Medshield MediPhila medical aid plan: 2019

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Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

MediPhila
2018 Costs:
Total Cost pm:

Main member:

R

Adult:

R

Child:

R
2019 Costs:
Total Cost pm:

Main member:

R1,332
(16.54%)

Adult:

R1332

Child:

R342
Savings (per year):
  • No savings option on this plan
Extended Fund: RR2,800 per family R R
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In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
MediPhila
Scheme Benefits: Gap Benefits:
Specialists:
  • Up to 100% scheme rate
  • You or gap cover pay the balance, if any
Hospital Choice:
  • Choose a Network Hospital or pay a 25% co-payment if you voluntarily choose another hospital
Specialised Radiology: 2018 benefits coming soon. 2017 benefits:
  • 1 scan per family, with 10% co-payment and subject to overall hospital limit
Supplementary Services: (Physio, etc)
  • Unlimited, subject to Overall Annual Limit
  • Physio: R2,500 per person
Transplants:
Co-payments:
  • Arthroscopic procedures: R4,000 co-payment
  • Wisdom teeth: R4,000 co-payment
  • Nissen Fundoplication: R5,000 co-payment
  • Hysterectomy: R5,000 co-payment
Alternatives to hospitals:
  • Physical rehab, sub acute, nursing services, hospice: PMBs only
  • Terminal care: R11,100 per family, as sublimit of above
Casualty:
  • From day-to-day benefit, unless PMB and acute medicine limit
Other:
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)
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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
MediPhila
Scheme Benefits Gap benefits
Main: Adult: Child:
General info:
GP consultations:
  • Nominated GP: Unlimited
  • Non-nominated GP: 2 consults per family. Therafter, a 40% co-payment
  • These procedures are paid for by Medshield if done in doctor's rooms:
    • Breast fine needle biopsy
    • Prostate needle biopsy
    • Circumcision
    • Excision wedge ingrown toenail skin of nail fold
    • Drainage skin abcess/curbuncle/whitlow/cyst
    • Vasectomy
    • Excision pterygium with or without draft
    • excission ganglion wrist
    • Excission of non-malignant lesions less than 2 cm
    • Routine diagnostic endoscopic procedures
Childcare:
  • No extra benefit available
Specialists consultations:
  • 1 consult per family
  • , then from day-to-day benefit, unless PMB
Pathology:
  • From day-to-day benefit, unless PMB
General radiology:
  • From day-to-day benefit, unless PMB
Specialised radiology:
  • R8,400 per family, in and out of hospital with a 8% co-payment, unless PMB
Supplementary Services: (Physio, etc)
  • From day-to-day benefit, unless PMB
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MATERNITY BENEFITS:
MediPhila
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate, including home births
Consultations:
    Medshield pays for:
  • 6 consults
  • Postnatal consults: 4 per pregnancy
Scans:
  • 2x 2D scans
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CANCER (ONCOLOGY):
MediPhila
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • PMBs only
  • Social worker: 6 visits per family
  • Macular degeneration: R20,000 per family, subject to overall oncology limit
  • Breast reconstruction: R80,000 per family
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DENTISTRY:
MediPhila
Scheme Benefits Gap benefits
Standard Dentistry:
  • Standard dentistry: R1,270 per family
Specialised Dentistry:
  • Specialised dentistry: R5,300 per family
  • Implants, orthodontics, crowns, bridges, inlays, mounted study models, partial metal base dentures and periodontics: no benefit
In-Hospital Dentistry:
  • Maxilo-facial surgery: No benefit, unless PMB
Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • No benefit, unless PMB
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MEDICATION:
MediPhila
Scheme Benefits Gap benefits
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for use of non-formulary: 40%
Acute (presrcibed) medication:
  • Acute Medicine Limit: R1,200 per family, from day-to-day benefit
Over-the-counter:
  • R315 per person and R440 per family, from Acute Medicine Limit, limited to R70 per script
Birth Control:
  • R105 per month per female
On Discharge:
  • R160 supply
Biological:
  • No benefit, unless PMB level of care
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OPTOMETRY:
MediPhila
Scheme Benefits Gap benefits
Optometry:
Limit:R710 per person, every 2 years
Consult:from above limit
Frames:from above limit
Single lensesfrom above limit
Bifocals:from above limit
Multifocalsfrom above limit
Contactsfrom above limit
Refractive Surgery:
Notes:
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MENTAL HEALTH:
MediPhila
Scheme Benefits Gap benefits
In-hospital:
Out-of-hospital:
  • PMBs only
Trauma:
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OTHER BENEFITS:
MediPhila
Scheme Benefits Gap benefits
General Appliances:
  • Stoma products etc: PMBs only
  • CPAP apparatus: PMBs only
  • Oxygen therapy equipment: PMBs only
  • Home ventilators: PMBs only
  • No benefit
1.1. Hearing Aids:
  • No benefit, unless PMB
  • No benefit
1.2. Wheelchairs:
  • No benefit, unless PMB
  • No benefit
Dialysis:
  • PMBs only
HIV:
  • No benefit
Emergency Transport:
  • No benefit
International Insurance:
  • No benefit
Other:
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WELLNESS/PREVENTATIVE BENEFITS:
MediPhila
Scheme Benefits Gap benefits
Flu vaccination:
  • R95, 18yrs+
  • No benefit
Pneumonia vaccines:
  • No benefit
  • No benefit
Back Rehabilitation Programme:
  • No benefit
  • No benefit
Biometric Screening:
  • Covered, 18yrs+
  • No benefit
Child Immunisation:
  • No benefit
  • No benefit
Pap Smear:
  • Covered
  • No benefit
Mammogram:
  • No benefit
  • No benefit
PAS Test:
  • No benefit
  • No benefit
HIV Test:
  • Covered
  • No benefit
Other:
  • TB test
  • HPV vaccination: Covered
  • No benefit
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PROSTHETICS:
MediPhila
Scheme Benefits Gap benefits
Overal Limit:
  • Internal and external: PMBs only
Sub-limits:
  • Hips and knees: R30,000
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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised