September dimension range 2016

Transcription

1 September 2015 dimension range 2016

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 22 supporting information 3 Summary of benefits 8 Preventive care benefits 9 Standard immunisation for children 9 Essential cover 11 Core benefits 14 Internally implanted prostheses 15 Day-to-day benefits 20 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 110 Videos to explain complex processes years experience in the industry and a solid reputation A solvency level that has been consistently above the industry requirement Multiple engagement opportunities through social and digital channels Consistent service on online and offline service platforms A dedicated call centre 2a sound healthcare investment Medihelp ticks all the boxes of a sound investment AA- rating for our claims-paying ability, awarded by Global Credit Rating A walk-in service offered at our 5 offices Products and additional value to suit every stage of your life One of only two schemes who have managed to up their service while the rest of the industry is on a downward trend SACSi 2015 A secured website to change and view your Medihelp profile & benefits One of the top five largest open medical schemes in the industry 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% Preventive care A menu of separate, additional preventive care benefits valued at R Peace of mind Health conscious An individualised, free wellness programme that keeps track of all your health data cover for trauma and emergencies No overall annual limit on hospital cover Larger family Only two children younger than 18 years are paid for on the Dimension Prime options, the rest receive free cover Kids are grown up Get active Join Medihelp s cycling/running club and get added discounts and value 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 Preventive care benefits Essential cover 2

6 summary of benefits 3 Non-/ Non-/ Non-/ This option delivers an affordable solution to the healthy who are seeking hospital cover, with the added value of access to insured preventive care and a pooled day-to-day benefit. Pay even less when choosing the network version of the option comprising 99 private hospitals, at 22% less. Looking for peace of mind and flexibility? is a hybrid option that provides comprehensive hospital cover, insured preventive care benefits and the flexibility of a savings account for day-to-day expenses, with a network alternative at 22% less. Medihelp s flagship option covers almost lives and provides generous insured benefits in and out of hospital for all your family s healthcare needs. With a network alternative at 20% less, you cannot go wrong when choosing this high-quality option. This option s superior insured benefits are designed to provide extensive cover for young and old alike. Its ample day-to-day, chronic and medicine benefits differentiate it from the rest and provide you with all the comprehensive cover you need.

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. Please speak to your accredited adviser to obtain a more detailed quotation based on your information. Principal member R1 452 R1 134 R1 926 (R234 savings contribution included per month and R2 808 per year) R1 500 (R180 savings contribution included per month and R2 160 per year) R2 460 R1 968 R3 582 Dependant R1 188 R924 R1 578 (R192 savings contribution included per month and R2 304 per year) R1 230 (R150 savings contribution included per month and R1 800 per year) R2 088 R1 668 R3 348 Child dependant <26 years R438 R342 R582 (R72 savings contribution included per month and R864 per year) R450 (R54 savings contribution included per month and R648 per year) R720 R576 R972 R2 640 R2 058 R3 504 (R426 savings contribution included per month and R5 112 per year) R2 730 (R330 savings contribution included per month and R3 960 per year) R4 548 R3 636 R6 930 R1 890 R1 476 R2 508 (R306 savings contribution included per month and R3 672 per year) R1 950 (R234 savings contribution included per month and R2 808 per year) R3 180 R2 544 R4 554 R2 328 R1 818 R3 090 (R378 savings contribution included per month and R4 536 per year) R2 400 (R288 savings contribution included per month and R3 456 per year) R3 900 R3 120 R5 526 R3 078 R2 400 R4 086 (R498 savings contribution included per month and R5 976 per year) R3 180 (R384 savings contribution included per month and R4 608 per year) R5 268 R4 212 R7 902 R3 516 R2 742 R4 668 (R570 savings contribution included per month and R6 840 per year) R3 630 (R438 savings contribution included per month and R5 256 per year) R5 988 R4 788 R8 874 R3 516 R2 742 R4 668 (R570 savings contribution included per month and R6 840 per year) R3 630 (R438 savings contribution included per month and R5 256 per year) R5 988 R4 788 *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 HOSPITAL BENEFITS (NO OAL) HOSPITAL BENEFITS (NO OAL) HOSPITAL BENEFITS (NO OAL) HOSPITAL BENEFITS (NO OAL) Any hospital 99 network facilities Any hospital 99 network facilities Any hospital 99 network facilities Any hospital Core benefits ESSENTIAL COVER Diagnosis, treatment and care costs of 270 PMB and 26 chronic conditions on the CDL DSPs & specialist network apply POST-HOSPITAL CARE Up to 30 days after discharge SPECIALISED RADIOLOGY R per family per year In and out of hospital ESSENTIAL COVER Diagnosis, treatment and care costs of 270 PMB and 26 chronic conditions on the CDL DSPs & specialist network apply POST-HOSPITAL CARE Up to 30 days after discharge SPECIALISED RADIOLOGY R per family per year In and out of hospital ESSENTIAL COVER Diagnosis, treatment and care costs of 270 PMB and 26 chronic conditions on the CDL DSPs & specialist network apply POST-HOSPITAL CARE Up to 30 days after discharge SPECIALISED RADIOLOGY R per family per year In and out of hospital ESSENTIAL COVER Diagnosis, treatment and care costs of 270 PMB and 26 chronic conditions on the CDL DSPs & specialist network apply POST-HOSPITAL CARE Up to 30 days after discharge SPECIALISED RADIOLOGY R per family per year In and out of hospital 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 (ER24) within RSA 24-hour helpline & trauma counselling ROAD & AIR TRANSPORT (ER24) within RSA 24-hour helpline & trauma counselling ROAD & AIR TRANSPORT (ER24) within RSA 24-hour helpline & trauma counselling ROAD & AIR TRANSPORT (ER24) within RSA 24-hour helpline & trauma counselling

