DSP 100 Medihelp Necesse Plan Comparison 2013
User Manual: DSP-100
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Necesse is Medihelp’s income-based network option which
offers primary and hospital care at a network of private
providers at a highly competitive rate.
• Choose any doctor within the Necesse network of over 1,200 GPs
nationwide. Visit our website at www.medihelp.co.za or dial
*120*6364# on your cell phone for a list of network doctors.
• Authorised specialist visits on referral from your Necesse network doctor.
• Basic dental services provided by a network of over 1,000 dentists.
• Optometry benefits are provided by a nationwide network of more than
2,000 optometrists.
• Pathology services provided by a network of providers.
• Acute medicine on the approved Necesse medicine list (formulary) is
available from your dispensing network doctor or on prescription from a
Medihelp network pharmacy.
• Pre-authorised chronic medicine for CDL conditions included.
•This option has no overall annual limit and focuses on making private healthcare services more accessible.
• Contributions are based on income and a network of private healthcare professionals provides access to quality care.
(network option)
• Necesse offers a hospital network of over 120 private facilities nationwide.
• Your Necesse network doctor or specialist on referral should admit
you to hospital.
• Hospital admissions require a referral from your Necesse doctor or specialist
and must be pre-authorised. Emergency admissions can be authorised on
the first workday after admission.
• Emergency transport services are provided by ER24.
Necesse subscription is based on three income categories ranging from R7,500
or less to the highest category of R11,001 and more ensuring that low income-
earners are also provided access to quality private healthcare.
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H
• Consultations 100% of the scheme tariff
Pre-authorisation from the 9th consultation per family
per year onwards
100% of the contracted tariff
According to formulary
Co-payments may apply
100% of the scheme tariff
R200 per beneficiary per year, maximum R68 per event
100% of the Necesse formulary
Co-payments may apply
Services rendered not during hospitalisation
100% of the scheme tariff
20% co-payment if not pre-authorised
• Black and white X-rays and soft-tissue
ultrasounds
100% of the scheme tariff
Necesse formulary applies
100% of the contracted tariff
Necesse formulary applies
Co-payments apply if services are rendered by
non-preferred providers
• Pre- and post-natal care provided by a
Necesse network doctor
• Midwife services by a registered practising
nurse
100% of the scheme tariff
• Gynaecologist services on referral by a
Necesse network doctor
100% of the scheme tariff
2 consultations per beneficiary
20% co-payment if not on referral
• Sonars (2D) on referral by a Necesse
network doctor or specialist
100% of the scheme tariff
2 two-dimensional sonars per beneficiary
Subject to pre-authorisation and clinical
protocols
• Hospitalisation
• Midwifery and confinement/delivery
• Gynaecologist and anaesthetist services
100% of the contracted tariff
Unlimited
20% co-payment per unauthorised non-emergency
admission or services rendered by a non-network
hospital
Subject to pre-authorisation and clinical
protocols
• Hospitalisation
• Midwifery and confinement/delivery
• Gynaecologist and anaesthetist services
100% of the contracted tariff
In the case of an elective caesarean section - R17,970
per confinement
20% co-payment per unauthorised non-emergency
admission or services rendered by a non-network
hospital
Subject to pre-authorisation
• Professional nursing fee
• Equipment
• Material and medicine
100% of the contracted/scheme tariff/medicine price
R9,000 per event for home delivery
Optometric examinations
Benefits are available per 2-year cycle
1 comprehensive consultation, including refraction test,
tonometry and visual fields test
• Spectacles or contact lenses
Benefits are limited to either spectacles
or contact lenses
• Spectacles
• Frame R150 (PPN frame)
• Lenses
One pair of standard
high-quality clear lenses
Clear single vision lenses
or
Clear Aquity bifocal lenses
• Contact lenses R395 (only PPN optometrists)
100% of the scheme tariff
R1,460 per member per year or
R2,240 per family per year
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Subject to clinical treatment guidelines and
managed care interventions
• Routine check-ups
(full mouth examination)
100% of the Medihelp Dental Tariff
1 consultation per beneficiary per year
• Oral hygiene
Fluoride treatments (Item codes:
8155/8159) and fissure sealants for
children <16 only (Item code: 8161)
100% of the Medihelp Dental Tariff
1 scale and polish treatment per beneficiary per year
• Fillings
(Item codes: 8341/8342/8343/8344/
8351/8352/8353/8354)
100% of the Medihelp Dental Tariff
4 teeth per beneficiary, once per tooth in 365 days
• Root canal therapy and extractions 100% of the Medihelp Dental Tariff
