Dimension Elite

Comprehensive medical cover, including chronic medicine and specialists.

What makes the Dimension Elite benefit option unique?

-Day-to-day benefits – ample separately insured benefits

-Major medical benefits, unlimited treatment (medical and surgical services, anaesthesia as well as material and medicines used during the rendering of a service) by GPs and specialists

– Dentistry benefits

– Optometry benefits

– Dependent children under 26 pay subscriptions for child dependants

– Preventative care – health and benefit booster

Monthly Contributions

Member	Subscription
Principal member	R2 874
Adult dependant	R2 688
Child dependant younger than 26 years	R780

Preventive Care

PREGNANCY AND BABY BENEFITS
Pregnancy benefits are subject to participation in the mom-2-be programme:

12 Pregnancy consultations & two 2D sonars per family per year
Two consultations per beneficiary in baby’s first year
Standard immunisation for children younger than 7 years

HEALTH TESTS (One test per beneficiary per year)

Blood sugar test – pathology (item codes 4050/4057)
Cholesterol test – pathology (item code 4027)
Pap smear – pathology (item codes 4566/4559)
Mammogram – radiology imaging only (item codes 3605/39175/34100/34101)

(females 40 years and older)

Prostate test – pathology (item code 4519)
(40 years and older)
HIV test (15 years and older)
Bone densitometry scan – radiology imaging only (item codes 3604/50120)
(females 50 years and older)

IMMUNISATIONS (vaccine only)

Flu vaccination – 1 per beneficiary per year
Tetanus vaccine – 1 per beneficiary per year
HPV vaccine – females between 10 and 26 years
(3 injections during the course of a year, once per lifetime)

BACK TREATMENT PROGRAMME
Back treatment programme – 1 programme per beneficiary per year at a Medihelp-appointed facility within reasonable proximity, as a prerequisite for spinal column surgery (subject to protocols and pre-authorisation)

Major Medical Benefits

	Description	Benefit
	DIAGNOSIS, TREATMENT AND CARE COSTS OF 270 PMB AND 26 CHRONIC CONDITIONS ON THE CDL Subject to protocols, pre-authorisation and DSPs	100% of the contracted tariff/cost Unlimited Co-payments may apply in case of voluntary non-DSP/non-protocol use
	BENEFITS FOR MAJOR TRAUMA THAT NECESSITATES HOSPITALISATION IN THE CASE OF: Motor vehicle accidents Stab wounds Gunshot wounds Head trauma Burns Near drowning Subject to authorisation, PMB protocols and case management	100% of the cost Unlimited
	POST-EXPOSURE PROPHYLAXIS	100% of the cost Unlimited
	EMERGENCY TRANSPORT SERVICES (ER24) RSA, Lesotho, Swaziland, Mozambique and Namibia In beneficiary’s country of residence Transport by road Transport by air	100% of the contracted tariff Unlimited
	Outside beneficiary’s country of residence Transport by road	100% of the cost R1 520 per case
	Transport by air	100% of the cost R9 930 per case
	24-HOUR HELPLINE AND TRAUMA COUNSELLING (ER24)	Phone 084 124
HOSPITALISATION (state and private hospitals and day clinics) Subject to pre-authorisation, protocols and case management Intensive and high-care wards Ward accommodation Theatre fees Treatment and ward medicine Consultations, surgery and anaesthesia		100% of the UPFS/contracted/scheme tariff/medicine price/cost Procedure-specific co-payments may apply (non-PMB cases) Unlimited 20% co-payment if not pre-authorised
Procedure-specific co-payments		See co-payments
Prostheses		See prostheses
CONFINEMENT (childbirth) Subject to pre-authorisation, protocols and case management		100% of the UPFS/contracted/scheme tariff/medicine price/cost Unlimited 20% co-payment if not pre-authorised
HOME DELIVERY Subject to pre-authorisation Professional nursing fees Equipment Material and medicine		100% of the contracted/scheme tariff/medicine price R9 500 per event 20% co-payment if not pre-authorised
STANDARD RADIOLOGY, PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES In hospital Subject to clinical protocols		100% of the contracted/scheme tariff/medicine price/cost Unlimited
SPECIALISED RADIOLOGY In and out of hospital On request of a specialist and subject to clinical protocols MRI and CT-imaging (Subject to pre-authorisation) Angiography		100% of the contracted/scheme tariff/medicine price/cost R23 400 per family per year
PHYSIOTHERAPY, OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES In hospital		100% of the contracted/scheme tariff/medicine price/cost Unlimited
OXYGEN In hospital		100% of the contracted/scheme tariff/cost Unlimited
NEUROSTIMULATORS Subject to pre-authorisation and clinical protocols Device and components		100% of the scheme tariff/cost R80 000 per beneficiary per year
RENAL DIALYSIS In and out of hospital Subject to pre-authorisation and clinical protocols		100% of the contracted/scheme tariff Unlimited
APPLICABLE PRESCRIPTION MEDICINE DISPENSED AND CHARGED BY THE HOSPITAL ON DISCHARGE FROM THE HOSPITAL (TTO) (Excluding chronic medicine)		100% of the contracted/scheme tariff/medicine price/cost R280 per admission
PSYCHIATRIC TREATMENT OF A MENTAL HEALTH CONDITION Subject to pre-authorisation, services rendered in an approved facility and prescribed by a medical doctor Professional services rendered in and out of hospital by a psychiatrist General ward accommodation Medicine supplied during the period of the treatment in the institution Outpatient consultations		100% of the contracted/scheme tariff/medicine price/cost R25 400 per beneficiary per year (maximum R35 200 per family per year) 20% co-payment if not pre-authorised
ONCOLOGY PMB cases Subject to pre-authorisation and registration on the Medihelp Oncology Management Programme Radiotherapy, including brachytherapy Chemotherapy and associated adjuvant medicine (medicine subject to the MORP)		100% of the contracted/scheme tariff/medicine price/cost Unlimited ICON enhanced protocols Co-payments apply for voluntary non-network services (10%) and/or deviating from protocol (15%)
Bone marrow/stem cell transplants		100% of the scheme tariff/cost Subject to protocols
Non-PMB cases Subject to pre-authorisation and registration on the Medihelp Oncology Management Programme Radiotherapy, including brachytherapy Chemotherapy and associated adjuvant medicine (medicine subject to the MORP)		100% of the contracted/scheme tariff/medicine price/cost R21 200 (in and out of hospital) ICON enhanced protocols Co-payments on voluntary obtained non-network services (10%) and/or treatment deviating from protocol (15%)
HOSPICE SERVICES AND SUB-ACUTE CARE FACILITIES AS AN ALTERNATIVE TO HOSPITALISATION Subject to pre-authorisation, and services rendered in an approved facility and prescribed by a medical doctor		100% of the contracted/scheme tariff/medicine price/cost Unlimited 20% co-payment if not pre-authorised
PRIVATE NURSING AS AN ALTERNATIVE TO HOSPITALISATION Subject to pre-authorisation (Excluding general day-to-day care)		100% of the contracted/scheme tariff/medicine price/cost 20% co-payment if not pre-authorised

UPFS – Uniform Patient Fee Schedule
EMS – Emergency medical service
CDL – Chronic Diseases List
DSP – Designated service providers
MRI – Magnetic resonance imaging
CT – Computerised tomography
PMB – Prescribed Minimum Benefits
TTO – To take out (medicine)
ICON – Independent Clinical Oncology Network
MORP – Medihelp Oncology Reference Price

Procedure-Specific Co-Payments

Description	Co-payment
All hospital admissions are subject to pre-authorisation, protocols and case management	Covered at: 100% of the UPFS/contracted/ scheme tariff/medicine price/cost 20% co-payment if not pre-authorised
NECK AND BACK FUSIONS	R6 000 per admission
ENDOSCOPIC PROCEDURES In hospital Gastrointestinal Colonoscopy Arthroscopy Sigmoidoscopy Renal endoscopy Endoscopic procedures of prostate Laparoscopy	R2 350 per admission
DENTAL PROCEDURES UNDER GENERAL ANAESTHESIA In hospital Subject to pre-authorisation and Denis managed care protocols For the removal of impacted teeth and extensive dental treatment for children younger than 5 years only	R680 per admission 100% of the Medihelp Dental Tariff Only for removal of impacted teeth and extensive dental treatment for children younger than 5 years – once per lifetime