9 summary of benefits Day-to-day benefits INSURED DAY-TO-DAY BENEFITS M = R1 000 per year M+ = R2 000 per year GPs & acute medicine prescribed by a GP INSURED GP CONSULTATIONS M = 2 GP consultations per year M+ = 4 GP consultations per year INSURED OPTICAL BENEFITS Spectacles/contact lenses EMERGENCY DENTAL BENEFITS 2 emergency visits 2 extractions per visit 1 root canal therapy and/or temporary filling per visit OTHER DAY-TO-DAY MEDICAL EXPENSES Paid from medical savings account INSURED DAY-TO-DAY POOLED BENEFITS M = R5 410 per year M+1 = R9 010 per year M+2 = R per year M+3+ = R per year GPs & specialists Psychology & physiotherapy Supplementary health services Acute medicine & self-medication STANDARD RADIOLOGY AND PATHOLOGY BENEFITS M = R2 440 per year M+ = R3 290 per year INSURED DENTISTRY BENEFITS INSURED OPTICAL BENEFITS Spectacles/contact lenses INSURED DAY-TO-DAY POOLED BENEFITS M = R2 330 per year M+1 = R3 900 per year M+2 = R4 800 per year M+3+ = R5 770 per year GPs & specialists Psychology & physiotherapy Supplementary health services CHRONIC MEDICINE BENEFITS (Non-PMB) M = R3 450 per year M+1 = R5 200 per year M+2 = R7 000 per year M+3+ = R7 500 per year ACUTE MEDICINE BENEFITS M = R3 530 per year M+1 = R5 870 per year M+2 = R7 170 per year M+3+ = R7 730 per year STANDARD RADIOLOGY BENEFITS R2 340 per family per year PATHOLOGY BENEFITS R2 340 per family per year INSURED DENTISTRY BENEFITS INSURED OPTICAL BENEFITS Spectacles/contact lenses M Member GP General practitioner PMB Prescribed minimum benefits DSP Designated service provider CDL Chronic Diseases List OAL Overall annual limit EMS Emergency medical services 6

10 summary of benefits 7 PREGNANCY AND BABY BENEFITS 12 pregnancy consultations & two 2D sonars Two consultations (< 1 year) Standard kids immunisation (< 7 years) PREGNANCY AND BABY BENEFITS 6 pregnancy consultations & two 2D sonars Two consultations (< 1 year) Standard kids immunisation (< 7 years) PREGNANCY AND BABY BENEFITS 12 pregnancy consultations & two 2D sonars Two consultations (< 1 year) Standard kids immunisation (< 7 years) PREGNANCY AND BABY BENEFITS 12 pregnancy consultations & two 2D sonars Two consultations (< 1 year) Standard kids immunisation (< 7 years) Preventive care HEALTH TESTS 1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose and/or cholesterol tests (only at Clicks and Dis-Chem clinics)* Routine tests, including mammograms, pap smears and prostate tests HIV test FOBT IMMUNISATION Flu vaccine Tetanus vaccine HPV vaccine Pneumovax vaccine for beneficiaries registered with asthma or COPD HEALTH TESTS 1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose and/or cholesterol tests (only at Clicks and Dis-Chem clinics)* Routine tests, including mammograms, pap smears and prostate tests HIV test FOBT IMMUNISATION Flu vaccine Tetanus vaccine HPV vaccine Pneumovax vaccine for beneficiaries registered with asthma or COPD HEALTH TESTS 1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose and/or cholesterol tests (only at Clicks and Dis-Chem clinics)* Routine tests, including mammograms, pap smears and prostate tests HIV test FOBT IMMUNISATION Flu vaccine Tetanus vaccine HPV vaccine Pneumovax vaccine for beneficiaries registered with asthma or COPD HEALTH TESTS 1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose and/or cholesterol tests (only at Clicks and Dis-Chem clinics)* Routine tests, including mammograms, pap smears and prostate tests HIV test FOBT IMMUNISATION Flu vaccine Tetanus vaccine HPV vaccine Pneumovax vaccine for beneficiaries registered with asthma or COPD 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 preventive care benefits Our preventive care benefits are designed to enable you to pick up on and prevent potential health problems, keeping you healthy and enhancing your available day-to-day benefits. Pregnancy and baby benefits All options Two 2D sonars per family per year 2 consultations for babies < 1 year old Immunisation for children < 7 years old, as published by the National Department of Health (administering fee at Dis-Chem or Clicks pharmacy clinics included) & ( and Non-network) & 12 pregnancy consultations per family per year ( and Non-network) 6 pregnancy consultations per family per year Back treatment programme Health tests One test per beneficiary per year 1 combo test (blood glucose, cholesterol, BMI and blood pressure measurement) or individual blood glucose and/or cholesterol tests (only at Clicks and Dis-Chem pharmacy clinics)* 1 pap smear (pathology: 4566/4559) 1 mammogram for women > 40 years (radiology imaging: 3605/39175/34100/34101) 1 prostate test for men > 40 years (pathology: 4519) 1 FOBT for beneficiaries > 50 years (pathology: 4351) 1 bone density test for women > 50 years (3604/50120) 1 HIV non-pathology test for beneficiaries > 15 years (consultation fees are paid from the available day-to-day benefits) HealthPrint wellness programme One Document-Based Care (DBC) back treatment programme per beneficiary per year at a DBC facility (subject to protocols and pre-authorisation) Immunisation 1 flu vaccine per beneficiary (administering fee at Dis-Chem or Clicks pharmacy clinics included) 1 tetanus vaccine per beneficiary (administering fee at Dis-Chem or Clicks pharmacy clinics included) 1 HPV vaccine for beneficiaries aged 10 to 26 years (3 injections in the course of one year, once per lifetime; administering fee at Dis-Chem or Clicks pharmacy clinics included) 1 Pneumovax vaccine in a 5-year cycle for beneficiaries > 55 years registered on the asthma or COPD programme HealthPrint is an online wellness programme that displays the results of your health assessment tests on the site. You can also: View, update and share your health information via the site Add your activity tracker and view your performance View your benefits used and check what healthcare benefits you have available Join the Medihelp Multisport club for runners and cyclists and qualify for discounts on gear and events, and receive a free Medihelp branded sports bag Join the programme for pregnant women or for moms with young children and access a wealth of relevant health information and added value from selected HealthPrint partners. Join HealthPrint in three easy steps: Visit Medihelp s 1 website 2 Click on the HealthPrint button 3 Complete your profile COPD Chronic obstructive pulmonary disease FOBT Faecal occult blood test HPV Human papilloma virus * 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. 8