Limited to 2 teeth per beneficiary per year
• Medicine prescribed by a dentist For member’s account
• Plastic dentures
Including associated laboratory costs
100% of the Medihelp Dental Tariff
1 set of plastic dentures (an upper and lower set) per
family in a 24-month cycle for patients 21 years and
older
Co-payment of 20% on Medihelp Dental Tariff applies
• Laughing gas in Denis network dentist’s
rooms
100% of the Medihelp Dental Tariff
• Dental procedures under conscious
sedation in the Denis network dentist’s
chair for extensive dental treatment only
Subject to pre-authorisation
• X-rays: Intra-oral 4 per beneficiary per year
• X-rays: Extra-oral 1 per beneficiary in a 3-year period
• Specialist consultations
100% of the contracted/scheme tariff
R2,240 per single member or
R3,180 per family per year
20% co-payment on consultation if not referred by a
Necesse network doctor
Benefits are subject to pre-authorisation by Medihelp
• Surgical and non-surgical procedures
• Diagnostic endoscopic procedures
performed in the specialist’s rooms
100% of the Necesse formulary
Co-payments may apply
Subject to the definition on p29
100% of the cost
Unlimited
• Outpatient and emergency consultations
(non-PMB cases)
• Medicine and services rendered by a non-
network general practitioner
• Pathology requested by a non-network
general practitioner (Lancet or Pathcare)
according to list of pathology codes
80% of the scheme tarrif
R780 per member per year
R1,560 per family per year
• Radiology
• Facility fee For member’s account
• Emergency transport services by road/air
within the borders of South Africa only
100% of the contracted tariff/cost
Phone 084 124 for advice in a medical emergency
Subject to pre-registration, pre-authorisation,
protocols and case management
• Intensive care units and high-care wards
• Ward accommodation
• Theatre costs
• Consultations by network general
practitioners or specialists
• Treatment and ward medicine
• Surgery and anaesthesia
100% of the contracted/scheme tariff/medicine price
Unlimited
20% co-payment per unauthorised non-emergency
admission or admission to a non-network hospital
100% of the medicine price
R260 per admission
Subject to pre-authorisation and clinical
protocols
100% of the cost
During hospitalisation
100% of the scheme tariff
R6,740 per family per year
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During hospitalisation
Pathology services should be rendered by
Lancet or Pathcare 100% of the contracted/scheme tariff
R20,780 per family per year
During hospitalisation
Services rendered during hospitalisation
100% of the scheme tariff/cost
Services rendered during and not during
hospitalisation
100% of the scheme tariff
R15,150 per family per year
Services rendered during hospitalisation
100% of the scheme tariff
R15,150 per family per year
Benefits are subject to pre-authorisation,
Denis clinical protocols, referral and rendered
by a Denis network dentist.
• Trauma cases (PMB only)
100% of the cost
• Extensive dental treatment for very
young children only
20% co-payment per unauthorised non-emergency or
services rendered by a non-network hospital
Services rendered during and not during
hospitalisation must be pre-authorised
• MRI and CT scans
100% of the scheme tariff
R11,230 per family per year
Subject to pre-authorisation and case
management
100% of the contracted tariff
R15,150 per family per year
20% co-payment per unauthorised admission to
sub-acute care facilities
General day-to-day care excluded (such as bathing)
100% of the cost
Unlimited
Co-payments may apply
• Chemotherapy and radiotherapy
• Surgery
100% of the cost
Unlimited
Co-payments may apply
Subject to registration on the management programme
provided by ICON
• Antiretroviral therapy and treatment by
DSP
100% of the cost
Unlimited
Co-payments may apply
Subject to registration on the management programme
provided by Optipharm
100% of the cost
Unlimited
Co-payments may apply
Subject to pre-registration, pre-authorisation,
protocols and case management
•Professional psychiatric services
• Ward accommodation
• Medicine and materials supplied or
administered during hospitalisation
100% of the contracted/scheme tariff/medicine price
20% co-payment applies to non-authorised and non-
network hospital admissions
• Applicable medicine dispensed and
charged by the hospital on the day of
discharge from hospital
100% of the medicine price
R260 per admission
(acute and chronic)
• Rendered by a designated service
provider
100% of the contracted tariff
Subject to pre-authorisation and enrolment on the
dialysis management programme
• Internally implanted prosthesis 100% of the scheme tariff/cost
• External prosthesis
100% of the scheme tariff/cost
R6,740 per family per year
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DTP – Diagnosis Treatment Pairs ICON – Independant Clinical Oncology Network CDL – Chronic Diseases List
R828 R1,020 R1,182
R654 R798 R924
R354 R444 R510
* If the member’s gross monthly income (before deductions) is more than R11,001, no proof of income is required.
