Medshield Premium Plus medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB. Pay for three children only.

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:
Hospital Choice:
  • Network
Specialised Radiology:
  • R21,550 per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • Physiotherapy: Unlimited
Transplants:
  • Unlimited
Co-payments:
Alternatives to hospitals:
  • Physical rehabilitation, sub-acute facilities, nursing services, hospice: R100,000 per family

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Paid from day-to-day benefit
  • Breast fine needle biopsy, vasectomy, prostate needle biopsy, circumcision: paid by scheme if done in rooms
  • Scopes: most paid by scheme if done in rooms
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • R21,550 per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
  • 200% scheme tariff
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:

Consultations:
  • 12 consults
  • Antenatal classes: R500 per family
  • 4 post-natal consultations with midwife
  • Paid by scheme
Scans:
  • 2x 2D scans
  • 1x Amniocentesis
  • Paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • Unlimited
  • Biological and other medicine: R318,000 per family
  • 6 visits per family from social worker, for psychological support during treatment
  • Macular degeneration: R40,000 per family
  • Breast reconstruction: R80,000 per family

Note: All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: from day-to-day benefit
  • In-hospital: unlimited, only for under 6yr olds
  • Specialised dentistry: R15,000 per family for wisdom teeth, implants and orthodontic treatment, paid by scheme
  • Crowns, bridges, inlays, dentures, periodontics, models: from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:

Orthodontics: See above
Maxillo Facial Surgery:
  • R15,900 per family

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: Additional 54 conditions covered
  • R11,910 per person and R23,815 per family, thereafter unlimited for PMBs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit, with R185 script limit
Birth Control:
  • R140 per monthly script
  • Mirena: one per female every four years. Includes consultation, insertion if done in rooms.
On Discharge:
  • R700 per admission
Notes:
  • PMB: Comprehensive formulary within limits, then Restrictive formulary
  • Out of formulary PMB or obtained from non-network provider: 40% co-payment
  • PMB: reimbursed at Maximum Generic Price

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OPTOMETRY:
Optometry:
  • Paid from day-to-day benefit
  • Refractive surgery: R15,400 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • R50,000 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:


Out-of-hospital:
  • R4,000 per family, subject to above limit

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OTHER BENEFITS:
General Appliances:
  • R5,350 per family
  • Peak flow meters, nebulizers, glucometers and blood pressure monitors: R750 per person, subject to above limit
  • Stoma products: Unlimited
  • Oxygen therapy equipment: Unlimited
  • Ventilators: Unlimited
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • Unlimited
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport:
International Coverage:
  • Up to R1 million per person per journey, with R350,000 limit on pre-existing conditions
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:

Pneumonia vaccines:
  • Covered
    • 60yrs+
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered
Mammogram:
  • Covered for 40yrs+, every 2 years.
PAS Test:
HIV Test: Covered

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,284 R3,909 R792
Children: Pay for three children only
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, maternity, alternative to hospitalisation, some non-surgical procedures including scopes, preventative benefits. Limits apply. All else paid from savings, from threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R12,852 R11,736 R2,376
Threshold (S+SP): R12,730 R11,770 R2,350
Above Threshold: 4,280 3,210 2,140

Compare with these plans:
Sub-limits:

    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