September dimension range 2017

Transcription

1 September 2016 dimension range 2017

2 General disclaimers This brochure is intended for marketing purposes and contains only a summary of Medihelp s benefits. On joining Medihelp, members receive a welcome guide with detailed information and a relevant benefit brochure. In case of a dispute, the registered Rules of Medihelp apply, which are available on request. The information in this brochure is subject to approval by the Council for Medical Schemes. The content of this brochure may change from time to time. Please refer to Medihelp s website for an updated brochure or consult Medihelp s Rules for the latest information. We encourage you to seek financial advice about your healthcare cover by speaking to your financial adviser.

3 contents 1 why medihelp 2 benefits 10 benefit option comparison 23 supporting information 3 Summary of benefits 8 Additional insured benefits 9 Standard immunisation for children 9 Essential cover 11 Core benefits 15 Internally implanted prostheses 16 Day-to-day benefits 21 Deductibles 23 Dimension Prime hospital network 25 Our healthcare partners 26 Explanation of terms 27 Summary of exclusions 28 Contact us

4 why medihelp it s all about you Everyone is unique, but the need to secure our wellness is something we all share. That is why Medihelp has individualised our approach to fulfilling your healthcare needs individualised value 10 Benefit options a product range which differs in price & benefits A member application with an electronic membership card Videos to explain complex processes Multiple engagement opportunities through social and digital channels Consistent service on online and offline service platforms A dedicated call centre A walk-in service offered at our 5 offices Products and additional value to suit every stage of your life A secured website to change and view your Medihelp profile & benefits A 30 days post-hospital care benefit to help you recover Support and treatment programmes for a selection of specific illnesses Tight budget Three of our options have a quality network alternative at a discounted rate of at least 20% Peace of mind cover for trauma and emergencies No overall annual limit on hospital cover Larger family Only two children younger than 18 years pay a monthly premium on the Dimension Prime options, the rest receive free cover 2a sound healthcare investment Medihelp ticks all the boxes of a sound investment 111 A solvency level that has been consistently above the industry requirement years experience in the industry and a solid reputation AA- rating for our claims-paying ability, awarded by Global Credit Rating One of the largest open medical schemes in the industry Preventive care A menu of separate, additional preventive care benefits Health conscious An individualised, free wellness programme provides relevant support during every life stage Kids are grown up Get active Join Medihelp MultiSport for running, walking and cycling Child dependant rates apply until they are 26 years old Ask you adviser about the option specifically for fulltime students

5 benefits Summary of benefits Contribution table Additional insured benefits Essential cover 2

6 summary of benefits 3 Non-/ Non-/ Non-/ The best hospital plan in its price range and the ideal solution if you are healthy and responsibly want the assurance of hospital cover. Additional insured benefits add to its value and include a pooled day-to-day benefit, pregnancy and baby consultations as well as preventive care services. Save 22% in monthly premiums when choosing the network alternative. This option provides comprehensive hospital cover and a savings plan combined with insured benefits for GP consultations as well as pregnancy, baby, preventive and eye care benefits. The network alternative will save you 22% in premiums. Regarded as Medihelp s flagship option, is the solid choice for all your family s healthcare needs. It provides comprehensive insured cover for medical expenses incurred in and out of hospital as well as preventive care benefits. You can choose either the freedom of choice version of the option or opt for the network alternative at 20% less. is a comprehensive plan with a separate insured chronic medicine benefit, wellbalanced insured cover for day-to-day medical expenses as well as solid hospital cover. This option provides the peace of mind required by those with more extensive healthcare needs.

7 contribution table This table provides a guideline for contributions based on your family s composition. You pay child dependant rates for kids until they are 26 years old and you only pay for the first two children under 18 on the Dimension Prime range. Please note that late-joiner penalties and employer subsidies were not taken into consideration. Speak to your accredited adviser to obtain a more detailed quotation based on your information. Non-network Non-network Non-network Principal member R1 608 R1 260 R2 136 (R258 savings contribution included per month and R3 096 ) R1 668 (R204 savings contribution included per month and R2 448 ) R2 730 R2 184 R3 972 Dependant R1 320 R1 026 R1 746 (R210 savings contribution included per month and R2 520 ) R1 368 (R168 savings contribution included per month and R2 016 ) R2 316 R1 848 R3 714 Child dependant <26 years R486 R378 R642 (R78 savings contribution included per month and R936 ) R498 (R60 savings contribution included per month and R720 ) R798 R636 R1 080 R2 928 R2 286 R3 882 (R468 savings contribution included per month and R5 616 ) R3 036 (R372 savings contribution included per month and R4 464 ) R5 046 R4 032 R7 686 R2 094 R1 638 R2 778 (R336 savings contribution included per month and R4 032 ) R2 166 (R264 savings contribution included per month and R3 168 ) R3 528 R2 820 R5 052 R2 580 R2 016 R3 420 (R414 savings contribution included per month and R4 968 ) R2 664 (R324 savings contribution included per month and R3 888 ) R4 326 R3 456 R6 132 R3 414 R2 664 R4 524 (R546 savings contribution included per month and R6 552 ) R3 534 (R432 savings contribution included per month and R5 184 ) R5 844 R4 668 R8 766 R3 900 R3 042 R5 166 (R624 savings contribution included per month and R7 488 ) R4 032 (R492 savings contribution included per month and R5 904 ) R6 642 R5 304 R9 846 R3 900 R3 042 R5 166 (R624 savings contribution included per month and R7 488 ) R4 032 (R492 savings contribution included per month and R5 904 ) R6 642 R5 304 *You only pay for two children younger than 18 years on the Dimension Prime range, after which child dependant rates will apply from the beginning of the year following the year in which they turn 18, until they are 26 years old. If you join after January, your savings amount will be calculated by counting the remaining months in the year. 4