This is a summary of the Necesse benefit option. In the case of a dispute, the registered Rules of Medihelp will apply,
subject to approval by the Registrar of Medical Schemes. All limits are valid for one year, unless otherwise indicated.
If a beneficiary joins during the course of a financial year, the benefits (limits) are calculated pro rata according to the
remaining number of months per year.
If no proof of income can be provided your subscription will be based on the highest income category.
Basic salary, overtime, commission
Bonuses (all types, e.g. 13th cheque,
production bonus etc.)
Allowances (all types, e.g. car/travelling, cell
phone etc.)
Fringe benefits (e.g. company car)
Past months’ official pay slips
Latest tax assessment – ITA 34
IRP 5 of previous tax year
Past months’ commission and bank statements*
Interest
Dividends
Rental income
Letter of auditor/accountant/tax adviser
Latest tax assessment – ITA 34
IT3(a) and past months’ bank statements*
Rental income – rental agreement and past three
months’ bank statements* indicating deposists
Income from vocation/profession
Total income from business
Latest tax assessment – ITA 34
Letter of auditor/accountant/tax adviser
Past months’ commission and bank statements*
Income from trusts
Latest tax assessment – ITA 34
Letter of auditor/accountant
Individuals who earn no income from a
vocation/profession/business
UIF payments and bank statements*
Income of person paying the subscriptions
Income from pensions or annuities
Latest tax assessment – ITA 34
Past months’ bank statements* indicating the
pension deposits
Past months’ pension payment advices
(Members without dependants)
Notice/letter on official letterhead of tertiary
institution where registered
A copy of relevant year’s student card
* Only bank statements indicating the account holder’s initials and surname will be accepted. Please indicate clearly
which payment refers to your income.
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You must choose a general practitioner (GP) in the Necesse network to visit.
Your network doctor will refer you to a physiotherapist, specialist and other
medical practitioners if required. You have to obtain pre-authorisation from
Medihelp from your 9th consultation (the family’s visits combined) onwards
by sending an SMS to Medihelp.
The Necesse network doctor and other medical practitioners will submit
claims directly to Medihelp. If you have paid the account yourself, you can
submit qualifying claims to Medihelp for a refund.
Please remember that only emergencies which meet the definition of an
emergency on this brochure (see “Explanation of terms”) will qualify for
Prescribed Minimum Benefits (PMB) and must be registered as such with
Medihelp.
Should you require medicine, your network GP will provide you with the
medicine if he/she is a dispensing doctor, or he/she will provide you with
a prescription for medicine listed on the Necesse formulary. Medicine on
prescription must be obtained from a pharmacy in the Medihelp Preferred
Pharmacy Network.
Only chronic medicine prescribed for the treatment of diseases on the
Chronic Diseases List (CDL) will qualify for benefits. Chronic medicine must be
registered with Medihelp. Your network doctor will complete an application
form to register the chronic medicine and you will receive a schedule of all
authorised medicine. Authorised chronic medicine should be obtained from a
pharmacy or courier pharmacy in the Medihelp Preferred Pharmacy Network.
Your network GP will refer you to a specialist if required. This entails that your
network doctor completes a specialist referral form which will be used to
obtain pre-authorisation for the specialist visit from Medihelp.
Your network doctor or the specialist you’ve been referred to must refer you
to a physiotherapist, occupational therapist, pathologist, radiologist or other
medical practitioner if required.
If referred you may only be admitted to a Necesse network hospital. If not, a
20% co-payment on the hospital account will apply. All hospital admissions,
including for psychiatric admissions, must be pre-authorised (and emergency
admissions on the first workday following the admission).
Account
23
H
is South Africa’s leading dental benefit management company.
Medihelp’s dental benefits are managed by Denis and granted in accordance with Denis protocols, while
Medihelp members obtain services from their regular dentists. In certain cases (particularly for specialised
dentistry), benefits are subject to approval by Denis.
