Medihelp Unify medical aid plan: 2020

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Unify
Total Cost pm:

Main member:

R2,598

Adult:

R2,136

Child:

R780
Savings: R7,776 R6,408 R2,304

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IN HOSPITAL PROCEDURES:
Unify
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • 100% scheme rate
network Specialists:
  • 100% scheme rate
non-Network GPs:
  • 100% scheme rate
network GPs:
  • 100% scheme rate
Hospital Choice:
  • Choose any hospital
Penalty for using other hospital:
  • n/a
  • 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: R10,400 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 or from savings
  • Gastroscopy and Colonoscopy:
    • in doctor's rooms: no co-payment
    • in day hospital: R2,750 co-payment
    • in-hospital: R3,850 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):
Unify
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
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 , unless PMB.
  • See Primary Health Care benefit above
Childcare:
  • R1,000 for GP consults for children 2-12, once day-to-day benefit is finished
Specialists consultations:
    From day-to-day benefit , unless PMB.
  • 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:
Unify
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:
  • From day-to-day benefits
Scans:
  • From day-to-day benefits

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CANCER (ONCOLOGY):
Unify
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • R231,800 per family per year

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DENTISTRY:
Unify
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard dentistry: from day-to-day 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:
  • Specialised dentistry: from day-to-day benefit
In-Hospital Dentistry:
  • From day-to-day benefit
Orthodontics:
  • From day-to-day benefit
Maxillo Facial Surgery:
  • From day-to-day benefit, unless PMB

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MEDICATION:
Unify
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 benefits
Birth Control:
  • From day-to-day benefits
On Discharge:
  • From day-to-day benefits
Biological:
  • No benefit, unless PMB level of care

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OPTOMETRY:
Unify
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
  • 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:
Unify
Scheme Benefits Notes and Links:
In-hospital:
  • R24,400 per person and R33,500 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:
Unify
Scheme Benefits Notes and Links:
General Appliances:
  • Medical Appliances and CPAP apparatus: paid from day-to-day savings
  • Hyperbaric oxygen: R630 per family
  • Stoma products and urine bags: paid by scheme
1.1. Hearing Aids:
  • From day-to-day benefit
1.2. Wheelchairs:
  • From day-to-day benefit
Dialysis:
  • PMBs only
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:
Unify
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered
Pneumonia vaccines:
  • No benefit
Biometric Screening:
  • Covered
Child Immunisation:
  • No benefit
Pap Smear:
  • Covered, every 3 years
Mammogram:
  • No benefit
PAS Test:
  • No benefit
HIV Test:
  • Covered
Other:
  • Tetanus vaccine

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PROSTHETICS:
Unify
Scheme Benefits: Notes and Links:
Overal Limit: Most non-PMB sublimits are increased by gap cover, if authorised by medical aid
  • EVARS prosthesis: R130,600
  • Vascular/cardiac prosthesis: R55,900
  • Health-essential functional prosthesis: R61,900. 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, (in and out of hospital): R9,600 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:

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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