Medimed Essential E medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB. Pay for all children. Income-limited plan: R17,001+pm only

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,990 R1,990 R440
Children: Pay for all children
Income limit: R17,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,388 R2,388 R528

Compare with these plans:
Hospital Choice:
  • Network, or a 20% co-payment applies
Specialised Radiology:
  • 3 scans per family, up to R10,000 per family, in and out of hospital
Supplementary Services: (Physio, etc)
  • R2,000 per person
Transplants:
  • R50,000 per family
  • Benefit is shared with Dialysis and Oncology Benefit
Co-payments:
Alternatives to hospitals:
  • R6,000 per person

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Network GPs: Unlimited, paid by scheme
  • Non-network GPs: 6 consults per person, paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,990 R1,990 R440
Children: Pay for all children
Income limit: R17,001+ (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R2,388 R2,388 R528

Compare with these plans:

Specialists consultations:
  • R3,000 per person and R6,000 per family
  • Paid by scheme
Pathology:
  • Unlimited
  • Paid by scheme
General radiology:
  • Unlimited
  • Paid by scheme
Specialised radiology:
  • 3 scans per family, up to R10,000 per family, in and out of hospital.
  • Paid by scheme
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit
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    MATERNITY BENEFITS:
    Hospital stay:
    • Covered
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R1,990 R1,990 R440
    Children: Pay for all children
    Income limit: R17,001+ (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R2,388 R2,388 R528

    Compare with these plans:

    Consultations:
    • No additional benefits (see out-of-hospital GP and Specialist benefit)
    Scans:
    • No additional benefits (see out-of-hospital radiology benefit)

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    CANCER (ONCOLOGY):
    Overall coverage (in and out of hospital):
    • R50,000 per family, shared with dialysis and organ transplants benefit

    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: R1,990 R1,990 R440
    Children: Pay for all children
    Income limit: R17,001+ (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R2,388 R2,388 R528

    Compare with these plans:

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    DENTISTRY:
    Dentistry:
    • R3,200 per person and R5,500 per family
    • One set of plastic dentures every two years
    • In-hospital (wisdom teeth and children under 12): R7,000 per family
    • Paid by scheme
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R1,990 R1,990 R440
    Children: Pay for all children
    Income limit: R17,001+ (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R2,388 R2,388 R528

    Compare with these plans:

    Orthodontics: See above
    Maxillo Facial Surgery: See above

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    MEDICATION:
    Chronic:
    • PMB chronic: paid by scheme on authorisation
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R1,990 R1,990 R440
    Children: Pay for all children
    Income limit: R17,001+ (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R2,388 R2,388 R528

    Compare with these plans:
    Acute (presrcibed) medication:
    • Unlimited if prescribed by GP according to formulary
    • Paid by scheme
    Over-the-counter:
    • R100 per prescription, and R400 per family
    • Paid from day-to-day benefit
    Birth Control:
    On Discharge:
    • See "Acute Medicine" benefit
    Notes:
    • For acute medicine not on the formulary: if there is a generic equivalent on the formulary, scheme will pay maximum of formulary generic alternative. If there is no generic equivalent, the member pays full amount out-of-pocket.

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    OPTOMETRY:
    Optometry:
    • Eye test: R235 per person every 2 years at network provider
    • Frames: R200 per person every two years
    • Lenses: R140 per person for single vision or R310 per person for bi/multifocals every 2 years
    • Contact Lenses: R650 per person, every 2 years as an alternative to glasses
    • Paid by scheme
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R1,990 R1,990 R440
    Children: Pay for all children
    Income limit: R17,001+ (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R2,388 R2,388 R528

    Compare with these plans:

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    MENTAL HEALTH:
    In-hospital:
    • R4,000 per person
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R1,990 R1,990 R440
    Children: Pay for all children
    Income limit: R17,001+ (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R2,388 R2,388 R528

    Compare with these plans:


    Out-of-hospital:
    • R3,000 per person and R6,000 per family, shared with out-of-hospital specialist benefit

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    OTHER BENEFITS:
    General Appliances:
    • Paid from day-to-day benefit
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R1,990 R1,990 R440
    Children: Pay for all children
    Income limit: R17,001+ (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R2,388 R2,388 R528

    Compare with these plans:

    1.1. Hearing Aids:
    • See "General Appliances" limit
    1.2. Wheelchairs:
    • See "General Appliances" limit
    Dialysis:
    • R50,000 per family, shared with organ transplant and oncology benefits
    HIV:
    • Unlimited, subject to protocols
    Emergency Transport: ER 24
    International Coverage:
    Other:

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    WELLNESS/PREVENTATIVE BENEFITS:
    Flu vaccination:
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R1,990 R1,990 R440
    Children: Pay for all children
    Income limit: R17,001+ (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R2,388 R2,388 R528

    Compare with these plans:

    Pneumonia vaccines:
    Back Rehabilitation Programme:
    Biometric Screening:
    Child Immunisation:
    Pap Smear:
    Mammogram:
    PAS Test:
    HIV Test:

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    PROSTHESIS:
    Overal Limit:
    Overall Annual Limit (OAL):
    Unlimited overall, with sub-limits
    Contributions:
    Main: Adult: Child:
    Total Cost: R1,990 R1,990 R440
    Children: Pay for all children
    Income limit: R17,001+ (other limits)
    Day-to-Day Benefit:
    Out-of-hospital, scheme pays for some: specialised radiology, GPs, specialists, medication, dentistry, optometry, radiology and pathology. Limits apply. All else paid from savings or out of pocket, unless PMB.
    Main: Adult: Child:
    (S) Savings: R2,388 R2,388 R528

    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