Tel: 086 0104 941
Fax: 086 6770 336
medihelpenq@denis.co.za
refers to pharmacies offering Medihelp the most cost-effective
professional fee structure for prescribed medicine. While standard co-payments on medicine still apply
as set out in the rules of the benefit options, members who make use of network pharmacies will not
have to pay any excess amounts in respect of higher professional fees charged by pharmacies to dispense
medicine items.
is the preferred provider for the rendering of HIV/Aids-related services and post-exposure
prophylaxis in the case of sexual assault or accidental exposure to HIV.
Tel: 086 0906 090
Emergencies: 083 564 9978
Fax: 086 0064 762
medihelp@optipharm.co.za
The optical providers manage Medihelp’s optical benefits. More
than 2,000 optometrists across South Africa are part of the PPN network. Although Medihelp members
may visit any optometrist, benefits will be paid according to the PPN tariffs and a co-payment may be
applicable should the costs exceed the benefit amount.
Tel: 086 0103 529 or
086 1101 477
www.ppn.co.za
The is the South African Oncology Consortium, the professional affiliation of South African
oncologists who determine the guidelines according to which patients receive cancer treatment.
Tel: 086 0100 678
Fax: 086 0064 762
oncology@medihelp.co.za
Our partner providing all emergency medical services is ER24. They offer emergency medical transport,
assistance and trauma counselling to Medihelp members.
Tel: 084 124
Document-based Care (DBC) offers a back treatment programme as prerequisite for spinal column
surgery to members who qualify, and if there is a DBC clinic in their vicinity. This programme is developed
by a multi-disciplinary medical team according to the patient’s clinical profile.
ICON is the Independent Clinical Oncology Network that determines clinical protocols according to
which patients of the Necesse benefit option receive cancer treatment from ICON network doctors.
Members of the Necesse benefit option can visit one of the more than 1,200 general practitioners (GPs)
located nationwide for quality primary healthcare. Please visit our website at www.medihelp.co.za for a
full list of network doctors. Alternatively you can dial *120*6364# on your cell phone to locate a network
GP near you.
This network of more than 120 facilities offers Necesse members access to tertiary (hospital) care. The
network has a national footprint and consists mainly of Netcare, Life and MediClinic hospitals. Please visit
our website for a full list of network hospitals.
This countrywide network must be used by members of the Dimension Prime Network benefit options
when they need to have planned procedures performed in hospital. Members pay a lower monthly fee
when they opt to make use of this network. The hospital network consists mainly of Netcare, Life and
MediClinic hospitals and a complete list is available on our website.
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• Routine examinations (check-ups) 100% of the MDT
1 per beneficiary per year
For member’s account
100% of the MDT
Savings account
100% of the MDT
2 per beneficiary per year
• Oral hygiene 100% of the MDT
1 scale and polish treatment and
fissure sealants for beneficiaries <16
Limited to Denis item codes
100% of the MDT
2 scale and polish treatments per
beneficiary per year
• Fillings
A treatment plan and X-rays may
be required for multiple fillings
100% of the MDT
4 teeth per beneficiary, once per tooth
in 365 days
Limited to Denis item codes
100% of the MDT
1 filling per tooth in 365 days
• Tooth extractions and root canal
treatment in the dentist’s chair 100% of the MDT
2 teeth per beneficiary per year 100% of the MDT
• Plastic dentures (including
professional and dental laboratory
fees)
100% of the MDT
1 set (upper and lower jaw) per family
in a 24-month cycle for patients
>21 years
Co-payment of 20% on total cost
applies
100% of the MDT
1 set (upper and lower jaw) per
beneficiary every 4 year period
• Partial metal frame dentures
For member’s account
100% of the MDT
1 partial frame (upper or lower jaw)
per beneficiary every 5 year period
100% of the MDT
2 partial frames (upper and lower jaw)
per beneficiary every 5 year period
• Crown and bridge work 100% of the MDT
1 crown per family per year, once per
tooth every 5 year period
100% of the MDT
2 crowns per family per year, once per
tooth every 5 year period
• Orthodontic treatment
Fixed braces – only one beneficiary
per family may begin orthodontic
treatment per calender year
100% of the MDT
R6,000 per beneficiary younger than
18 years per lifetime
100% of the MDT
R8,000 per beneficiary younger than
18 years per lifetime
• Periodontal treatment
Subject to registration on the Perio
Programme
100% of the MDT
• X-rays
• Intra-oral 4 per beneficiary per year 100% of the MDT
• Extra oral 1 per beneficiary in a 3-year period 1 per beneficiary in a 3-year period
• Dental procedures under conscious
sedation in the dentist’s chair
(sedation cost) 100% of the MDT
Extensive dental treatment only
100% of the MDT
Removal of impacted teeth only
100% of the MDT
Removal of impacted teeth and
extensive dental treatment only 100% of the MDT
Extensive dental treatment only
• Dentist’s account For member’s account 100% of the MDT
Savings account
All benefits are subject to Denis protocols, and pre-authorisation in the case of specialised dentistry.
