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Medshield MediPhila Medical Aid Plan

Overall, the Medshield MediPhila Medical Aid Plan is a trustworthy and comprehensive medical aid plan that offers a generous overall annual limit and 24/7 medical emergency assistance to up to 3 Family Members. The Medshield MediPhila Medical Aid Plan starts from R1851 ZAR.

👤 Main Member Contribution	R1,851
👥 Adult Dependent Contribution	R1,851
🍼 Child Dependent Contribution	R477
🌎 International Cover	Only Organ Transplants
📉 Annual Limit	Unlimited Hospital Cover
➡️ Hospital Cover	Unlimited
💙 Home Care	☑️ Yes
⚕️ Chronic Conditions	☑️ Yes
🔁 Maternity Benefits	☑️ Yes
💳 Medical Savings Account	None

Medshield MediPhila Plan – 13 Key Point Quick Overview

Medshield MediPhila Plan Overview
Medshield MediPhila Plan Contributions
Medshield MediPhila Plan Benefits and Cover Comprehensive Breakdown
Medshield MOM Program and Benefits
MediPhila SmartCare Services and Benefits
MediPhila Wellness Benefits
MediPhila Ambulance and Emergency Services
MediPhila Prescribed Minimum Benefits
MediPhila COVID-19 Benefits and Access to Care
MediPhila Plan Exclusions and Waiting Periods
Medshield MediPhila Plan vs. Similar Plans from other Medical Schemes
Our Verdict on The MediPhila Plan
MediPhila Plan Frequently Asked Questions

Medshield MediPhila Plan Overview

The Medshield MediPhila medical aid plan is one of 11, starting from R1,851, and includes chronic cover, a generous overall annual limit for day-to-day medical expenses, extensive in-hospital cover, dentistry, specialized and basic radiology, pathology, wellness, child immunization, and more. Gap Cover is not available on the Medshield MediPhila Plan. However, Medshield offers 24/7 medical emergency assistance. According to the Trust Index, Medshield has a trust rating of 4.1.

MedShield has the following medical aid plans to offer:

Medshield MediPhila Plan Contributions

👤 Main Member	👥 +1 Adult Dependent	🍼 +1 Child Dependent
R1,851	R1,851	R477

Medshield MediPhila Plan Benefits and Cover Comprehensive Breakdown

MediPhila Hospital-At-Home

Medshield offers a Hospital-at-Home service delivered by Quro Medical.
The Hospital-at-Home service offers an alternative to hospitals as the center of patient care and management.
Hospital-at-Home provides active treatment at home instead of a general hospital ward for a specified period without compromising the quality of care.
Patients more vulnerable to hospital-acquired infections and developing new health complications may benefit from care at home.
Patients who usually need admission to a general hospital ward are eligible for Hospital-at-Home.
Quro Medical works with each patient and their treating doctor to develop a personalized treatment plan to deliver at home.
Treatment plans are amended accordingly if a patient’s medical needs change during treatment.
The clinical team at Quro Medical arranges routine home visits customized to the individual’s specific needs that may occur daily or more frequently to provide the necessary treatment and care.
Other channels allow patients to access advice and support outside of home visits.