Internally Implanted Prostheses

Description	Benefit
All hospital admissions are subject to pre-authorisation, protocols and case management	Covered at: 100% of the UPFS/contracted/scheme tariff/medicine price/cost 20% co-payment if not pre-authorised The member is liable for the difference in cost should PMB spinal, hip, knee and cardiac prostheses not be obtained from the DSP
INTERNALLY IMPLANTED PROSTHESES EVARS prosthesis	R93 400 per beneficiary per year
Vascular/cardiac prosthesis	R40 000 per beneficiary per year
Health-essential functional prosthesis Intra-ocular lenses	R44 300 per beneficiary per year Sub-limit: 2 lenses per beneficiary per year R3 070 per lens
Hip, knee and shoulder replacements For the hospital account and prosthesis components	100% of the UPFS/contracted/scheme tariff/medicine price/cost Performed by ICPS supplier Subject to patients who qualify in terms of the clinical criteria of the DSP Scheme only pays R14 100 per admission for hospital account and prosthesis components (combined) if patient doesn’t qualify
Prosthesis with reconstructive or restorative surgery and external breast prostheses In and out of hospital	R7 000 per family per year

UPFS – Uniform Patient Fee Schedule
ICPS – Improved Clinical Pathway Services
DSP – Designated service provider

Day-to-Day Benefits

Description	Benefit
GPs, SPECIALISTS AND EMERGENCY UNITS Treatment (medical and surgical services, anaesthesia as well as material and medicines used during the service)	100% of the contracted/scheme tariff/medicine price/cost Unlimited
Consultations and follow-up consultations	100% of the contracted/scheme tariff/medicine price/cost M = R2 070 per year or M+ = R3 980 per year
PHYSIOTHERAPY Treatment and material
CLINICAL PSYCHOLOGY AND PSYCHIATRIC NURSING
OCCUPATIONAL AND SPEECH THERAPY, DIETICIAN SERVICES, AUDIOMETRY, PODIATRY, MASSAGE, ORTHOPTIC, CHIROPRACTIC, HOMEOPATHIC, HERBAL AND NATUROPATHIC, OSTEOPATHIC AND BIOKINETIC SERVICES
MEDICINE Medicine obtained in the Medihelp Preferred Pharmacy Network and prescribed/dispensed by a medical doctor Acute medicine (including medicine dispensed at an emergency unit and over-the-counter (OTC) medicine, immunisations, contraceptives and homeopathic, herbal, naturopathic and osteopathic medicine)	80% of the medicine price (MMAP) M = R3 130 per year or M+ = R5 940 per year
Chronic non-PMB medicine Subject to pre-authorisation and registration on Medihelp’s chronic medicine management programme	80% of the medicine price (MMAP) M = R3 050 per year or M+ = R4 750 per year
Chronic PMB medicine Subject to pre-authorisation and registration on Medihelp’s PMB medicine management programme	100% of the MRP Unlimited
OPTOMETRY Subject to pre-authorisation by PPN and services should be obtained from a PPN provider Optometric examinations 1 comprehensive consultation, including refraction test, tonometry and visual field test	100% of the contracted tariff 1 examination per 24-month cycle per beneficiary from the date of the first service
Spectacles or contact lenses Benefits are limited to either spectacles or contact lenses Spectacles Frames and/or lens enhancements	R750 per 24-month cycle per beneficiary from the date of the first service
Lenses (one pair of standard clear Aquity lenses)	Single vision or bifocal lenses or multifocal lenses per beneficiary per 24-month cycle from the date of the first service
Contact lenses	R1 510 per beneficiary per 24-month cycle from the date of the first service
OXYGEN Out of hospital Subject to pre-authorisation, clinical protocols and services prescribed by a medical doctor	100% of the contracted/scheme tariff/cost Unlimited 20% co-payment if not pre-authorised
DENTAL SERVICES Subject to Denis managed care protocols Conservative dental services Routine check-ups	100% of the Medihelp Dental Tariff 2 per beneficiary per year (once in 6 months)