MDT = Medihelp Dental Tariff Please refer to dental exclusions and protocols per option.
• Dental surgery under general
anaesthesia in a hospital/day clinic
only
100% of the MDT
Trauma cases (PMB only)
100% of the MDT
R2,300 co-payment per admission 100% of the MDT
R1,500 co-payment per admission 100% of the MDT
R650 co-payment per admission 100% of the MDT
R640 co-payment per admission
• Removal of impacted teeth
under general anaesthesia in a
hospital/day clinic only For member’s account
• Laughing gas (in the dentist’s chair) 100% of the MDT
For member’s account 100% of the MDT
Savings account 100% of the MDT
• Maxillofacial surgery and oral
pathology
Surgery in the dentist’s chair
• Benefits for temporomandibular
joint (TMJ) therapy is limited to
non-surgical interventions/
treatment
For member’s account
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• Oral hygiene instruction and evaluation.
• Professionally applied adult fluoride.
• Dental bleaching.
• Nutritional and tobacco counselling.
• Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments.
• Fissure sealants on patients 16 years and older.
• Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis.
• Resin bonding for restorations charged as a separate procedure to the restoration.
• Polishing of restorations.
• Gold foil restorations.
• Ozone therapy.
• Replacement of amalgam (silver) fillings with composite (white) fillings.
• Tooth-coloured fillings on molars and premolars (Necesse).
• Root canal therapy on primary (milk) teeth.
• Direct and indirect pulp capping procedures.
• Diagnostic dentures and the associated laboratory costs.
• Snoring appliances and the associated laboratory costs.
• Provisional dentures and associated laboratory costs.
• The clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to
new dentures. (The laboratory fee will be covered at the Medihelp Dental Tariff where managed care
protocols apply.)
• The laboratory cost associated with mouth guards. (The clinical fee will be covered at the Medihelp
Dental Tariff where managed care protocols apply.)
• High impact acrylic.
• Cost of gold, precious metal, semi-precious metal and platinum foil.
• Laboratory delivery fees.
• Metal base to full dentures, including the laboratory cost.
• High impact acrylic.
• Cost of gold, precious metal, semi-precious metal and platinum foil.
• Laboratory delivery fees.
• Crown and bridge procedures for cosmetic reasons and the associated laboratory costs.
• Crown and bridge procedures where there is no extensive tooth structure loss and associated
laboratory costs.
• Full mouth rehabilitations and the associated laboratory costs.
• Provisional crowns and the associated laboratory costs.
• Porcelain veneers, inlays and the associated laboratory costs.
• Emergency crowns that are not placed for immediate protection in tooth injury, and the associated
laboratory costs.
• Cost of gold, precious metal, semi-precious metal and platinum foil.
• Laboratory delivery fees.
• Dolder bars and associated abutments on implants, including the laboratory cost.
• Laboratory delivery fees.
• Orthodontic treatment for cosmetic reasons and associated laboratory costs.
• Orthodontic treatment for persons 18 years and older.
• Orthodontic re-treatment and the associated laboratory costs.
• Cost of invisible retainer material.
• Laboratory delivery fees.
• Surgical periodontics, which includes gingivectomies, periodontal flap surgery, tissue grafting and
hemisection of a tooth.
• Perio chip placement.
• Orthognathic (jaw correction) surgery and any related hospital cost and laboratory costs.
• Bone augmentations.
• Bone and other tissue regeneration procedures.
• Cost of bone regeneration material.
• The auto-transplantation of teeth.
• Sinus lift procedures.