8 summary of benefits 5 Non-network Non-network Non-network HOSPITAL BENEFITS (NO OAL) HOSPITAL BENEFITS (NO OAL) HOSPITAL BENEFITS (NO OAL) HOSPITAL BENEFITS (NO OAL) Any hospital 106 network facilities Any hospital 106 network facilities Any hospital 106 network facilities Any hospital ESSENTIAL COVER Diagnosis, treatment and care costs of 270 PMB and 26 chronic conditions on the CDL DSPs & specialist network apply ESSENTIAL COVER Diagnosis, treatment and care costs of 270 PMB and 26 chronic conditions on the CDL DSPs & specialist network apply ESSENTIAL COVER Diagnosis, treatment and care costs of 270 PMB and 26 chronic conditions on the CDL DSPs & specialist network apply ESSENTIAL COVER Diagnosis, treatment and care costs of 270 PMB and 26 chronic conditions on the CDL DSPs & specialist network apply Core benefits POST-HOSPITAL CARE Up to 30 days after discharge SPECIALISED RADIOLOGY In and out of hospital Member pays the first R1 500 per examination Balance paid at POST-HOSPITAL CARE Up to 30 days after discharge SPECIALISED RADIOLOGY In and out of hospital Member pays the first R1 500 per examination Balance paid at POST-HOSPITAL CARE Up to 30 days after discharge SPECIALISED RADIOLOGY In and out of hospital Member pays the first R1 500 per examination Balance paid at POST-HOSPITAL CARE Up to 30 days after discharge SPECIALISED RADIOLOGY In and out of hospital Member pays the first R1 000 per examination Balance paid at TRAUMA-RELATED BENEFITS Including post-exposure prophylaxis in the event of sexual assault or accidental exposure to HIV TRAUMA-RELATED BENEFITS Including post-exposure prophylaxis in the event of sexual assault or accidental exposure to HIV TRAUMA-RELATED BENEFITS Including post-exposure prophylaxis in the event of sexual assault or accidental exposure to HIV TRAUMA-RELATED BENEFITS Including post-exposure prophylaxis in the event of sexual assault or accidental exposure to HIV EMS ROAD & AIR TRANSPORT (Netcare 911) within RSA 24-hour helpline & trauma counselling ROAD & AIR TRANSPORT (Netcare 911) within RSA 24-hour helpline & trauma counselling ROAD & AIR TRANSPORT (Netcare 911) within RSA 24-hour helpline & trauma counselling ROAD & AIR TRANSPORT (Netcare 911) within RSA 24-hour helpline & trauma counselling

9 summary of benefits Non-network Non-network Non-network Day-to-day benefits INSURED DAY-TO-DAY BENEFITS M = R1 050 M+ = R2 100 GPs, specialists, physiotherapy, acute and self-medication INSURED GP CONSULTATIONS M = 2 GP consultations M+ = 4 GP consultations INSURED OPTICAL BENEFITS Spectacles/contact lenses EMERGENCY DENTAL BENEFITS 2 emergency visits 2 extractions per visit Pulp amputation and/or removal: 2 per visit OTHER DAY-TO-DAY MEDICAL EXPENSES Paid from medical savings account INSURED DAY-TO-DAY POOLED BENEFITS M = R5 700 M+1 = R9 550 M+2 = R M+3+ = R GPs & specialists Clinical psychology & physiotherapy Supplementary health services Acute medicine & self-medication STANDARD RADIOLOGY AND PATHOLOGY BENEFITS M = R2 450 M+ = R3 450 INSURED DENTISTRY BENEFITS INSURED OPTICAL BENEFITS Spectacles/contact lenses INSURED DAY-TO-DAY POOLED BENEFITS M = R2 450 M+1 = R4 100 M+2 = R5 050 M+3+ = R6 100 GPs & specialists Clinical psychology & physiotherapy Supplementary health services CHRONIC MEDICINE BENEFITS (Non-PMB) M = R3 650 M+1 = R5 500 M+2 = R7 400 M+3+ = R7 950 ACUTE MEDICINE BENEFITS M = R3 700 M+1 = R6 200 M+2 = R7 600 M+3+ = R8 150 STANDARD RADIOLOGY BENEFITS R2 450 per family PATHOLOGY BENEFITS R2 450 per family INSURED DENTISTRY BENEFITS INSURED OPTICAL BENEFITS Spectacles/contact lenses M Member OAL Overall annual limit GP General practitioner CDL Chronic Diseases List PMB Prescribed minimum benefits DSP Designated service provider MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price 6