MediPhila Major Medical Benefits In-Hospital

📌 Overall Annual Limit	There is no overall annual limit on hospitalization.
📍 Hospitalization	Subject to pre-approval. Specialist services are covered by treating/attending doctors. PMBs Unlimited cover. Non-PMBs Limited to 1 million per family yearly.
☑️ Surgical Procedures	Subject to the hospitalization limit.
✅ Medicine upon discharge	Limited to R255 per admission. Per the Maximum Generic Pricing of Medicine Price List and Medshield Formulary.
🚑 Hospitalisation Alternatives Physical Rehabilitation Sub-Acute Facilities Nursing Services Hospice Terminal Care	Clinical Protocols will apply. Unlimited but subject to PMB and PMB level of care. 25% co-payment for using a non-MediPhila Network Hospital. Terminal care is limited to R13,175 per family per year and is subject to the overall limit on hospitalization alternatives.
⚕️ Oxygen Therapy Equipment	Unlimited cover but subject to PMB and PMB level of care. Subject to pre-authorization and the relevant Managed Healthcare Program. Clinical Protocols will apply.
➡️ Home Ventilators	Unlimited cover but subject to PMB and PMB level of care. Subject to pre-authorization and the relevant Managed Healthcare Program. Clinical Protocols will apply.
🩸 Blood, Blood Equivalents, and Blood Products	Unlimited cover but subject to PMB and PMB level of care. Subject to pre-authorization and the relevant Managed Healthcare Program. Clinical Protocols will apply.
🩺 Medical Practitioner Consultations and Visits during hospital admission	Clinical Protocols apply. Subject to the Hospitalisation limit.
❤️ Organ, Tissue, and Haemopoietic Stem Cell (Bone Marrow) Transplants Immuno-Suppressive Medication Post Transplantation biopsies and scans. Related radiology and pathology	Unlimited cover but subject to PMB and PMB level of care. 25% co-payment for using a non-MediPhila Network Hospital. Limited to harvests in South Africa. Solid organ transplant donor work-up fees. No international donor search benefits. Bone marrow transplantation is confined to allogenic and autologous grafts from the South African Bone Marrow Registry.
🌎 International Corneal Grafts and Transplants	Limited to R46,615 per beneficiary. Subject to the OAL. Clinical protocols apply.
👁️‍🗨️ Local Corneal Grafts and Transplants	Limited to R19,980 per beneficiary. Subject to the OAL. Clinical protocols apply.
📈 Pathology and Medical Technology	Subject to the hospitalization limit.
📉 Physiotherapy	Limited to R2,955 per beneficiary yearly. Subject to the hospitalization limit and then the daily limit unless pre-approved for PMBs and PMB level of care.
📊 Internal Prostheses and Devices	Subject to pre-authorization by the relevant Managed Healthcare Program. Unlimited with PMB and PMB treatment. Hips and knees sub-limit: R35,510 per beneficiary (subject to PMB and PMB level of care).
🦵 External Prostheses	Unlimited but subject to PMB and PMB level of care. Must be referred by a Network FP. Subject to pre-approval.
📌 Long Leg Callipers	Pre-approval is necessary. Must be provided by a DSP, Network Provider, or Preferred Provider. Unlimited but subject to PMB and PMB level of care. A Network FP must refer the member.
📍 Basic Radiology	Subject to the hospitalization limit.
☑️ Specialized Radiology CT Scans, MUGA Scans, MRI Scans, Radio Isotope Studies CT Colonography (Virtual colonoscopy) Interventional Radiology replacing Surgical Procedures	Clinical protocols apply. Subject to pre-approval and the relevant Managed Healthcare Program. Subject to the hospitalization limit. Limited to R7,440 per family yearly (in and out-of-hospital)
✅ Chronic Renal Dialysis Material Medication Related Radiology and Pathology	Unlimited if PMB and PMB level of care are met. A non-DSP will incur a 35% upfront co-payment. Use of a DSP with Rand one for PMB admittance.
🩺 Non-Surgical Procedures and Tests	Subject to the hospitalization limit.
🧠 Mental Health	Subject to pre-authorization by the relevant Managed Healthcare Program. The Medshield Specialist Network may be utilized. Limited to a maximum of three days if admitted by a family physician. Unlimited if PMB and PMB level of care are met. A non-DSP will incur a 40% upfront co-payment. Use of a DSP with Rand one for PMB admittance.
💊 Rehabilitation for Substance Abuse	Subject to PMB and PMB level of care.
👩‍⚕️ Consultations and Visits, Procedures, Assessments, Therapy, Treatment, or Counselling	Subject to PMB and PMB level of care.
1️⃣ HIV and Aids	According to the Managed Healthcare Protocols. Pre-authorization and Managed Healthcare Program registration are required.
2️⃣ Anti-retroviral and related medicines	Voluntary out-of-formulary or PMB medication from a non-DSP supplier requires a 35% upfront co-payment. Courier DSP – Rand one.
3️⃣ HIV/AIDS-related Pathology and Consultations	Voluntary out-of-formulary or PMB medication from a non-DSP supplier requires a 35% upfront co-payment. Courier DSP – Rand one.
4️⃣ National HIV Counselling and Testing (HCT)	Voluntary out-of-formulary or PMB medication from a non-DSP supplier requires a 35% upfront co-payment. Courier DSP – Rand one.
🍼 Infertility Interventions and Investigations	Clinical Protocols apply. Limited to interventions and investigations only. Pre-authorization and Managed Healthcare Program registration are required.

MediPhila Dentistry Benefits

🪥 Basic Dentistry (Out-of-Hospital)	According to the Dental Managed Healthcare Programme, Protocols, and the Medshield Dental Network. If there is no pre-authorization for plastic dentures, a 20% penalty will be charged. There is a limit of R1,610 per family yearly. Subject to the specialized dentistry limit.
🦷 Specialized Dentistry	Limited to R6,540 per family yearly.
☑️ Impacted Teeth, Wisdom Teeth, and Apicectomy	Subject to the specialized dentistry limit. Day Clinic wisdom teeth extraction requires an R1,800 upfront co-payment. In-hospital pre-authorization requires R4,000 upfront co-payment. However, in Practitioners’ offices, conscious sedation does not require co-payment. Only hospitalization, general anesthetics, or conscious sedation for bone impactions. Practitioners only cover out-of-hospital apicectomy of permanent teeth. Pre-authorization and Hospital Managed Healthcare Programs. Dental Managed Healthcare Programs, Protocols, and Medshield Dental Network. General anesthesia and conscious sedation pre-authorization, in- and out-of-hospital. Apicectomy, impacted tooth removal, and wisdom tooth removal under local anesthesia do not require authorization.
😊 Maxillo-Facial Surgery	All services are subject to pre-authorization by the relevant Managed Healthcare Program. Non-elective surgery only. Subject to Dental Managed Healthcare Programs and Protocols. MediPhila Hospital Network services are required. Use of the Medshield Specialist Network might apply. This benefit is only for PMB treatment.

MediPhila Oncology Benefits

✅ Oncology Limit	Unlimited cover. Subject to PMB and PMB level of care.
✅ Active Treatment (Includes Stoma Therapy, Incontinence Therapy, and Brachytherapy)	Subject to the Oncology Limit. ICON Standard Protocols apply.
✅ Oncology Medicine	Subject to the Oncology Limit. ICON Standard Protocols apply.
✅ Radiology and Pathology	Subject to the Oncology Limit.
✅ PET and PET-CT	Limited to 1 Scan per family per annum. Subject to the Oncology Limit.
✅ Integrated Continuous Cancer Care	Four visits per family per annum. Subject to the Oncology Limit
✅ Specialized Drugs for Oncology, Non-Oncology, and Biological Drugs	Subject to the Oncology Limit.
✅ Vitreoretinal Benefit	Limited to R21,100 per family per year. Clinical protocols apply.

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MediPhila Chronic Medicine Benefits

🅰️ Using a MediPhila Chronic Network Pharmacy from Rand one	Exclusive to PMB. Medicines will be approved according to the Medshield Formulary, with coverage from Rand one. Use of a non-MediPhila Chronic Network Pharmacy will incur an upfront co-payment of 35%.
🅱️ Supply of Medication (One month in advance)	Exclusive to PMB. Medicines will be approved according to the Medshield Formulary, with coverage from Rand one. Use of a non-MediPhila Chronic Network Pharmacy will incur an upfront co-payment of 35%.

MediPhila Chronic Disease List

✅ Addison’s disease
✅ Asthma
✅ Bi-Polar Mood Disorder
✅ Bronchiectasis
✅ Cardiac failure
✅ Glaucoma
✅ Cardiomyopathy
✅ Diabetes
✅ Chronic renal disease
✅ Chronic obstructive pulmonary disease
✅ Coronary artery disease
✅ Crohn’s disease

and many more.

MediPhila Maternity Benefits

There will be benefits during pregnancy, after birth, and following delivery. However, pre-authorization with the applicable Managed Healthcare Program is required before hospital admission.
Unless otherwise specified, benefits are allocated for each pregnancy subject to the Total Yearly Limit.
A complimentary baby bag from Medshield can be obtained during the third trimester.

🍼 Antenatal Consultations	Six Consultations per pregnancy. It might be subject to the use of the Medshield Specialist Network.
🤰 Antenatal Classes and Postnatal Midwife Consults	Four Visits per event.
📊 Scans	Two 2D scans per pregnancy.
👶 Confinement and postnatal Consultations	Use of a non-DSP requires an upfront co-payment of 25%. Subject to prior authorization by the applicable Managed Healthcare Program.
✅ Confinement in a registered birthing unit or Out-of-Hospital Confinement in a registered birthing unit or Out-of-Hospital	Unlimited Clinical Protocols apply. Member must use a MediPhila Network Hospital.
👩‍⚕️ Delivery by a registered Midwife or a Practitioner	This only applies to registered Midwives.
➡️ Hire a water bath and oxygen cylinder	Unlimited cover provided.

Medshield MOM Program and Benefits

To support women on their journey to motherhood, Medshield MOM has launched a dedicated website that provides information and resources for all stages of pregnancy, birth, and postpartum. This website is an easily accessible hub of valuable health, fitness, nutrition, motherhood, babies, toddlers, and more content tailored to the pre-and post-partum phases. As a Medshield member, you can take advantage of the pregnancy-related benefits. The Medshield MOM website will ensure you are fully informed of your options. Some of the features and advantages include, but are not limited to, the following:

A guide for your journey from start to finish.
Convenient, dependable, and easily accessible pregnancy resources.
A toddler benefit that includes information on child immunization, child nutrition, a nurse helpline available 24/7, and digital/online kid yoga.
Advice formulated by professionals.
Reminders through email to arrange doctor’s appointments and request hospital pre-authorizations, etc.
Emails containing updates on your unborn child’s growth and development.
Mothers can register and enter the specific week of their pregnancy journey. Then, they will begin getting content based on that time and continuing ahead.
The Medshield MOM bags are made locally utilizing recyclable, eco-friendly materials. These distinctive bags are filled with excellent Bennetts products for your child.

MediPhila SmartCare Services and Benefits

SmartCare gives access to Videomed and telephone plus video consultations through a select group of healthcare professionals. SmartCare is a developing healthcare benefit aiming to provide members with convenient care access. SmartCare services include the following:

Acute Consultations – Infections of the chest and upper respiratory tract, urinary tract, eyes, ears, etc.
Chronic Consultations – Medication and refills for hypertension, diabetes, excessive cholesterol, etc. Then, members are advised to utilize the Medshield Chronic Medication Courier Service DSP to have their chronic medication delivered directly to their home or place of business.

1️⃣ Pharmacy/clinic private nurse practitioner consultations	Unlimited cover.
2️⃣ Nurse-led Videomed family practitioner (FP) consultations	One visit per family is subject to the Overall Yearly Limit, followed by the Family Practitioner (FP) Consultations and Visits Limit.
3️⃣ WhatsApp doc advice line	Unlimited cover.

MediPhila Day-to-Day Benefits

📌 Day-to-Day Limits	There is an R3,590 limit per family per year.
📍 Family Practitioner (FP) Consultations and Visits FP consults and visits are available in person, over the phone, and remotely. Each beneficiary is required to select one Family Practitioner from the MediPhila Family Practitioner (FP) Network. From Rand one, the MediPhila FP Network is applicable.	Unlimited cover. Members can access visits without pre-approval as follows (after these limits, visits are subject to pre-authorization): Main Member Only – 8 visits Main Member +1 – 9 visits Main Member2+ – 11 visits
👨‍⚕️ Medshield Family Practitioner (FP) Network (Out-of-Hospital consults and visits)	Unlimited cover. Members can access visits without pre-approval as follows (after these limits, visits are subject to pre-authorization): Main Member Only – 8 visits Main Member +1 – 9 visits Main Member2+ – 11 visits
👩‍⚕️ Registered Chronic Beneficiaries extended FP consults and visits	2 visits per beneficiary. Subject to Disease Management Program registration. Subject to the OAL once these consultations have been depleted: Main Member Only – 8 visits Main Member +1 – 9 visits Main Member2+ – 11 visits
🚑 Out-of-Hospital FP/emergency FP consults and visits	Limited to 2 visits per family to an FP on the MediPhila FP Network. After these visits have been used, the benefit is subject to the following number of visits: Main Member Only – 8 visits Main Member +1 – 9 visits Main Member2+ – 11 visits After these visits are depleted, a 40% co-payment for visits exists.
🏥 Medical Specialist Consultations and Visits	One visit per family per year, subject to the Day-to-Day Limit and recommendation from the Network FP. A 40% co-payment will be imposed if no reference is made.
⚠️ Casualty and emergency visits	Consultations are subject to FP site visits. Medicine use is restricted to the Acute Medicine Limit and the Day-to-Day Limit. The facility fee is subject to a daily limit.
💊 Acute Medicine	Subject to the daily limit. Limited to R1,565 per family. The Acute basic formulary applies from Rand one. Medshield formularies and pricing must be followed. Dependent on the utilization of the Medshield Pharmacy Network.
🩺 Pharmacy Advised Therapy (PAT)	Subject to the Acute Medication Limit. Limited to R90 per script and one script per beneficiary daily.
🤓 Optometry	Subjected to applicable Optometric Managed Healthcare Program and Procedures One set of Optical Lenses and a frame, restricted to R895 every 24 months per beneficiary. An Optical Service Date Cycle determines this. The use of a DSP is required. Subject to the OAL.
👁️ Optometric Refraction Eye Tests	One test per beneficiary per 24-month optical cycle. Subject to the OAL.
👁️‍🗨️ Spectacles (Only single vision, excludes Bi-Focal, Multifocal, and Contact Lenses, and any other add-ons)	Subject to Optical Limit.
👓 Reading Glasses	There is a limit of R190 per beneficiary. Subject to Optical Limit. Must be supplied by a registered Optometrist, Ophthalmologist, Supplementary Optical Practitioner, or a registered Pharmacy.
📈 Pathology and Medical Technology	The Medshield MediPhila Basic Pathology formulary applies. PMB level of care applies to non-formulary tests. Only if referred by a Network FP
💙 Covid-19 PCR/Antigen Test	The 1st test is included in the overall annual limit, and subsequent tests provide no benefit unless the result is positive and subject to PMB.
📈 Basic Radiology	Subject to the Radiology Managed Healthcare Program and Protocols. Subject to the Medshield MediPhila Basic Radiology formulary. Only covered when referred by a Network GP.
📉 Specialized Radiology	Limited to R7,440 In- and Out-of-Hospital, per family yearly. Limited to (and included in) the Specialised Radiology Limit. Subject to pre-authorization by the relevant Managed Healthcare Program
📊 Non-Surgical Procedures and Tests: FP Network	Subject to the In-Hospital Limit.
🚩 Non-Surgical Procedures and Tests: Non-FP Network	Subject to daily limits.
🅰️ Procedures and Tests performed in the Practitioner’s rooms	Subject to the relevant Managed Healthcare Program. Subject to the In-Hospital Limit.
🅱️ Routine diagnostic Endoscopic Procedures performed in the Practitioner’s rooms	In practitioner’s rooms, subject to In-Hospital Restriction. MediPhila Protocols List using FP Network. Subject to Managed Healthcare Program pre-authorization.
📌 Intrauterine Devices and Alternatives	Covers consultation, pelvic ultrasound, sterile tray, device, and insertion, if performed the same day. Subject to the applicable clinical protocols. The Medshield Specialist Network must be utilized. It should be performed at the practitioner’s office. Only covered if no hormonal contraceptives are taken, but only upon application Limited to 1 per female recipient. Subject to the Yearly Maximum Limit. Included are all IUD brands up to the cost of the Mirena device. One Mirena/Kyleena device per female patient every five years. Implanon – one per female recipient every three years. One Nova T/Copper device per female patient every two years.