• The closure of an oral-antral opening (item code 8909) when claimed during the same visit with
impacted teeth (item codes 8941, 8943 and 8945).
• Where the reason for admission to hospital is dental fear or anxiety.
• Multiple hospital admissions.
• Where the only reason for admission to hospital is to acquire a sterile facility.
• The cost of dental materials for procedures performed under general anaesthesia.
• The hospital and anaesthetist claims for the following procedures will not be covered when performed
under general anaesthesia:
• Apicectomies.
• Dentectomies.
• Frenectomies.
• Conservative dental treatment (fillings, extractions and root canal therapy) in hospital for adults.
• Professional oral hygiene procedures.
• Implantology and associated surgical procedures.
• Surgical tooth exposure for orthodontic reasons.
• Removal of impacted teeth in hospital (Necesse).
• Special reports.
• Dental testimony, including dento-legal fees.
• Behaviour management.
• Intramuscular and subcutaneous injections.
• Procedures that are defined as unusual circumstances and unlisted procedures.
• Appointments not kept.
• Treatment plan completed (code 8120).
• Electrognathographic recordings, pantographic recordings and other such electronic analyses.
• Caries susceptibility and microbiological tests.
• Pulp tests.
• Cost of mineral trioxide.
• Enamel microabrasion.
• Medicine prescribed by a dentist (Necesse).
• Specialised dentistry: crowns and bridges, implants, orthodontics, periodontics and maxillofacial
surgery (Necesse).
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• Services which are not mentioned in the Rules as well as services which in the opinion of the Board
of Trustees, are not aimed at the generally accepted medical treatment of an actual or a suspected
medical condition or handicap, which is harmful or threatening to necessary bodily functions (the
process of ageing is not considered to be a suspected medical condition or handicap).
• Travelling and accommodation/lodging costs, including meals as well as administration costs of a
beneficiary and/or service provider.
• Aptitude, intelligence/IQ and similar tests as well as the treatment of learning problems.
• Operations, treatments and procedures –
• of own choice;
• for cosmetic purposes; and
• for the treatment of obesity, with the exception of the treatment of obesity which is motivated by a
medical specialist as life-threatening and approved beforehand by Medihelp.
• Treatment of wilfully self-inflicted injuries, unless it is a prescribed minimum benefit.
• Services which are claimable from the Compensation Commissioner, an employer or any other party,
subject to the stipulations of rule 15.4.
• The completion of medical and other questionnaires/certificates not requested by Medihelp and the
services related thereto.
• Costs for evidence in a lawsuit.
• Costs exceeding the scheme tariff for a service or the maximum benefit to which a member is entitled,
subject to Annexure 2.
• Facility fees.
• Services rendered to beneficiaries outside the Medihelp network or if voluntarily obtained from a non-
designated service provider in the case of a PMB condition (Necesse).
• Injuries sustained during participation in a strike, unlawful demonstration, unrest or violent conduct,
except in the case of a prescribed minimum benefit (Necesse).
• Services rendered outside the borders of the Republic of South Africa (Necesse).
• The treatment of infertility, other than that stipulated in the Regulations to the Medical Schemes Act,
1998.
• Treatment of alcoholism and drug abuse as well as services rendered by institutions which are
registered in terms of the Prevention of and Treatment for Substance Abuse Act, 2008 (Act No 70
of 2008) or other institutions whose services are of a similar nature, other than stipulated in the
Regulations to the Medical Schemes Act, 1998.
• Treatment of impotence.
• Treatment of occupational diseases.
• Hymenectomy (Dimension Prime 1 and Necesse).
• Back and neck fusion procedures, subject to PMB (Necesse).
• Circumcision (Necesse).
• The artificial insemination of a person as defined in the National Health Act, 2003 (Act No 61 of 2003).
• Immunisation (including immunisation procedures and material) which is required by an employer,
excluding flu immunisations and standard child immunisations.
• Standard immunisation (Necesse).
• Exercise, guidance and rehabilitation programmes.
• Services rendered by social workers.
• Costs of visits at home and home programmes.
• When only accommodation is provided and/or general care services rendered.
• The cost of transport with an ambulance/emergency vehicle –
• from a hospital/other institution to a residence;
• in the event of a self-inflicted injury, unless it is a prescribed minimum benefit;
• in the event of a visit to friends/family; and
• to the rooms of a medical practitioner when the objective of the visit/consultation/treatment does
not pertain to admission in a hospital.