10 summary of benefits 7 Non-network Non-network Non-network PREGNANCY AND BABY BENEFITS 12 pregnancy consultations Two 2D sonars Two consultations (< 1 year) PREGNANCY AND BABY BENEFITS 6 pregnancy consultations Two 2D sonars Two consultations (< 1 year) PREGNANCY AND BABY BENEFITS 12 pregnancy consultations Two 2D sonars Two consultations (< 1 year) PREGNANCY AND BABY BENEFITS 12 pregnancy consultations Two 2D sonars Two consultations (< 1 year) Additional insured benefits HEALTH TESTS 1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose and/or cholesterol tests (Clicks and Dis-Chem clinics)* Routine tests, including mammograms, pap smears and prostate tests HIV voluntary counselling and testing (Clicks and Dis-Chem clinics) FOBT IMMUNISATION Flu vaccine Tetanus vaccine HPV vaccine Pneumovax vaccine for beneficiaries registered with asthma or COPD Standard kids immunisation (< 7 years) HEALTH TESTS 1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose and/or cholesterol tests (Clicks and Dis-Chem clinics)* Routine tests, including mammograms, pap smears and prostate tests HIV voluntary counselling and testing (Clicks and Dis-Chem clinics) FOBT IMMUNISATION Flu vaccine Tetanus vaccine HPV vaccine Pneumovax vaccine for beneficiaries registered with asthma or COPD Standard kids immunisation (< 7 years) HEALTH TESTS 1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose and/or cholesterol tests (Clicks and Dis-Chem clinics)* Routine tests, including mammograms, pap smears and prostate tests HIV voluntary counselling and testing (Clicks and Dis-Chem clinics) FOBT IMMUNISATION Flu vaccine Tetanus vaccine HPV vaccine Pneumovax vaccine for beneficiaries registered with asthma or COPD Standard kids immunisation (< 7 years) HEALTH TESTS 1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose and/or cholesterol tests (Clicks and Dis-Chem clinics)* Routine tests, including mammograms, pap smears and prostate tests HIV voluntary counselling and testing (Clicks and Dis-Chem clinics) FOBT IMMUNISATION Flu vaccine Tetanus vaccine HPV vaccine Pneumovax vaccine for beneficiaries registered with asthma or COPD Standard kids immunisation (< 7 years) BACK TREATMENT PROGRAMME BACK TREATMENT PROGRAMME BACK TREATMENT PROGRAMME BACK TREATMENT PROGRAMME HPV Human papilloma virus BMI Body mass index COPD Chronic obstructive pulmonary disease FOBT Faecal occult blood test * These benefits are not available if you have been registered for a chronic/pmb condition, as it can no longer be considered as preventive care.

11 additional insured benefits Our additional insured benefits are designed to enhance your available day-to-day benefits, and include pregnancy, baby and preventive care benefits. Pregnancy and baby benefits Preventive care Benefit Immunisation Benefit More information Pregnancy consultations 2D sonars Consultations < 1 year Preventive care and 3 ( and Non-network) and 12 per family 2 per family 2 per baby ( and Non-network) 6 per family Health tests Benefit Item codes More information Standard immunisation > 7 years > 7 years Flu vaccine Tetanus vaccine HPV vaccine Pneumovax vaccine years years > 55 years > 55 years As published by the Department of Health One per beneficiary Three injections in the course of one year, once per lifetime 1 vaccine in a 5-year cycle Administering fee at Dis-Chem or Clicks pharmacy clinics included Administering fee at Dis-Chem or Clicks pharmacy clinics included Must be registered on Medihelp s treatment programme for asthma or COPD (NAPPI code ) Blood glucose* Total cholesterol* or combination test* (blood glucose, total cholesterol, BMI) HIV* voluntary counselling and testing As negotiated with participating pharmacies Pap smear _ One per Pathology: beneficiary 4566/4559 Mammogram _ Radiology: 3605/ 39175/34100/ years + FOBT Pathology: years + 50 years + Prostate test _ Pathology: 4519 (PSA level) 40 years + Bone mineral _ Radiology: density test (BMD) 50 years /50120 Available at Clicks or Dis-Chem pharmacy clinics A medical doctor must request the services The consultation will be paid from the available day-to-day benefits Back treatment programme One Document-Based Care back treatment programme per beneficiary at a DBC facility (subject to protocols and pre-authorisation). HealthPrint wellness programme HealthPrint is an online wellness programme that supports you with relevant health information through every life stage. You can also: View, update and share your health information and results of your health assessment via the site Add your activity tracker and view your performance Join Medihelp MultiSport, receive sports gear at a discounted price and participate as part of the Medihelp team in supported events Join lifestage-specific programmes such as the pregnancy and baby programme and receive added value. BMI Body mass index FOBT Faecal occult blood test PMB Prescribed minimum benefits HPV Human papilloma virus COPD Chronic obstructive pulmonary disease * These benefits are not available if you have been registered for a chronic/pmb condition as it is no longer considered as preventive care. 8

12 standard immunisation for children 9 Younger than 7 years of age: Schedule published by the Department of Health. See additional insured benefits for more details about applicable benefits. At birth BCG for TB Oral polio vaccine 6 weeks Oral polio vaccine Rotavirus vaccine Diphtheria, tetanus, acellular pertussis, inactivated polio vaccine and haemophilus influenzae type B and Hepatitis B vaccine combined (1) Pneumococcal conjugated vaccine 10 weeks Diphtheria, tetanus, acellular pertussis, inactivated polio vaccine and haemophilus influenzae type B and Hepatitis B vaccine combined (2) 14 weeks Rotavirus vaccine Diphtheria, tetanus, acellular pertussis, inactivated polio vaccine and haemophilus influenzae type B and Hepatitis B vaccine combined (3) Pneumococcal conjugated vaccine 6 months Measles vaccine (1) 9 months Pneumococcal conjugated vaccine Chicken pox vaccine 12 months Measles vaccine (2) 18 months Diphtheria, tetanus, acellular pertussis, inactivated polio vaccine and haemophilus influenzae type B and Hepatitis B vaccine combined (4) 6 years Tetanus and diphtheria vaccine essential cover We offer 100% cover for 270 conditions and the following 26 chronic diseases treated by designated service providers and networks according to treatment protocols: 1. Addison s disease 2. Asthma 3. Bipolar mood disorder 4. Bronchiectasis 5. Cardiac failure 6. Cardiomyopathy 7. Chronic obstructive pulmonary disease (COPD) 8. Chronic renal disease 9. Coronary artery disease 10. Crohn s disease 11. Diabetes insipidus 12. Diabetes mellitus type Diabetes mellitus type Dysrhythmia 15. Epilepsy 16. Glaucoma 17. Haemophilia A and B 18. Hyperlipidaemia 19. Hypertension 20. Hypothyroidism 21. Multiple sclerosis 22. Parkinson s disease 23. Rheumatoid arthritis 24. Schizophrenia 25. Systemic lupus erythematosus (SLE) 26. Ulcerative colitis