Oral hygiene 1 fluoride treatment for children younger than 13 years only Fissure sealants for children younger than 16 years only	100% of the Medihelp Dental Tariff 2 scale and polish treatments per beneficiary per year (once in 6 months)
Fillings (Treatment plans and X-rays may be requested for multiple fillings)	100% of the Medihelp Dental Tariff 1 filling per tooth in 365 days
Tooth extractions and root canal treatment in the dentist’s chair	100% of the Medihelp Dental Tariff
Laughing gas (in the dentist’s chair)	100% of the Medihelp Dental Tariff
Dental procedures under conscious sedation in the dentist’s chair (sedation cost) Subject to pre-authorisation and managed care protocols	100% of the Medihelp Dental Tariff Extensive dental treatment and the removal of impacted teeth only 20% co-payment if not pre-authorised
Plastic dentures	100% of the Medihelp Dental Tariff 1 set (upper and lower jaw) per beneficiary in a 4-year period, from the date of the first service
X-rays Intra-oral X-rays	100% of the Medihelp Dental Tariff
Extra-oral X-rays	100% of the Medihelp Dental Tariff 1 per beneficiary in a 3-year period, from the date of the first service
Specialised dental services Subject to pre-authorisation and Denis managed care protocols Partial metal frame dentures	100% of the Medihelp Dental Tariff 2 partial frames (upper and lower jaw) per beneficiary in a 5-year period, from the date of the first service
Maxillofacial surgery and oral pathology Surgery in the dentist’s chair Benefits for temporomandibular joint (TMJ) therapy are limited to non-surgical interventions/treatment	100% of the Medihelp Dental Tariff
Crowns and bridges Subject to pre-authorisation	100% of the Medihelp Dental Tariff 2 crowns per family per year, once per tooth in a 5-year period, from the date of the first service 20% co-payment if not pre-authorised
Implants	For member’s account
Orthodontic treatment Subject to pre-authorisation and orthodontic needs analysis (Only one beneficiary per family may begin orthodontic treatment per calendar year)	100% of the Medihelp Dental Tariff R9 200 per beneficiary younger than 18 years per lifetime 20% co-payment if not pre-authorised Payment from date of authorisation only
Periodontal treatment Subject to pre-authorisation and registration on the Perio Programme Conservative non-surgical therapy only	100% of the Medihelp Dental Tariff 20% co-payment if not pre-authorised
PATHOLOGY AND MEDICAL TECHNOLOGIST SERVICES Subject to clinical protocols and requested by a medical doctor	100% of the contracted/scheme tariff/cost R2 130 per family per year
STANDARD RADIOLOGY Out of hospital Subject to clinical protocols and requested by a medical doctor or chiropractor (black and white X-rays only)	100% of the scheme tariff/medicine price/cost R2 130 per family per year
EXTERNAL PROSTHESES, MEDICAL, SURGICAl AND ORTHOPAEDIC APPLIANCES Services in and out of hospital and prescribed by a medical doctor Artificial eyes, speech and hearing aids	100% of the scheme tariff/cost R5 670 per beneficiary per 3-year cycle
Artificial limbs and wheelchairs	100% of the scheme tariff/cost R4 530 per beneficiary per 3-year cycle
Incontinence products/supplies Hyperbaric oxygen treatment Other appliances	100% of the scheme tariff/cost R450 per beneficiary per year
Stoma components and urine bags	100% of the scheme tariff/cost Unlimited
MRP – Medihelp Reference Price MMAP – Maximum Medical Aid Price GP – General practitioner PMB – Prescribed Minimum Benefits PPN – Preferred Provider Negotiators DSP – Designated service provider

This is a summary of the available benefits. In the event of a dispute the registered Rules of Medihelp will apply, subject to approval by the Registrar of Medical Schemes. If a beneficiary joins during the course of a financial year, the benefits are calculated pro rata according to the remaining number of months per year. Please note that the Rules for 2014 will be released in due course. Phone Medihelp on 086 0100 678 if you have any enquiries about the Rules of Medihelp.

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