12 standard immunisation for children Younger than 7 years of age: Schedule published by the Department of Health. See preventive care for more details about applicable benefits. 9 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 combined Hepatitis B vaccine Pneumococcal conjugated vaccine 10 weeks Diphtheria, tetanus, acellular pertussis, inactivated polio vaccine and haemophilus influenzae type B combined Hepatitis B vaccine 14 weeks Rotavirus vaccine Diphtheria, tetanus, acellular pertussis, inactivated polio vaccine and haemophilus influenzae type B combined Hepatitis B vaccine Pneumococcal conjugated vaccine 9 months Measles vaccine Pneumococcal conjugated vaccine Chicken pox vaccine 18 months Diphtheria, tetanus, acellular pertussis, inactivated polio vaccine and haemophilus influenzae type B combined Measles vaccine 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 EMS EMERGENCY TRANSPORT SERVICES (ER24) RSA, Lesotho, Swaziland, Mozambique, Namibia and Botswana Subject to pre-authorisation In beneficiary s country of residence Transport by road Transport by air Outside beneficiary s country of residence Transport by road R1 700 per case R1 700 per case R1 700 per case R1 700 per case Transport by air R per case R per case R per case R per case 24-HOUR HELPLINE AND TRAUMA COUNSELLING (ER24) 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 Up to 30 days after discharge from a private hospital Speech therapy Occupational therapy Physiotherapy DSP applies M = R1 590 per year M+ = R2 120 per year DSP applies M = R1 590 per year M+ = R2 120 per year DSP applies M = R1 590 per year M+ = R2 120 per year M = R1 590 per year M+ = R2 120 per year PROSTHESES See page 14 See page 14 See page 14 See page 14 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 PMB and non-pmb R per event R per family per year R per implant per year R per event R per family per year R per implant per year R per event R per family per year R per implant per year R per event R per family per year R per implant per year 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 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 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) 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) R per beneficiary per year R310 per admission R per beneficiary per year (maximum R per family per year) 100% of the cost DSP: ICON R per beneficiary per year R per beneficiary per year (maximum R per family per year) 100% of the cost DSP: ICON R per beneficiary per year R310 per admission R per beneficiary per year (maximum R per family per year) 100% of the cost DSP: ICON R per beneficiary per year R320 per admission R per beneficiary per year (maximum R per family per year) 100% of the cost DSP: ICON PMB Prescribed minimum benefits ICON Independent Clinical Oncology MORP Medihelp Oncology Reference Price DSP Designated service provider * See explanation of terms for more information. TTO To take out (medicine) MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price

17 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 EVARS prosthesis R per beneficiary per year R per beneficiary per year R per beneficiary per year R per beneficiary per year Vascular/cardiac prosthesis R per beneficiary per year R per beneficiary per year R per beneficiary per year R per beneficiary per year Health-essential functional prosthesis R per beneficiary per year R per beneficiary per year R per beneficiary per year R per beneficiary per year Hip, knee and shoulder replacements* Protocols apply In case of acute injury where replacement is the only clinically appropriate treatment modality Hospitalisation: In case of acute injury where replacement is the only clinically appropriate treatment modality Hospitalisation: In case of acute injury where replacement is the only clinically appropriate treatment modality Hospitalisation: Subject to DSP: ICPS if patient qualifies in terms of clinical criteria. If not, a R benefit applies for the hospital account and prosthesis components (combined) (Non-PMB) Prosthesis: Health-essential functional prosthesis benefits apply (Non-PMB) Prosthesis: Health-essential functional prosthesis benefits apply (Non-PMB) Prosthesis: Health-essential functional prosthesis benefits apply (Non-PMB) Intra-ocular lenses Sub-limit subject to healthessential functional prosthesis benefit 2 lenses per beneficiary per year R3 400 per lens Sub-limit subject to healthessential functional prosthesis benefit 2 lenses per beneficiary per year R3 400 per lens Sub-limit subject to healthessential functional prosthesis benefit 2 lenses per beneficiary per year R3 400 per lens Sub-limit subject to healthessential functional prosthesis benefit 2 lenses per beneficiary per year R3 400 per lens Prosthesis with reconstructive or restorative surgery External breast prostheses In and out of hospital R3 500 per family per year R7 850 per family per year R7 850 per family per year R7 850 per family per year ICPS Improved Clinical Pathway Services DSP Designated service provider EVARS Endovascular aortic replacement surgery MT 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 14

