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 3 Network
Scheme Benefits Notes and Links:
General Appliances:
  • Medical Appliances, hyperbaric oxygen: R1,250
  • 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:



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WELLNESS/PREVENTATIVE BENEFITS:
Prime 3 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 3 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) or external breast prostheses, (in and out of hospital): R9,150 per family per year
  • Cochlear implants: R99,800 per person
  • Artificial eyes: R4,500 per family, every 3 years
  • Artificial limbs: R4,500 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