• The cost of harvesting and/or preserving human tissues, including, but not limited to, stem cells, for
future use thereof to treat a medical condition which has not yet been diagnosed in a beneficiary.
• Pathology services requested by a person other than a medical practitioner.
• Radiology services requested by a person other than a medical practitioner, with the exception of a
chiropractor who may request black and white X-rays.
• Breast augmentation.
• Breast reduction.
• Gastroplasty.
• Gender reversal operations.
• Lipectomy.
• Epilation.
• Otoplasty/reconstruction of the ear.
• Refractive procedures.
• Sclerotherapy.
• Hip, knee and shoulder replacements (Necesse).
• Bandages, cotton wool dressings and plasters on prescription that are not used by a supplier of service
during a treatment/procedure.
• Food substitutes, food supplements and patent food, including baby food.
• Multivitamin and multi-mineral supplements alone or in combination with stimulants (tonics).
• Slimming remedies, provided that benefits shall be considered if motivated by a medical specialist as
life-essential to be used for a limited period, and if approved beforehand by the Principal Officer.
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• All patent substances, suntan lotions, anabolic steroids, contact lens solutions as well as substances
not registered by the South African Medicines Control Council, except medicine items approved by
Medihelp in the following instances –
• medicine items with patient-specific exemptions in terms of section 21 of the Medicines and Related
Substances Control Act, 1965 (Act No 101 of 1965) as amended;
• homeopathic and naturopathic medicine items that have valid NAPPI codes; and
• where well-documented, sound evidence-based proof exists of efficacy and cost-effectiveness.
• All biological and other medicine items as per Medihelp’s medicine exclusion list.
• High technology treatment modalities, surgical devices and medication.
• Combination analgesic medicine claimed from acute medicine benefits exceeding 360 units per
beneficiary per year.
• Non-steroidal anti-inflammatory medicine claimed from acute medicine benefits exceeding 180 units
per beneficiary per year.
• Roaccutane and Retin A, or any skin-lightening agents (Necesse).
• Homeopathic and herbal medicine, as well as household remedies or any other miscellaneous
household product of a medicinal nature (Necesse).
• Oral contraceptives and contraceptive intra-uterine devices (Necesse).
• Medicine used in the treatment of a non-PMB/CDL chronic condition (Necesse).
• Vaccines administered by specialists (Necesse).
• Blood pressure and peak flow measurement apparatus.
• Motorised mobility aids/devices.
• Commode.
• Toilet seat raiser.
• Hospital beds for use at home.
• Devices to improve sight, other than spectacles and contact lenses.
• Mattresses and pillows.
• Bras without external breast prostheses.
• Insulin pumps and consumables (available only on Dimension Elite).
• Hearing aids and services rendered by audiologists and acousticians (Necesse).
The is a non-surgical intervention in lieu of surgery for the management of
spinal column disease/conditions/abnormalities. This approach to the treatment of back and neck pain is
used as an alternative to back surgery, and involves an inter-disciplinary team handling the rehabilitation
programme, which is individualised for each patient based on the patient’s needs and clinical diagnosis.
The programme is not available on the Necesse network option.
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.
MEDICHRON (Medihelp’s medicine management division) considers benefits for all chronic medicine.
is the tariff as approved by the Board of Trustees and contractually agreed with service
providers, which includes per diem, fixed and global fees.
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. Members must make co-payments in
the following cases:
• When doctors and other providers of medical services charge fees which exceed Medihelp’s scheme
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% (e.g. for acute medicine), 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 SAOC
network in the case of oncology) or when a pre-determined co-payment is applicable to a specific
benefit as indicated per benefit option.
An 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”).
is Diagnosis Treatment Pairs
shall only be considered where the patient suffers from an abdominal aortic aneurysm
with an accompanying high risk for anaesthesia.
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A can consist of, inter alia, a scientifically compiled list of medicine, e.g. for the treatment of
the 26 conditions on the Chronic Diseases List (CDL), or a list of pathology tests or appropriate radiology
tests, depending on the discipline.
necessarily replace a part of the body or a component thereof, or
perform an essential function of the body.
should take place in a controlled clinical environment to determine HIV status and
should include pre- and post-testing counselling. This test may be followed by pathology tests according
to Scheme protocols.
refer to benefits for services rendered by a hospital during a patient’s stay in
hospital. Services include ward accommodation and ward medicine, general radiology and pathology,
physiotherapy and other supplementary services rendered during hospitalisation. Hospital benefits
are subject to pre-registration and a 20% co-payment will be applicable to the hospital account if the
admission is not pre-registered. A 30% co-payment is also applicable to the Dimension Prime Network
range should the patient be admitted to a non-network hospital, and a 20% co-payment in the case of
Necesse. Emergency admissions must be registered on the first workday following the admission (see also
“emergency medical condition”). Procedure-specific co-payments may apply.