18 15 day-to-day benefits Description Benefit Benefit Benefit Benefit GPs Consultations and follow-up consultations SPECIALISTS AND EMERGENCY UNITS 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 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 over-the-counter (OTC) medicine, immunisations, contraceptives and homeopathic, herbal, naturopathic and osteopathic medicine) Please note: Original medicine when no generic equivalent is available 80% of the MMAP will apply Voluntary use of original medicine when generic equivalent is available 70% of the MMAP will apply M = R1 000 per year M+ = R2 000 per year Pooled benefit for GP consultations and acute medicine prescribed by a GP This option does not cover these benefits 100% of the MMAP Generic medicine M = R1 000 per year M+ = R2 000 per year See GP consultations Pooled benefit for acute medicine prescribed by a GP and GP consultations M = 2 GP consultations per year M+ = 4 GP consultations per year Additional and other consultations and services paid from savings account 100% of the MMAP M = R5 410 per year M+1 = R9 010 per year M+2 = R per year M+3+ = R per year 100% of the MMAP Generic medicine * M = R2 330 per year M+1 = R3 900 per year M+2 = R4 800 per year M+3+ = R5 770 per year 100% of the MMAP Generic medicine M = R3 530 per year M+1 = R5 870 per year M+2 = R7 170 per year M+3+ = R7 730 per year 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 * 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

19 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 MMAP 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 100% of the MMAP This option does not cover this benefit 100% of the MMAP Generic medicine M = R3 450 per year M+1 = R5 200 per year M+2 = R7 000 per year M+3+ = R7 500 per year 100% 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 440 per year M+ = R3 290 per year R2 340 per family per year R2 340 per family per year MHRP Medihelp Reference Price MMAP Maximum Medical Aid Price GP General practitioner 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 16

20 day-to-day benefits Description Benefit Benefit Benefit Benefit EXTERNAL PROSTHESES, MEDICAL, SURGICAL AND ORTHOPAEDIC APPLIANCES Services in and out of hospital Artificial eyes, speech and hearing aids R3 400 per family per 3-year period R3 400 per family per 3-year period Artificial limbs and wheelchairs R3 400 per family per 3-year period Medical appliances Incontinence products/supplies This option does not cover these benefits R1 060 per family per year R5 670 per beneficiary per 3-year period R4 530 per beneficiary per 3-year period R1 280 per beneficiary per year 17 Hyperbaric oxygen treatment In and out of hospital Stoma components and urine bags R530 per family per year R7 950 per beneficiary per 24-month cycle R7 950 per beneficiary per 24-month cycle CPAP apparatus Prescribed by a medical doctor R7 950 per beneficiary per 24-month cycle 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 1 composite examination per beneficiary per 24-month cycle R200 (PPN frame) 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 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 lenses (paid at the cost of bifocal lenses) per beneficiary per 24-month cycle R1 000 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 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

21 day-to-day benefits Description Benefit Benefit Benefit Benefit DENTAL SERVICES Subject to Denis managed care protocols Emergency dental services Conservative dental services Routine check-ups Oral hygiene Fluoride treatment for children 5-13 years Fissure sealants for children younger than 16 years only This option does not cover these benefits Emergency benefits additional to savings account 2 emergency visits to treat pain and sepsis per beneficiary per year (code 8104) 2 extractions per appointment (code 8201) 2 emergency root canal therapies (combined codes 8307/8132) per visit per beneficiary per year 2 per beneficiary per year (once in 6 months) 2 scale and polish treatments per beneficiary per year (once in 6 months) 2 per beneficiary per year (once in 6 months) 2 scale and polish treatments per beneficiary per year (once in 6 months) 2 per beneficiary per year (once in 6 months) 2 scale and polish treatments per beneficiary per year (once in 6 months) Fillings (treatment plans and X-rays may be requested for multiple fillings) 1 filling per tooth in 365 days Tooth extractions and root canal treatment in the dentist s chair Laughing gas (in the dentist s chair) 1 filling per tooth in 365 days 1 filling per tooth in 365 days 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 18

22 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 19 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 per lifetime Payment from date of authorisation 1 crown per family per year, once per tooth in a 5-year period This option does not cover this benefit R7 800 per beneficiary from 9-18 years per lifetime Payment from date of authorisation 2 crowns per family per year, once per tooth in a 5-year period This option does not cover this benefit R per beneficiary from 9-18 years 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 per year.