13 benefit option comparison Core benefits Internally implanted prostheses Day-to-day benefits Deductibles 10

14 core benefits 11 Core benefits include major medical expenses such as hospitalisation, post-hospital care, medical emergencies and home care as an alternative to hospitalisation. Essential cover Description Benefit Benefit Benefit Benefit DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB AND 26 CHRONIC CONDITIONS ON THE CDL Subject to protocols, pre-authorisation and DSPs 100% of the cost 100% of the cost 100% of the cost 100% of the cost Trauma BENEFITS FOR MAJOR TRAUMA THAT NECESSITATES HOSPITALISATION IN THE CASE OF: Motor vehicle accidents Stab wounds Gunshot wounds Head trauma Burns Near drowning Subject to authorisation, PMB protocols and case management 100% of the cost 100% of the cost 100% of the cost 100% of the cost POST-EXPOSURE PROPHYLAXIS EMERGENCY TRANSPORT SERVICES (Netcare 911) RSA, Lesotho, Swaziland, Mozambique, Namibia and Botswana Subject to pre-authorisation and protocols In beneficiary s country of residence Transport by road Transport by air EMS Outside beneficiary s country of residence Transport by road R1 800 per case R1 800 per case R1 800 per case R1 800 per case Transport by air R per case R per case R per case R per case 24-HOUR HELPLINE AND TRAUMA COUNSELLING (Netcare 911) Phone Phone Phone Phone PMB Prescribed minimum benefits EMS Emergency medical services CDL Chronic Diseases List MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

15 core benefits Description Benefit Benefit Benefit Benefit HOSPITALISATION (state and private hospitals and day clinics) Subject to pre-authorisation, protocols and case management Intensive and high-care wards Ward accommodation Theatre fees Treatment and ward medicine Consultations, surgery and anaesthesia POST-HOSPITAL CARE Professional services required for up to 30 days after discharge following a Medihelp authorised private hospital admission Speech therapy Occupational therapy Physiotherapy DSP applies M = R1 650 M+ = R2 200 DSP applies M = R1 650 M+ = R2 200 DSP applies M = R1 650 M+ = R2 200 M = R1 650 M+ = R2 200 PROSTHESES See page 15 See page 15 See page 15 See page 15 CONFINEMENT (childbirth) Subject to pre-authorisation, protocols and case management HOME DELIVERY Subject to pre-authorisation Professional nursing fees Equipment Material and medicine STANDARD RADIOLOGY, PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES In hospital Subject to clinical protocols SPECIALISED RADIOLOGY In and out of hospital On request of a specialist and subject to clinical protocols MRI and CT imaging (subject to pre-authorisation) Angiography ORGAN TRANSPLANTS Subject to pre-authorisation and clinical protocols Cornea implants R per event Member pays the first R1 500 per examination 100% of the cost R per implant R per event Member pays the first R1 500 per examination 100% of the cost R per implant R per event Member pays the first R1 500 per examination 100% of the cost R per implant R per event Member pays the first R1 000 per examination 100% of the cost R per implant MRI Magnetic resonance imaging CT Computerised tomography PMB Prescribed minimum benefits DSP Designated service provider MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price 12

16 13 core benefits Description Benefit Benefit Benefit Benefit PHYSIOTHERAPY, OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES In hospital OXYGEN In hospital NEUROSTIMULATORS Subject to pre-authorisation and clinical protocols Device and components RENAL DIALYSIS In and out of hospital Subject to pre-authorisation and clinical protocols APPLICABLE PRESCRIPTION MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON DISCHARGE FROM THE HOSPITAL (TTO) (Excluding PMB chronic medicine) PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION Subject to pre-authorisation, services rendered in an approved/ network hospital/facility and prescribed by a medical doctor Professional services rendered in and out of hospital by a psychiatrist General ward accommodation Medicine supplied during the period of the treatment in the institution Outpatient consultations R per beneficiary R320 per admission R per beneficiary (maximum R per family ) R per beneficiary R per beneficiary (maximum R per family ) R per beneficiary R320 per admission R per beneficiary (maximum R per family ) R per beneficiary R330 per admission R per beneficiary (maximum R per family ) ONCOLOGY* Subject to pre-authorisation and registration on the Medihelp Oncology Management Programme. Protocols and DSP (ICON) apply Radiotherapy Brachytherapy Chemotherapy and associated adjuvant medicine (medicine subject to the MORP) Bone marrow/stem cell transplants (subject to protocols) 100% of the cost DSP: ICON 100% of the cost DSP: ICON 100% of the cost DSP: ICON 100% of the cost DSP: ICON PMB Prescribed minimum benefits ICON Independent Clinical Oncology MORP Medihelp Oncology Reference Price DSP Designated service provider TTO To take out (medicine) MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price * See explanation of terms for more information.

17 core benefits Description Benefit Benefit Benefit Benefit HOSPICE SERVICES AND SUB-ACUTE CARE FACILITIES AS AN ALTERNATIVE TO HOSPITALISATION Subject to pre-authorisation, and services rendered in an approved facility and prescribed by a medical doctor PRIVATE NURSING AS AN ALTERNATIVE TO HOSPITALISATION Subject to pre-authorisation (Excluding general day-to-day care) APPENDECTOMY Subject to pre-authorisation Conventional procedure Laparoscopic procedure Hospitalisation: R per beneficiary Hospitalisation: R per beneficiary Hospitalisation: R per beneficiary Hospitalisation: R per beneficiary PROSTATECTOMY Subject to pre-autorisation Conventional or laparoscopic procedure Robotic assisted laparoscopic procedure Hospitalisation: R per beneficiary Hospitalisation: R per beneficiary Hospitalisation: R per beneficiary Hospitalisation: R per beneficiary MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price 14