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MediPhila Wellness Benefits

Medshield’s Wellness Benefit program empowers members to proactively manage their health by undergoing preventative tests and procedures. The company strongly advises its members to schedule the necessary tests at least once per year. Medshield members must use pharmacies included in their benefit options’ Pharmacy Network to access the Wellness Benefits. Members must note that benefits are subject to the Overall Annual Limit. Once that limit has been reached, the benefits will be subject to the Day-to-Day limit. However, consultations for specific services are excluded from these limits.

📌 Birth Control (Contraceptive Medicine)	Limited to a maximum of 13 prescriptions per year per female recipient between the ages of 14 and 55, with an R130 limit per prescription. Subject to Acute Medical Benefit Limit. Only relevant in the absence of intrauterine devices and alternatives.
📍 COVID-19 Vaccines	Subject to the Overall Annual Limit. Protocols apply.
☑️ Flu Vaccines	One per beneficiary aged 18 or older is included in the Yearly limit. There is no benefit after that.
✅ Pap Smear	One per female beneficiary.
✳️ Health Risk Assessment on the SmartCare Network Cholesterol Blood Glucose Blood Pressure Body Mass Index (BMI)	One per beneficiary 18>
📌 National HIV Counselling Testing (HCT)	One test per beneficiary.
📍 HPV Vaccination	One course of two injections per female beneficiary between 9 to 13 years old. Subject to qualifying criteria.
☑️ PSA Screening for Male Beneficiaries	Subject to the OAL.
✅ Tuberculosis Test	One test per beneficiary.

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Wellness Benefits – Child Immunisations

This benefit and immunization program as per the Department of Health Protocols according to these age groups:

MediPhila Ambulance and Emergency Services

A 24-hour Hotline will be available to members and their registered dependents. In addition, members can dial 086 100 6337 to reach the Ambulance and Emergency Services, provider.

Subject to pre-approval by the supplier of Ambulance and Emergency Services.
Air Evacuation necessitates scheme approval.
Applying Clinical Procedures.

🤰 At Birth	Tuberculosis (BCG) Polio OPV
🍼 6 Weeks	Polio (OPV) Diphtheria Tetanus, Pertussis (Whooping Cough) Hepatitis B Hemophilus Influenza B (HIB) Rotavirus Pneumococcal
👶 10 Weeks	Polio Diphtheria Tetanus Pertussis (Whooping Cough) Hepatitis B Hemophilus Influenza B (HIB) Pneumococcal Rotavirus (Optional)
❤️ 14 Weeks	Polio Diphtheria Tetanus Pertussis (Whooping Cough) Hepatitis B Hemophilus Influenza B (HIB) Rotavirus Pneumococcal
🧡 6 Months	Measles MV (1)
💛 9 Months	Measles, Pneumococcal, and Chickenpox CP
💚 12 Months	Measles MV (2)
💙 15 Months	Chickenpox CP
💜 18 Months	Polio, Diphtheria, Tetanus, Pertussis (Whooping Cough) Measles Mumps and Rubella (MMR)
📌 6 Years	Polio Diphtheria and Tetanus (DT)

MediPhila Prescribed Minimum Benefits

Medshield members are entitled to coverage for Prescribed Minimum Benefits (PMBs), regardless of their chosen benefit option. Medshield assumes the cost of PMB treatments if they are provided by one of Medshield’s Designated Service Providers (DSPs) in compliance with the Scheme Rules. The Medical Schemes Act 131 of 1998 mandates that all medical plans must cover the costs associated with the following:

Any potentially fatal medical emergency
A set of 26 Chronic Disease List (CDL) diseases that are well-defined
271 DTP diagnoses.