23 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 Member pays the first R9 540 Balance paid at 100% of the MT Member pays the first R8 500 Balance paid at 100% of the MT Member pays the first R7 450 Balance paid at 100% of the MT Member pays the first R6 360 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 R850 Balance paid at 100% of the MT Member pays the first R2 650 per admission Balance paid at 100% of the MT Dimension Prime 2 Non-network/ Member pays the first R3 250 per admission Balance paid at 100% of the MT Dimension Prime 3 Non-network/ Medihelp pays Member pays the first R2 650 per admission Balance paid at 100% of the MT Dimension Elite Member pays the first R2 650 per admission Balance paid at 100% of the MT Dental procedures under general anaesthesia These benefits 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. Benefit Non-network/ In hospital The removal of impacted teeth and extensive dental treatment for children younger than 5 years once per lifetime Member pays the first R2 760 per admission Difference covered at the MT (item codes for the removal of impacted teeth 8941/8943/8945 on dentist s account) Dentist s services for member s account Non-network/ Member pays the first R1 810 per admission Difference covered at the MT (item codes for the removal of impacted teeth 8941/8943/8945 on dentist s account) Dentist s services paid from savings account Non-network/ Member pays the first R780 per admission Difference covered at the MT 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 the MT 20

24 deductibles 21 options 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. Members of the Dimension Prime 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 network on the network options. The DSPs are MobileMeds and the GPs of Faranani Solutions. It is advisable for chronic medicine users to rather choose the alternative non-network options. Pre-authorisation is important Medicine benefits are applied as follows: Generic medicine 100% of the MMAP Original medicine if no generic equivalent is available 80% of the MMAP Original medicine if a generic equivalent is available 70% of the MMAP MMAP Maximum Medical Aid Price PMB Prescribed minimum benefits MT Medihelp tariff paid by Medihelp for benefits that can include a contracted tariff or the single exit price 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 in the dentist s chair (sedation cost and 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 applies. Emergency transport services (ER24) in and outside the country of residence (air and road transport) should be pre-authorised to qualify for the applicable benefit. If not pre-authorised, 50% of the benefit applies except in the case of emergency medical conditions.

25 supporting information Dimension Prime hospital network Our healthcare partners Explanation of terms Exclusions Contact us 22

26 dimension prime hospital network Members of the Dimension Prime 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 You can also phone *120*6364# on your cell phone, or download our Medihelp member app, which is available on these devices: Gauteng City/town Name Practice No Pretoria Pretoria East Private Hospital Pretoria Unitas Hospital Pretoria Zuid-Afrikaans Hospital Vanderbijlpark Cormed Clinic Vanderbijlpark Mediclinic Emfuleni Vereeniging Mediclinic Vereeniging Vereeniging Midvaal Private Hospital Gauteng 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 Pine Haven 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 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 Limpopo City/town Name Practice No Bela-Bela St Vincent s Hospital Polokwane Mediclinic Limpopo Hospital Polokwane Mediclinic Limpopo Day Clinic

27 Mpumalanga City/town Name Practice No emalahleni emalahleni Day Hospital emalahleni emalahleni Private Hospital Ermelo Mediclinic Ermelo Kriel Kriel Clinic Trust Middelburg Middelburg Private Hospital Nelspruit Kiaat Hospital Nelspruit Lowveld Hospital Nelspruit Mediclinic Nelspruit 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 Louis Leipoldt Cape Town Mediclinic Milnerton Cape Town Melomed Bellville Medical Centre 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 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 Essential information about 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. OneHealth and Optipharm OneHealth and Optipharm are Medihelp s partners in offering HIV/Aids-related services, post-exposure prophylaxis in the case of sexual assault or accidental exposure to HIV, and oncology PMB medicine. Specialist networks Two specialist networks (for Medihelp s non-network range and the Dimension Prime 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. ER24 ER24 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. Preventive care Clicks and Dis-Chem are Medihelp s designated service providers for preventive care health assessment tests. DSP MobileMeds MobileMeds is the efficient PMB chronic medicine delivery service for members of the Dimension Prime range. MobileMeds delivers your PMB medicine to your nearest Faranani doctor s practice or an address of your choice (subject to a 60% deductible). MobileMeds is brought to you by Strata Healthcare Management, Medihelp s administrator. DSPs for PMB chronic medicine (Dimension Prime range only) Members of the Dimension Prime options must obtain their PMB chronic medicine from a designated service provider (DSP) to avoid a 60% deductible. These DSPs are Optipharm and Faranani Solutions (general practitioners).,, 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. PMB Prescribed minimum benefits ICON Independent Clinical Oncology ICPS Improved Clinical Pathway Services DSP Designated service provider PPN Preferred Provider Negotiators