18 internally implanted prostheses Description Benefit Benefit Benefit Benefit INTERNALLY IMPLANTED PROSTHESES All hospital admissions and prostheses are subject to pre-authorisation, protocols and case management 15 EVARS prosthesis R per beneficiary R per beneficiary R per beneficiary R per beneficiary Vascular/cardiac prosthesis R per beneficiary Health-essential functional prosthesis R per beneficiary R per beneficiary R per beneficiary R per beneficiary R per beneficiary R per beneficiary R per beneficiary Hip, knee and shoulder replacements* Protocols apply In case of acute injury where replacement is the only clinically appropriate treatment modality Hospitalisation: Prosthesis: Health-essential functional prosthesis benefits apply (Non-PMB) In case of acute injury where replacement is the only clinically appropriate treatment modality Hospitalisation: Prosthesis: Health-essential functional prosthesis benefits apply (Non-PMB) In case of acute injury where replacement is the only clinically appropriate treatment modality Hospitalisation: Prosthesis: Health-essential functional prosthesis benefits apply (Non-PMB) Subject to DSP (ICPS) if patient qualifies in terms of clinical criteria (only hip and knee replacements). If not, a R benefit applies for the hospital account and prosthesis components (combined) (Non-PMB) Intra-ocular lenses Sub-limit subject to healthessential functional prosthesis benefit 2 lenses per beneficiary R3 600 per lens This option does not cover Implantable hearing devices (including devices and components) this benefit Sub-limit subject to healthessential functional prosthesis benefit 2 lenses per beneficiary R3 600 per lens This option does not cover this benefit Sub-limit subject to healthessential functional prosthesis benefit 2 lenses per beneficiary R3 600 per lens R per beneficiary Sub-limit subject to healthessential functional prosthesis benefit 2 lenses per beneficiary R3 600 per lens R per beneficiary Prosthesis with reconstructive or restorative surgery External breast prostheses In and out of hospital R3 700 per family R8 300 per family R8 300 per family R8 300 per family ICPS Improved Clinical Pathway Services DSP Designated service provider EVARS Endovascular aortic replacement surgery PMB MT Prescribed minimum benefits Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price * Benefit not applicable to wear and tear

19 day-to-day benefits Description Benefit Benefit Benefit Benefit GPs AND SPECIALISTS Consultations and follow-up consultations PHYSIOTHERAPY Treatment and material CLINICAL PSYCHOLOGY AND PSYCHIATRIC NURSING OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES M = R1 050 M+ = R2 100 Pooled benefit for GP and specialist consultations, physiotherapy, acute medicine and self-medication This option does not cover these benefits M = 2 GP consultations M+ = 4 GP consultations Additional consultations and other services paid from savings account M = R5 700 M+1 = R9 550 M+2 = R M+3+ = R * M = R2 450 M+1 = R4 100 M+2 = R5 050 M+3+ = R6 100 MEDICINE Medicine obtained in the Medihelp Preferred Pharmacy and prescribed/dispensed by a medical doctor Acute generic medicine (including medicine dispensed at an emergency unit and self-medication, immunisations, contraceptives and homeopathic, herbal, naturopathic and osteopathic medicine) Please note: Original medicine when no generic equivalent is available 80% of the MT will apply Voluntary use of original medicine when generic equivalent is available 70% of the MMAP will apply 100% of the MMAP Generic medicine M = R1 050 M+ = R2 100 See GP and specialist consultations pooled benefit for acute and self-medication, GP and specialist consultations and physiotherapy 100% of the MMAP Generic medicine 100% of the MMAP Generic medicine M = R3 700 M+1 = R6 200 M+2 = R7 600 M+3+ = R8 150 MMAP Maximum Medical Aid Price GP General practitioner MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price M Member * has no limit for medical and surgical treatment, anaesthesia as well as material and medicines used during a consultation, but consultations are subject to the consultations benefit 16

20 day-to-day benefits Description Benefit Benefit Benefit Benefit Non-PMB generic chronic medicine Subject to pre-authorisation and registration on Medihelp s chronic medicine management programme Original medicine when no generic equivalent is available 80% of the MT will apply Voluntary use of original medicine when generic equivalent is available 70% of the MMAP will apply PMB chronic medicine Subject to pre-authorisation and registration on Medihelp s PMB medicine management programme OXYGEN Out of hospital Subject to pre-authorisation, clinical protocols and services prescribed by a medical doctor PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES Out of hospital Subject to clinical protocols and requested by a medical doctor STANDARD RADIOLOGY Out of hospital Subject to clinical protocols and requested by a medical doctor or chiropractor (black and white X-rays only) This option does not cover this benefit This option does not cover this benefit 100% of the MMAP Generic medicine M = R3 650 M+1 = R5 500 M+2 = R7 400 M+3+ = R % of the MHRP 100% of the MHRP 100% of the MHRP 100% of the MHRP DSP & formulary apply This option does not cover these benefits DSP & formulary apply DSP & formulary apply M = R2 450 M+ = R3 450 R2 450 per family R2 450 per family 17 MHRP Medihelp Reference Price MMAP Maximum Medical Aid Price GP General practitioner PMB Prescribed minimum benefits DSP Designated service provider M Member MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