🏥 In-Hospital Admissions for treating PMBs	If you are diagnosed with a PMB disease requiring hospitalization, you must comply with the Medshield hospital authorization process. It would help if you utilized a hospital that is a part of the Hospital Network for your selected insurance package, as all stay, and treatment fees have negotiated prices. Specialist services obtained during hospitalization are reimbursed at the Scheme rate. If the Scheme rate does not cover the entire claim amount, you must apply to the Scheme and request that the Specialist’s rate be paid at cost instead of the Scheme rate.
🚑 Out-of-Hospital treatment and managing PMBs	Members diagnosed with any 26 CDL conditions covered by Medshield and MediPhila must apply to Mediscor for approval. The member automatically receives a Care Plan (treatment plan) notification from the Scheme after the healthcare provider claims with the ICD-code as authorized. The Care Plan details and approves benefits like radiography, pathology, and doctors’ visits. The member and their treating provider must fill out a PMB Application form to seek clearance for further treatment after using the Care Plan. If approved, a revised Care Plan will include the additional treatment.
📌 MediPhila Option Payment for PMB conditions	Risk allocates your benefit option’s Day-to-Day maximum. PMB will be paid from your Day-to-Day limit until it is spent, then from Risk until your Care Plan services are used. You and your treatment provider must submit a new PMB Application if you need services that are not on the Care Plan (Clinical Protocols will apply).
📍 271 DTP Conditions	Members with DTP must complete a PMB application form with their doctor. If they do not complete a PMB Application form, the Day-to-Day or Savings will pay for treatment. The Care Plan (treatment plan) will list the covered treatments for the condition after clinical assessment and approval.
➡️ COVID-19 as a PMB	Respiratory DTP PMB includes Covid-19. After seeing a doctor, members might need a COVID-19 PCR or SARS-CoV-2 Antigen test. According to the Plan Regulations, this benefit requires a doctor or nurse referral and payment. MediPhila covers either a PCR or an antigen test, but not both.

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MediPhila COVID-19 Benefits and Access to Care

The COVID-19 PCR Test or Antigen Tests have the following features and conditions:

The First COVID PCR or antigen test is covered in the Overall Annual Limit (OAL).
Depending on the option, the Second and subsequent tests are covered by daily limits or a medical savings plan. If these benefits are not available, members must pay for the tests.
The 2nd and subsequent positive PCR or Antigen tests are covered first from Day-to-Day benefit or Savings, then from OAL if PMB applies.
The pathology test will be reimbursed as a PMB by Risk after emailing the positive results to Medshield. Risk
Benefits require a PMB Application form, and Clinical Protocols apply.
Travel and non-symptomatic COVID-19 tests are excluded from this benefit.
Scheme risk gives members the Day-to-Day restriction. Therefore, PMB COVID-19 treatment will pay from a Day-to-Day benefit until it is gone and then from Risk (OAL).

MediPhila Plan Exclusions and Waiting Periods

MediPhila Exclusions

MediPhila does not cover the following:

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 that is harmful or threatening to necessary bodily functions (the aging process is not considered a suspected medical condition or handicap)
Travel and housing expenses, including meals, as well as administrative expenditures incurred by a beneficiary or service provider
Aptitude, intelligence/IQ, and comparable examinations, as well as treatment for learning difficulties
The treatment of infertility that is not specified in the Medical Schemes Act of 1998 Regulations
Alone or in conjunction with stimulants, multivitamins, and multimineral supplements (tonics)
Nonsteroidal anti-inflammatory medication claimed from acute medicine benefits more than 180 units per recipient annually
Roaccutane, Retin-A, or any other skin-whitening agents
Dental testimony, as well as den-to-legal fees
Behavior management
Injections intramuscular and subcutaneous
Processes categorized as exceptional conditions and unlisted procedures
Blood pressure device
Motorized assistive mobility devices
Commode
Toilet seat raiser
Tests for caries susceptibility and microbiology
Pulp tests
The price of mineral trioxide
Enamel microabrasion
Specialized dentistry, including laboratory fees for crowns and bridges, implants, orthodontics, periodontics, and maxillofacial surgery

MediPhila Waiting Periods

Often, there is a waiting period for pre-existing conditions. This is to prevent new members from abusing medical insurance for a short period to finance pricey procedures and then canceling their membership shortly after. According to the Medical Schemes Act No. 131 of 1998, the following waiting periods may apply:

A 3 (three) month general waiting time for all benefits.
A maximum 12 (twelve) month exclusion for a previous ailment.
A late joiner contribution penalty.