29 explanation of terms The back treatment programme provided by the DBC (Document-Based Care) is a nonsurgical intervention in lieu of surgery for the management of spinal column disease/conditions/ abnormalities. This approach to the treatment of back and neck pain involves an inter-disciplinary team handling the rehabilitation programme, which is individualised for each patient based on the patient s needs and clinical diagnosis. Patients are assessed to ascertain if they are eligible to participate in the programme. Chronic medicine is medicine used for the long-term treatment (three months or longer) of a chronic condition, and which meets the following requirements: It must be used to prevent and treat a serious medical condition; It must be used for an uninterrupted period of three months or longer; It must be used to sustain life, to delay the progress of a disease, and to repair natural physiology; It must be registered in South Africa for the treatment of the medical condition for which it is prescribed; and It must be the accepted treatment according to local and international treatment protocols and algorithms. Contraceptives refer to injectable, intra-uterine, transdermal and oral contraceptives. Cost means the cost of PMB services, payable in full by Medihelp if the services are registered with Medihelp as qualifying for PMB and rendered by DSPs according to accepted PMB treatment protocols. CPAP is an apparatus which provides continuous positive airway pressure to assist breathing. A cycle means the stated length of the benefit cycle commencing on the date of the first service and thereafter calculated from the date of each subsequent service. Deductibles are the difference between the cover provided by Medihelp and the cost/tariff charged for the medical service, and are payable directly to the service provider. Deductibles are applicable in the following cases: When doctors and other providers of medical services charge fees which exceed Medihelp s tariffs, the member is responsible for paying the difference between the amount charged and the amount which Medihelp pays; When Medihelp s benefit allocation is not 100%, or where the cost exceeds the limit available for the service (e.g. for medical, surgical and orthopaedic appliances); and When the member chooses not to obtain services from a designated service provider (e.g. the ICON network in the case of oncology) or when a pre-determined deductible is applicable to a specific benefit as indicated per benefit option. An emergency medical condition means any sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide such treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person s life in serious jeopardy. An emergency medical condition must be certified as such by a medical practitioner. Emergencies qualify for PMB and must therefore also be registered for PMB (see also PMB ). EVARS prosthesis means endovascular aortic replacement surgery and is considered when the patient suffers from an aortic aneurysm with an accompanying risk for anaesthesia. A formulary consists of a scientifically compiled list of cost-effective and appropriate chronic medicine applicable to the Dimension Prime options. Hospital benefits refer to benefits for services rendered by a hospital during a patient s stay in hospital. Services include ward accommodation and ward medicine, standard radiology and pathology, physiotherapy and other supplementary services rendered during hospitalisation. Hospital benefits are subject to pre-authorisation and Medihelp pays 80% of the hospital account if the admission is not pre-authorised. 65% benefits are paid on the Dimension Prime options in case of a voluntary admission to a non-network hospital. Emergency admissions must be registered on the first workday following the admission (see also emergency medical condition ). Procedure-specific deductibles may apply on the Dimension range. The Maximum Medical Aid Price (MMAP) is the reference price used by Medihelp to determine benefits for acute and chronic medicine. The MMAP is the average price of all the available generic equivalents for an ethical patented medicine item. The Medihelp Reference Price (MHRP) is applicable to all pre-authorised PMB medicine. The price is determined according to the most cost-effective treatment based on evidence-based principles. The MHRP will differ for the different benefit options and is subject to change (e.g. when new generic equivalents are introduced to the market). Please visit Medihelp s website at (member site) for the latest MHRP. Members are advised to consult their doctor when using PMB medicine to make sure they use medicine on the MHRP where possible and so prevent or reduce deductibles. Medihelp tariff refers to the tariff paid by Medihelp for different medical services, and can include for example the contracted tariff for services agreed with certain groups of service providers such as hospitals, the Medihelp Dental Tariff for dental services, and the single exit price for acute medicine. The various tariffs are defined in the Rules of Medihelp. 26