21 day-to-day benefits Description Benefit Benefit Benefit Benefit EXTERNAL PROSTHESES, MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES Services in and out of hospital Artificial eyes R4 080 per family per 3-year cycle Speech and hearing aids R4 080 per family per 3-year cycle Artificial limbs R4 080 per family per 3-year cycle Wheelchairs R4 080 per family per 3-year cycle Medical appliances Hyperbaric oxygen treatment In and out of hospital Stoma components Incontinence products/supplies CPAP apparatus Prescribed by a medical doctor OPTOMETRY Subject to pre-authorisation by PPN and services should be obtained from a PPN provider Optometric examinations 1 composite consultation, including refraction test, tonometry and visual field test Spectacles or contact lenses Benefits are limited to either spectacles or contact lenses Spectacles Frames and/or lens enhancements This option does not cover these benefits R8 400 per beneficiary per 24-month cycle This option does not cover these benefits R550 per family 1 composite examination per beneficiary per 24-month cycle R200 per beneficiary for a frame and/or lens enhancements per 24-month cycle Lenses (one pair of standard clear Aquity lenses) Single vision or bifocal lenses per beneficiary per 24-month cycle Contact lenses R950 per beneficiary per 24-month cycle PPN Preferred Provider Negotiators CPAP Continuous positive airway pressure MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price R4 080 per family per 3-year cycle R4 080 per family per 3-year cycle R4 080 per family per 3-year cycle R4 080 per family per 3-year cycle R1 100 per family R8 400 per beneficiary per 24-month cycle 1 composite examination per beneficiary per 24-month cycle R600 per beneficiary for a frame and/or lens enhancements per 24-month cycle Single vision, bifocal or multifocal (paid at the cost of bifocal lenses) lenses per beneficiary per 24-month cycle R1 000 per beneficiary per 24-month cycle R6 800 per beneficiary per 3-year cycle R6 800 per beneficiary per 3-year cycle R5 440 per beneficiary per 3-year cycle R5 440 per beneficiary per 3-year cycle R1 350 per beneficiary R8 400 per beneficiary per 24-month cycle 1 composite examination per beneficiary per 24-month cycle R750 per beneficiary for a frame and/or lens enhancements per 24-month cycle Single vision, bifocal or multifocal lenses per beneficiary per 24-month cycle R1 510 per beneficiary per 24-month cycle 18

22 day-to-day benefits Description Benefit Benefit Benefit Benefit DENTAL SERVICES Subject to Denis managed care protocols 19 Conservative dental services Routine check-ups 2 per beneficiary (once in 6 months) 2 per beneficiary (once in 6 months) 2 per beneficiary (once in 6 months) Oral hygiene Fluoride treatment for children 5-13 years Fissure sealants for children younger than 16 years only 2 scale and polish treatments per beneficiary (once in 6 months) 2 scale and polish treatments per beneficiary (once in 6 months) 2 scale and polish treatments per beneficiary (once in 6 months) Fillings (treatment plans and X-rays may be requested for multiple fillings) 1 filling per tooth in 365 days This option does not cover these benefits Tooth extractions and root canal treatment in the dentist s chair 2 emergency visits to treat pain and sepsis per beneficiary per year (item code 8104) 2 extractions per visit (item code 8201) Pulp amputation (item code 8307) and/or removal (item code 8132) 2 per visit per beneficiary Other treatments paid from savings account 1 filling per tooth in 365 days 1 filling per tooth in 365 days Laughing gas (in the dentist s chair) Dental procedures under conscious sedation in the dentist s chair (sedation cost) Subject to pre-authorisation and managed care protocols Removal of impacted teeth only (Dentist s account only for item codes 8941/8943/8945) Removal of impacted teeth only (Dentist s account only for item codes 8941/8943/8945) Extensive dental treatment and the removal of impacted teeth only Extensive dental treatment and the removal of impacted teeth only MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

23 day-to-day benefits Description Benefit Benefit Benefit Benefit Plastic dentures This option does not cover these benefits 1 set (upper and lower jaw) per beneficiary in a 4-year period 1 set (upper and lower jaw) per beneficiary in a 4-year period X-rays Intra-oral X-rays Extra-oral X-rays 1 per beneficiary in a 3-year period Specialised dental services Subject to pre-authorisation and Denis managed care protocols Partial metal frame dentures This option does not cover these benefits 1 per beneficiary in a 3-year period 1 partial frame (upper or lower jaw) per beneficiary in a 5-year period 1 per beneficiary in a 3-year period 2 partial frames (upper and lower jaw) per beneficiary in a 5-year period Maxillofacial surgery and oral pathology Surgery in the dentist s chair Benefits for temporomandibular joint (TMJ) therapy are limited to non-surgical interventions/treatment Crowns and bridges Subject to pre-authorisation Implants Subject to pre-authorisation Orthodontic treatment (only one beneficiary per family may begin orthodontic treatment per calendar year) Subject to pre-authorisation and orthodontic needs analysis Periodontal treatment (conservative non-surgical therapy only) Subject to pre-authorisation and registration on the Perio Programme Once per tooth in a 5-year period For beneficiaries from 9-18 years old per lifetime Payment from date of authorisation 1 crown per family, once per tooth in a 5-year period This option does not cover this benefit R8 230 per beneficiary from 9-18 years old per lifetime Payment from date of authorisation 2 crowns per family, once per tooth in a 5-year period This option does not cover this benefit R per beneficiary from 9-18 years old per lifetime Payment from date of authorisation MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price This is a summary of benefits. In the event of a dispute, the registered Rules of Medihelp will apply (which are subject to approval by the Council for Medical Schemes). If a beneficiary joins during the course of a financial year, the benefits are calculated pro rata according to the remaining number of months. 20