Standard are child immunisations in accordance with the guidelines set by the
Department of Health on the standard immunisation chart.
A is the maximum benefit amount which is paid for a specific service, apparatus or appliance, for
example in the case of prostheses.
include benefits for hospitalisation, PMB, trauma recovery and benefits that
complement care when patients need to recover. Co-payments and sub-limits may be applicable in some
cases.
means services pertaining to the jaws and face, particularly with reference to
specialised surgery in this region.
means a substance or mixture of substances which is accepted as being ethical by medical
science and which is registered with the South African Medicines Control Council, to be administered or
applied for the prevention, treatment or healing of an illness (see also “chronic medicine”).
refers to:
• Thewhich 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; or
• The which 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 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 co-payments.
means the benefits for dentistry in accordance with the dental schedule of the
Scheme as agreed between Medihelp and Denis.
offer benefits to members in collaboration with a medical provider network.
Members must make use of the network to qualify for benefits and prevent co-payments.
means from 1 January to 31 December of a year. Should a beneficiary enrol within a financial
year, benefit amounts will be pro-rated according to the remaining number of months of the year. All
limits are valid for a year unless otherwise indicated.
means benefits for a service must be authorised before it is rendered.
are paid for 26 chronic conditions on the CDL and 270 diagnoses
with their treatments as published in the Regulations of the Medical Schemes Act, 1998 (Act No 131 of
1998). In terms of these Regulations, medical schemes are compelled to grant benefits for the diagnosis,
treatment and care costs of any of these conditions as well as emergency medical conditions (that meet
the published definition) without imposing any limits. PMB are subject to pre-authorisation, protocols,
and the utilisation of designated service providers, where applicable, e.g. the SAOC, (or ICON in case of
Necesse) for cancer treatment.
is a service rendered to patients at their home as an alternative to hospitalisation only.
Benefits for private nursing are subject to pre-authorisation by Medihelp and exclude general day-to-day
services such as bathing and general care.
are clinical guidelines compiled by experts in the field of a specific medical condition for the
treatment of that condition based on best practice principles.
is the tariff for medical services as approved by the Board of Trustees.
means that no overall annual limit (benefit amount) or period (e.g. a 3-year cycle) applies to
the specific service/procedure. This does not refer to the number of days spent in hospital or the number
of procedures applicable.
include artificial aortic valves, pacemakers and related or connected
functional appliances.
30
Medihelp is an authorised financial services provider
OneHealth/Optipharm
Tel: 086 0906 090
Emergencies: 083 564 9978
Fax: 086 0064 762
medihelp@optipharm.co.za
Medihelp
Tel: 086 0100 678
Fax: 012 336 9540
medihelp@medihelp.co.za
Medihelp
Tel: 086 0100 678
Fax: 012 336 9523 (Necesse)
Fax: 086 0064 762 (All other benefit options)
necesse@medihelp.co.za (Necesse)
pmb@medihelp.co.za (All other benefit options)
Medihelp
Tel: 086 0100 678
Fax: 012 334 2466 (chronic and PMB medicine)
Fax: 012 334 2425 (more than 30 days’ supply)
medicineapp@medihelp.co.za
Tel: 086 0100 678
Fax: 012 336 9540
www.medihelp.co.za
medihelp@medihelp.co.za
Tel: 086 0100 678
Fax: 012 336 9540
medihelp@medihelp.co.za
Tel: 086 0100 678
Fax: 012 336 9523
hmanagement@medihelp.co.za
Tel: 086 0100 678
Fax: 086 0064 762
oncology@medihelp.co.za
Tel: 086 0200 678
Tel: 086 0100 678
Fax: 012 336 9540
medihelp@medihelp.co.za
Tel: 086 1123 267
complaints@medicalschemes.com
www.medicalschemes.com
Tel: 012 334 2428
Fax: 012 336 9538
fraud@medihelp.co.za
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