Medshield Premium Plus 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.

Premium Plus
2018 Costs:
Total Cost pm:

Main member:

R

Adult:

R

Child:

R
2019 Costs:
Total Cost pm:

Main member:

R5,370
(11.18%)

Adult:

R4,917

Child:

R1026
Savings: R12,888 R11,796 R2,460
Above Threshold: 4,535 3,400 2,270
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In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Premium Plus
Scheme Benefits: Gap Benefits:
Specialists:
  • 100%-200% scheme rate
  • You or gap cover pay the balance, if any
Hospital Choice:
  • Choose any hospital
Specialised Radiology: 2018 benefits coming soon. 2017 benefits:
  • R21,550 per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • Physio: R2,500 per person
Transplants:
  • Covered
Co-payments:
  • Endoscopic procedures: R1,000 co-payment
  • Functional Nasal Surgery: R1,000 co-payment
  • Laparoscopic procedures: R2,000 co-payment
  • Arthroscopic procedures: R2,000 co-payment
  • Wisdom teeth: R2,000 co-payment
  • Hernia Repair (except in infants): R3,000 co-payment
  • Back and Neck surgery: R4,000 co-payment
  • Nissen Fundoplication: R5,000 co-payment
  • Hysterectomy: R5,000 co-payment
  • non-PMB internal prosthesis: 25% co-payment
Alternatives to hospitals:
  • Physical rehab, sub acute, nursing services, hospice: R120,000 per family, only immediately following an event
  • Terminal care: R33,500 per family, as sublimit of above
Casualty:
  • From day-to-day benefit, unless PMB
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):
Premium Plus
Scheme Benefits Gap benefits
Main: Adult: Child:
General info:
GP consultations:
  • From day-to-day benefit, unless PMB
  • 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:
  • 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:
  • R24,000 per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • From day-to-day benefit, unless PMB
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MATERNITY BENEFITS:
Premium Plus
Scheme Benefits Gap benefits
Hospital stay:
  • 200% scheme rate, including home births
Consultations:
    Medshield pays for:
  • 12 consults
  • Antenatal classes: R500 per family
  • Postnatal consults: 4 per pregnancy
Scans:
  • 2x 2D scans
  • 1 x Amniocentesis
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CANCER (ONCOLOGY):
Premium Plus
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Overall limit: Unlimited
  • Active treatment, incl stoma therapy, incontinence therapy and brachytherapy: Unlimited, subject to ICON Enhanced protocols
  • Oncology Medicine: R318,000 per family, subject to overall oncology limit
  • Specialised and biological drugs (oncology and non-oncology): Subject to Oncology Medicine Limit
  • PET and PET-CT: R20,225 per family, with a 10% co-payment for non-PMB
  • Social worker: 6 visits per family
  • Macular degeneration: R40,000 per family, subject to overall oncology limit
  • Breast reconstruction: R80,000 per family
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DENTISTRY:
Premium Plus
Scheme Benefits Gap benefits
Standard Dentistry:
  • Standard dentistry: day-to-day benefit
Specialised Dentistry:
  • Specialised dentistry: R16,500 per year, including implants, orthodontic treatment, wisdom teeth, crowns, bridges, inlays, partial metal base dentures, periodontics, study models
  • Crowns, bridges, inlays, partial metal base dentures, periodontics, study models: from day-to-day benefits, up to specialised dentistry limit
In-Hospital Dentistry:
  • Maxilo-facial surgery: R16,500 per family, non elective surgery only
  • In-hospital: only for children under 6yrs
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • Maxillo-facial and oral surgery: R16,500 per family, non-elective surgery only
  • Maxillo-facial surgery: 200% scheme rate
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MEDICATION:
Premium Plus
Scheme Benefits Gap benefits
Chronic:
  • Conditions covered: CDL conditions
  • Co-payment for use of non-formulary: 40%
Acute (presrcibed) medication:
  • From day-to-day benefit
Over-the-counter:
  • From day-to-day benefit, unless PMB, limited to R210 per script
Birth Control:
  • R160 per month per female
  • Mirena: 1 per female, if done in doctor's rooms.
On Discharge:
  • R750 supply
Biological:
  • No benefit, unless PMB level of care
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OPTOMETRY:
Premium Plus
Scheme Benefits Gap benefits
Optometry:
Limit:From day-to-day benefit, every 2 years
Consult:from above
Frames:from above
Single lensesfrom above
Bifocals:from above
Multifocalsfrom above
Contactsfrom above
Refractive Surgery:R16,200 per family, paid by scheme
Notes:Reading glasses: R160
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MENTAL HEALTH:
Premium Plus
Scheme Benefits Gap benefits
In-hospital:
Out-of-hospital:
  • R4,470 per family, included in above overall limit
Trauma:
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OTHER BENEFITS:
Premium Plus
Scheme Benefits Gap benefits
General Appliances:
  • Overall limit: R5,670 per family
  • Peak flow meters, nebulizers, glucometers and blood pressire monitors: R750 per person, subject to overall limit
  • Stoma products etc: unlimited if pre-authorised
  • CPAP apparatus: part of overall limit
  • Oxygen therapy equipment: unlimited if pre-authorised
  • Home ventilators: unlimited if pre-authorised
  • No benefit
1.1. Hearing Aids:
  • See Overall Appliance limit
  • No benefit
1.2. Wheelchairs:
  • See Overall Appliance limit
  • No benefit
Dialysis:
  • Unlimited, subject to DSP use
HIV:
  • No benefit
Emergency Transport:
  • No benefit
International Insurance:
  • R1 million per journey, subject to conditions.
  • No benefit
Other:
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WELLNESS/PREVENTATIVE BENEFITS:
Premium Plus
Scheme Benefits Gap benefits
Flu vaccination:
  • R95, 18yrs+
  • No benefit
Pneumonia vaccines:
  • Covered, for high risk individuals and 60yrs+
  • No benefit
Back Rehabilitation Programme:
  • No benefit
Biometric Screening:
  • Covered, 18yrs+
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • Covered
  • No benefit
Mammogram:
  • Covered, 40yrs+ every 2 years
  • No benefit
PAS Test:
  • No benefit
HIV Test:
  • Covered
  • No benefit
Other:
  • Bone Density: Covered, 50yrs+ every 3 years
  • TB test
  • Adult vaccinations: R1,430 per family
  • HPV vaccination: Covered
  • No benefit
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PROSTHETICS:
Premium Plus
Scheme Benefits Gap benefits
Overal Limit:
  • Internal and external: R56,700 per family, with a 25% co-payment for non-PMB internal prosthesis cases
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