24 21 deductibles Visiting network service providers, following the correct pre-authorisation process and negotiating tariffs with your doctor are just some of the ways you can manage or reduce out-of-pocket medical expenses Procedure-specific deductibles There are a limited number of low-incidence procedures that require a procedure-specific payment. Back and neck fusion Non-network/ Member pays the first R Balance paid at 100% of the MT Non-network/ Member pays the first R9 000 Balance paid at 100% of the MT Non-network/ Member pays the first R7 850 Balance paid at 100% of the MT Member pays the first R6 700 Balance paid at 100% of the MT Endoscopic procedures There are only four endoscopic procedures where a member is required to contribute to the cost. If the procedure is performed in the doctor s rooms it will significantly reduce or eliminate that expense. These benefits apply to non-network and network options. Endoscopic procedures Gastroscopy Colonoscopy Gastroscopy Colonoscopy Arthroscopy Sigmoidoscopy Facility In the doctor s rooms In hospital Dimension Prime 1 Non-network/ Member pays the first R900 Balance paid at 100% of the MT Member pays the first R2 800 per admission Balance paid at 100% of the MT Dimension Prime 2 Non-network/ Member pays the first R3 400 per admission Balance paid at 100% of the MT Dimension Prime 3 Non-network/ Medihelp pays Member pays the first R2 800 per admission Balance paid at 100% of the MT Dimension Elite Member pays the first R2 800 per admission Balance paid at 100% of the MT Dental procedures under general anaesthesia These benefits rendered in hospital are subject to pre-authorisation and Denis managed care protocols. Procedures are paid at 100% of the Medihelp tariff (MT). These benefits apply to non-network and network options. Non-network/ Member pays the first R2 900 per admission Balance paid at 100% of the MT Removal of impacted teeth (Dentist s account covered for item codes 8941, 8943 and 8945) Extensive dental treatment for children younger than 5 years once per lifetime (Dentist s account: for member s account) Non-network/ Member pays the first R1 900 per admission Balance paid at Removal of impacted teeth (Dentist s account covered for item codes 8941, 8943 and 8945) Extensive dental treatment for children younger than 5 years once per lifetime (Dentist s account: available funds in savings account) Non-network/ Member pays the first R800 per admission Difference covered at Removal of impacted teeth Extensive dental treatment for children younger than 5 years once per lifetime MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price Dimension Elite Member pays the first R750 per admission Difference covered at Removal of impacted teeth Extensive dental treatment for children younger than 5 years once per lifetime

25 deductibles options Members of the Dimension Prime network options should use network hospitals for all planned admissions. A 65% benefit applies when an out-of-network hospital is used by choice. 40% of the Medihelp Reference Price is paid if PMB chronic medicine is obtained outside the formulary and/or DSP on the network options. It is advisable for chronic medicine users to rather choose the alternative non-network options. Pre-authorisation is important Medicine benefits Ask your pharmacist for the generic equivalent of prescribed medicine to avoid unnecessary out-of-pocket expenses. The only difference between an original medicine item and its generic equivalent is the price. Medicine benefits are applied as follows: Generic medicine 100% of the MMAP Original medicine if no generic equivalent is available 80% of the MT Original medicine if a generic equivalent is available 70% of the MMAP Specialised radiology Services rendered in and out of hospital must be requested by a specialist. Benefits are subject to clinical protocols and the deductibles below. Always pre-authorise the services listed below: 100% of the Medihelp tariff applies if these services or procedures are pre-authorised: All planned hospital admissions (protocols and case management apply) Oxygen for out-of-hospital use (protocols and case management apply) Dental procedures under conscious sedation (sedation cost) in the dentist s chair (managed care protocols apply) Specialised dental services Crowns and bridges Implants Periodontal treatment (conservative non-surgical therapy only and subject to registration on the Perio Programme) Should these services not be pre-authorised, an 80% benefit will apply. Emergency transport services (Netcare 911) in and outside the country of residence (air and road transport) should be pre-authorised to qualify for the applicable benefit. If not preauthorised, 50% of the benefit applies except in the case of emergency medical conditions. Description Non-network/ MRI and CT imaging (subject to preauthorisation) Angiography CT Computerised tomography MRI Magnetic resonance imaging MMAP Maximum Medical Aid Price Member pays the first R1 500 per examination Balance paid at 100% of the MT Non-network/ Member pays the first R1 500 per examination Balance paid at 100% of the MT Non-network/ Member pays the first R1 500 per examination Balance paid at 100% of the MT Dimension Elite Member pays the first R1 000 per examination Balance paid at 100% of the MT PMB Prescribed minimum benefits MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price 22

26 supporting information dimension prime hospital network Members of the Dimension Prime network benefit options must be admitted to one of the network hospitals or day clinics below when they need to undergo planned procedures. Our website lists all the network hospitals. Visit Gauteng You can also phone *120*6364# on your cell phone, or download our Medihelp member app, which is available on these devices: ios, Android and Windows. ios Android Windows City/town Name Practice No Alberton Clinton Clinic Alberton Union Hospital Benoni Linmed Hospital Florida Mayo Clinic Johannesburg Garden City Clinic Johannesburg Mulbarton Hospital Johannesburg Park Lane Clinic Johannesburg Rand Clinic Kempton Park Birchmed Surgical Centre Krugersdorp Bellstreet Hospital Krugersdorp Krugersdorp Private Hospital Krugersdorp Pinehaven Hospital Midrand Cure Day Clinics (Midstream) Pretoria Akasia Hospital Pretoria Brooklyn Surgical Centre Pretoria Cure Day Clinics (Erasmuskloof) Pretoria Intercare Day Hospital (Hazeldean) Pretoria Jakaranda Hospital Pretoria Louis Pasteur Hospital Pretoria Medkin Clinic Pretoria Montana Private Hospital Pretoria Pretoria East Private Hospital Gauteng City/town Name Practice No Pretoria Unitas Hospital Pretoria Zuid-Afrikaans Hospital Vanderbijlpark Cormed Clinic Vanderbijlpark Mediclinic Emfuleni Vanderbijlpark PJ Schutte Theatre Unit Vereeniging Mediclinic Vereeniging Vereeniging Midvaal Private Hospital KwaZulu-Natal City/town Name Practice No Amanzimtoti Kingsway Hospital Ballito Alberlito Hospital Durban Chatsmed Garden Hospital Durban Nu-Shifa Hospital Durban St Augustine s Hospital Howick Mediclinic Howick Ladysmith La Verna Hospital Newcastle Mediclinic Newcastle Pietermaritzburg Mediclinic Pietermaritzburg Pietermaritzburg St Anne s Hospital Pinetown The Crompton Hospital Port Shepstone Hibiscus Hospital Richards Bay The Bay Hospital Shelly Beach Shelly Beach Day Clinic Umhlanga Umhlanga Hospital Umhlanga KZN Day Clinic Limpopo City/town Name Practice No Bela-Bela St Vincent s Hospital Lephalale Marapong Private Hospital Makhado Zoutpansberg Private Hospital Polokwane Mediclinic Limpopo Polokwane Mediclinic Limpopo Day Clinic Tzaneen Mediclinic Tzaneen

27 Mpumalanga City/town Name Practice No emalahleni emalahleni Day Hospital emalahleni emalahleni Private Hospital Ermelo Mediclinic Ermelo Middelburg Middelburg Private Hospital Nelspruit Kiaat Private Hospital Nelspruit Lowveld Hospital Nelspruit Mediclinic Nelspruit Secunda Mediclinic Secunda North West City/town Name Practice No Klerksdorp Sunningdale Hospital Klerksdorp Wilmed Park Private Hospital Potchefstroom Potchefstroom Medical and Dental Centre Rustenburg Ferncrest Hospital Vryburg Vryburg Private Hospital Northern Cape City/town Name Practice No Kimberley Mediclinic Kimberley Upington Mediclinic Upington Western Cape City/town Name Practice No Cape Town Christiaan Barnard Memorial Hospital Cape Town Kuilsriver Private Hospital Cape Town Mediclinic Cape Gate Cape Town Mediclinic Durbanville Cape Town Mediclinic Durbanville Day Hospital Cape Town Mediclinic Louis Leipoldt Cape Town Mediclinic Milnerton Cape Town Melomed Bellville Cape Town Melomed Gatesville Cape Town N1 City Hospital Medihelp may change the information contained in this document from time to time and will publish any changes on our website at Western Cape City/town Name Practice No Cape Town Vincent Pallotti Hospital George Mediclinic Geneva George Mediclinic George Hermanus Mediclinic Hermanus Mossel Bay Bayview Hospital Oudtshoorn Mediclinic Klein Karoo Paarl Cure Day Clinics (St Stephen s Paarl) Paarl Mediclinic Paarl Plettenberg Bay Mediclinic Plettenberg Bay Somerset West Mediclinic Vergelegen Stellenbosch Mediclinic Stellenbosch Vredenburg West Coast Private Hospital Worcester Mediclinic Worcester Eastern Cape City/town Name Practice No East London Life Beacon Bay Hospital East London St Dominic s Hospital East London St James Operating Theatres Grahamstown Settlers Hospital Humansdorp Isivivana Private Hospital Port Alfred Port Alfred Hospital Port Elizabeth Greenacres Hospital Port Elizabeth Medical Forum Theatre Queenstown Life Queenstown Private Hospital Uitenhage Cuyler Clinic Free State City/town Name Practice No Bethlehem Bethlehem Medical Centre Bloemfontein Citymed Theatre Bloemfontein Horizon Eye Care Centre Bloemfontein Mediclinic Bloemfontein Bloemfontein Universitas Private Hospital Kroonstad Kroon Hospital Welkom Welkom Medical Centre

28 our healthcare partners We partner with preferred providers and networks to give you access to affordable, quality care. 25 All options options Dental Information Systems (Denis) Dental Information Systems (Denis) is South Africa s leading dental benefit management company. Members may visit any dentist of their choice, but benefits are managed by Denis and granted in accordance with Denis protocols. Medihelp Preferred Pharmacy Medihelp s Preferred Pharmacy consists of more than pharmacies who offer Medihelp members the most cost-effective professional fee structure for prescribed medicine. This means that members who visit network pharmacies will not have to pay any excess amounts for higher professional fees which non-network pharmacies charge to dispense medicine items. DSP DSPs for Dimension Prime network range only PMB chronic medicine Members must obtain their PMB chronic medicine from a designated service provider (DSP) to avoid a 60% deductible. Order authorised PMB chronic medicine from MobileMeds. Oncology medicine Dis-Chem Oncology is the DSP for oncology PMB medicine. OneHealth and Dis-Chem Direct OneHealth is the managed healthcare partner for HIV/Aids-related services and post-exposure prophylaxis and Dis-Chem Direct is the designated service provider (DSP) for HIV/Aids medicine. Specialist networks Two specialist networks (for Medihelp s non-network range and the Dimension Prime network range) effectively manage any PMB specialist care that our members may require, while reducing their out-of-pocket expenses. For members of our network options, specific specialist networks also ensure streamlined care between the specialist and the network hospital, especially with regard to PMB services. Netcare 911 Netcare 911 is our partner in providing emergency medical services, including emergency medical transport, emergency assistance and trauma counselling. ICON ICON is the Independent Clinical Oncology to which more than 80% of the country s oncologists belong. They provide the highest quality cancer care through a countrywide footprint of high-tech chemotherapy and radiotherapy facilities. ICON is Medihelp s designated service provider for oncology treatment. DBC Medihelp s back treatment programme is offered in cooperation with Document-Based Care (DBC). Each programme is developed by a multidisciplinary medical team according to the individual s clinical profile.,, PPN The Preferred Provider Negotiators (PPN) provide Medihelp s optical benefits in partnership with more than optometrists across South Africa. Medihelp members may visit any optometrist and benefits are paid according to PPN tariffs. ICPS Improved Clinical Pathway Services provide non-pmb hip and knee replacement for qualifying patients on. Preventive care Clicks and Dis-Chem are Medihelp s designated service providers for preventive care health assessment tests. MobileMeds MobileMeds is a convenient medicine ordering and delivery service, especially for authorised monthly chronic medicine. PMB Prescribed minimum benefits