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Medshield MediPhila Plan vs. Similar Plans from other Medical Schemes

🔎 Medical Aid Plan	🥇 Medshield MediPhila	🥈 Medihelp MedVital Elect	🥉 Bankmed Basic
👤 Main Member Contribution	R1,851	R	R
👥 Adult Dependent Contribution	R1,851	R	R
🍼 Child Dependent Contribution	R477	R	R
🌎 International Cover	Only Organ Transplants	Scheme Tariff	Members pay costs and claim back
📈 Annual Limit	Unlimited Hospital Cover	None	Unlimited
🏥 Hospital Cover	Unlimited	Unlimited	Unlimited
💶 Prescribed Minimum Benefits	✅ Yes	✅ Yes	✅ Yes
💙 Home Care	✅ Yes	None	✅ Yes
👶 Maternity Benefits	✅ Yes	✅ Yes	✅ Yes

Our Verdict on The MediPhila Plan

Overall, MediPhila is designed to provide members access to a range of healthcare services, including hospitalization, chronic medication, and specialist consultations. The Medshield MediPhila Plan includes unlimited hospitalization at any private hospital, cover for 27 chronic conditions, and a network of healthcare providers from which to choose. In addition, members also have access to Medshield’s wellness program, which includes benefits such as health assessments and coaching. Advantages of the Medshield MediPhila Plan include comprehensive coverage for a range of healthcare services and access to a vast network of healthcare providers.

Furthermore, the plan also offers a range of wellness benefits, which can help members to maintain their health and prevent chronic conditions from developing. Drawbacks of the Medshield MediPhila Plan include higher premiums than other plans offered by Medshield. Additionally, the plan may not be suitable for those who do not require comprehensive coverage for a range of healthcare services. Compared to the MediCurve Plan, which Medshield also offers, the MediPhila Plan offers more comprehensive coverage for healthcare services, including hospitalization and chronic medication.

However, the MediCurve Plan may be more suitable for those looking for more affordable premiums and do not require comprehensive coverage.

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MediPhila Plan Frequently Asked Questions

What is the MediPhila Plan?

The MediPhila Plan is a comprehensive medical aid plan offered by Medshield that provides members with coverage for hospitalization, chronic medication, specialist consultations, and more.

What are healthcare services covered under the MediPhila Plan?

The MediPhila Plan covers a range of healthcare services, including unlimited hospitalization at any private hospital, coverage for 27 chronic conditions, and a network of healthcare providers from which to choose.

Does the MediPhila Plan offer a wellness program?

Yes, the MediPhila Plan includes a wellness program that provides health assessments and coaching benefits.

Can I choose my own healthcare provider with the MediPhila Plan?

Yes, the MediPhila Plan provides members with a healthcare network from which to choose.

What are the advantages of the MediPhila Plan?

he advantages of the Medshield MediPhila Plan are numerous and consist of comprehensive coverage for a wide range of healthcare services and access to an extensive network of healthcare providers.

How does the MediPhila plan compare to MediCurve Plan from Medshield?

The MediPhila Plan from Medshield covers more healthcare services, like being admitted to the hospital and medication for long-term health issues, than the MediCurve Plan they also provide.

Adriaan Schoeman

Adriaan holds an MBA and specializes in medical aid research. With his commitment to perfection, he ensures the accuracy of all data presented on medicalaid.com every three months. When he is not conducting research, Adriaan can be found indulging in his passion for trout fishing amidst nature.