• Benefits, in-hospital, Medshield Plan, out-hospital, Scheme Plans

Medshield Premium Plus:
in-and-out of hospital benefits (2025)

Contents:

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

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 Providers. Where stipulated, you must use 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.

Monthly Costs (2026)

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

Medshield:Premium Plus (2026)
Main member: Adult member: Child member:
Total Cost pm:
  • R9,489
  • R8,691
  • R1,815
Savings:
  • R28,464
  • R26,076
  • R5,448
Self Payment Gap:
(What you need to pay out of pocket before you can access the "Above Threshold" benefit)
  • R5,036
  • R5,924
  • R552
"Above Threshold" benefit (ATB):
Additional cover the scheme makes available to you, once you've paid the self payment gap.
  • 7,500
  • 5,500
  • 3,700
Children Rates:
  • Under 21yrs, or students under 28 yrs
  • Only pay for 3 children (excl students)
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In-hospital Procedures (2025):

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

Medshield: Premium Plus
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
GPs and Specialists:
  • Paid in full
 Gap Cover:
Can push payout up to 700% scheme rate
(Plans coming soon)
Hospital Choice:
  • Any hospital
Penalty for using other hospital:
  • n/a
 Gap Cover:
Can cover the penalty in full
(Plans coming soon)
Co-payments: In-hospital or Day Clinic:
  • Endoscopic Procedures: R1,000 co-payment
  • Wisdom teeth extraction, day clinic: R800 co-payment
  • Functional Nasal surgery: R1,000 co-payment
  • Laparoscopic, Arthroscopic procedures: R2,000 co-payment
  • Wisdom Teeth, Apicoectomy: R2,000 co-payment
  • Hernia repair: R3,000 co-payment
  • Back and neck surgery: R4,000 co-payment
  • Nissen Fundoplication R5,000 co-payment
  • Hysterectomy: R5,000 co-payment
Note:
  • 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, especially if you don't use a DSP for a PMB or when buying medicine.
 Gap Cover:
Can cover most co-payments
(Plans coming soon)
Specialised Radiology:
  • CT scans, MUGA, MRI, Radio Isotope studies: R33,100 per family, in and out-of-hospital
  • PET scans: 2 scans per family, for oncology
Gap Cover:
Can cover most co-payments and increase sublimits
(Plans coming soon)
Scopes:
  • No co-payment if done in rooms
 Gap Cover:
Can cover most co-payments and increase sublimits
(Plans coming soon)
Supplementary Services: (Physio, etc)
  • Physio: R3,000 per person, then from day-to-day benefit
Transplants:
  • Covered
  • Corneal Grafts: : up to R51,900
Dialysis:
  • Covered
Exclusions:
  • NB: See scheme's rules for all exclusions. All schemes have plenty!
 Gap Cover:
Coming soon
Alternatives to hospitals:
  • Physical rehab, sub-acute facilities, nursing, hospice: R166,000 per family
  • Terminal care: R60,000 per family
Casualty/ER:
  • 2 facility fees per family
  • Thereafter, from day-to-day benefit
Gap Cover:
Can cover ER claims
(Plans coming soon)
Other: .
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)

Medshield: Premium Plus
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
Main Member: Adult: Child:
Savings:
  • R28,464
  • R26,076
  • R5,448
Self Payment Gap:
(What you need to pay out of pocket before you can access the "Above Threshold" benefit)
  • R5,036
  • R5,924
  • R552
"Above Threshold" benefit (ATB):
Additional cover the scheme makes available to you, once you've paid the self payment gap.
  • 7,500
  • 5,500
  • 3,700
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
  • When savings is depleted, 2 more visits per person
  • Emergency and chronic: Unlimited, once savings is finished
  • Nurse consult: Unlimited
  • Nurse-led videomed consult: Unlimited
Childcare:
  • Paediatric: 2 consults, under age of 2
  • Immunisation: Covered up to 12 yrs
 Gap Cover:
Can pay for child ER visits
(Plans coming soon)
Specialist consultations:
  • From day-to-day benefit
  • 30% co-payment if non-DSP is used
Pathology:
  • From day to day benefits
  • Not paid from Above Threshold Benefit
General radiology:
  • From day to day benefits
  • Not paid from Above Threshold Benefit
Specialised radiology:
  • CT scans, MUGA, MRI, Radio Isotope studies: R33,100 per family, in and out-of-hospital
  • PET scans: 2 scans per family, for oncology
Gap Cover:
Can pay co-payments and increase sublimits
(Plans coming soon)
Scopes:
  • No co-payment if done in rooms
 Gap Cover:
Can pay co-payments and increase sublimits
(Plans coming soon)
Supplementary Services: (Physio, etc)
  • From day to day benefit
General Appliances:
  • In and out of hospital: R17,500 per family
  • Stoma Products: Unlimited, if pre-authorized
1.1. Hearing Aids:
  • From appliance limit
1.2. Wheelchairs:
  • From appliance limit
PMBs = Prescribed Minimum Benefits (more info) | DSP = Designated Service Provider

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.

Medication Benefit (2025):

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

Medshield: Premium Plus
Assume scheme pays all these costs, unless otherwise stated
Main Member: Adult: Child:
Savings:
  • R28,464
  • R26,076
  • R5,448
Self Payment Gap:
(What you need to pay out of pocket before you can access the "Above Threshold" benefit)
  • R5,036
  • R5,924
  • R552
"Above Threshold" benefit (ATB):
Additional cover the scheme makes available to you, once you've paid the self payment gap.
  • 7,500
  • 5,500
  • 3,700
Other Day-to-Day Funds:
Chronic:
  • Additional 54 conditions
  • R18,400 per person and R36,800 per family
Acute (prescribed) medication:
  • From day-to-day benefit
  • Not paid from Above Threshold benefit
Over-the-counter:
  • From day-to-day benefit
  • R1,000 per family if paid from Above Threshold
Birth Control:
  • IUD and alternatives: 1 device, every 2-5 years
  • Pills: R225 per female per month
On Discharge:
  • R1,000 per admission
Biological:
  • Specialised oncology drugs: R437,250 per family
PMBs = Prescribed Minimum Benefits (more info) | DSP = Designated Service Provider

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.

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