MediPhila
About this plan
🥇 Best suited for members seeking affordable network healthcare and essential day-to-day benefits.
Principal Member
From
R2,145
per month
Adult Dependant
From
R2,145
per month
Child Dependant
From
R558
per month
What's covered
Hospital cover
Savings account
Day-to-day
Chronic cover
Dental
Optical
Maternity
Mental health
Waiting periods
- General
- 3 months
- Pre-existing conditions
- 12 months
MediPhila
Medshield MediPhila Medical Aid Plan (🇿🇦 2026)
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 R2 145 ZAR.| 👤 Main Member Contribution | R2 145 |
| 👥 Adult Dependent Contribution | R2 145 |
| 🍼 Child Dependent Contribution | R558 |
| 🌎 International Cover | YES |
| 📉 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 10, starting from R2 145, 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 2.4 from hellopeter.
💙 MedShield has the following medical aid plans to offer:
- ✅ MedShield MediCurve
- ✅ MedShield PremiumPlus
- ✅ MedShield MediValue Prime
- ✅ MedShield Value Compact
- ✅ MedShield MediSaver
- ✅ MedShield MediPlus Prime
- ✅ MedShield MediPlus Compact
- ✅ MedShield MediPhila
- ✅ MedShield MediCore
- ✅ MedShield MediBonus
Medshield MediPhila Plan Contributions
| 👤 Main Member | 👥 +1 Adult Dependent | 🍼 +1 Child Dependent |
| R2 145 | R2 145 | R558 |
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. 30% Upfront co-payment for use of non-Compact Network Hospital. |
| ☑️ Surgical Procedures | Subject to the hospitalization limit. |
| ✅ Medicine upon discharge | Limited to R500 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. 30% co-payment for using a non-MediPhila Network Hospital. Terminal care is limited to R38,350 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. 30% 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 R54,250 per beneficiary. Subject to the OAL. Clinical protocols apply. |
| 👁️🗨️ Local Corneal Grafts and Transplants | Limited to R23,250 per beneficiary. Subject to the OAL. Clinical protocols apply. |
| 📈 Pathology and Medical Technology | Unlimited. |
| 📉 Physiotherapy | Limited to R3,300 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. |
| 🦵 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 R8,600 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 30% 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. 30% upfront co-payment for out-of-formulary PMB medication voluntarily obtained or PMB medication voluntarily obtained from a provider other than the DSP |
| 2️⃣ Anti-retroviral and related medicines | Voluntary out-of-formulary or PMB medication from a non-DSP supplier requires a 30% 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 30% 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 30% 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 R1,900 per family yearly. Subject to the specialized dentistry limit. |
| 🦷 Specialized Dentistry | Limited to R7,600 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. Failure to obtain an authorisation prior to treatment will attract a 20% penalty. 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. 25% upfront co-payment for the use of a non-DSP |
| ✅ 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 R24,600 per family per year. Clinical protocols apply. |
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MediPhila Chronic Medicine Benefits
| 🅰️ Using a MediPhila Chronic Network Pharmacy from Rand one | Use the following pharmacies: Pharmacy Direct, Clicks Retail, Clicks Direct Medicine and Dis-Chem Pharmacies. Covers medicine for all 26 PMB CDL’s and an additional condition. |
| 🅱️ Supply of Medication (One month in advance) | Exclusive to PMB. Medicines will be approved according to the Medshield Formulary, with coverage from Rand one. 20% upfront co-payment for the use of non-formulary medicine. |
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
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 | Subject to prior authorization by the applicable Managed Healthcare Program. The use of the Medshield Specialist Network may apply. |
| ✅ Confinement in a registered birthing unit or Out-of-Hospital Confinement in a registered birthing unit or Out-of-Hospital | Unlimited Clinical Protocols apply. 30% upfront co-payment applies for the voluntary use of a non Network Hospital. Member must use a MediPhila Network Hospital. |
| 👩⚕️ Delivery by a registered Midwife or a Practitioner | This only applies to registered Midwives. Unlimited. |
| ➡️ Hire a water bath and oxygen cylinder | Unlimited cover provided. |
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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 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, 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. |
MediPhila Day-to-Day Benefits
| 📌 Day-to-Day Limits | There is an R4,700 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. | Each beneficiary must nominate a maximum of one General Practitioner from the MediPhila GP Network. MediPhila GP Network applies from Rand one. 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 |
| 👨⚕️ Virtual Care: General Practitioners (GP) | 3 consultations per beneficiary. |
| 👩⚕️Non Registered Chronic Beneficiaries extended FP consults and visits | 2 visits per beneficiary. Thereafter subject to the amount of GP visits stated above. Once these are exhausted, a 40% upfront co-payment will apply. |
| 🚑 Out-of-Hospital FP/emergency FP consults and visits | Limited to 2 visits per family to an FP on the MediPhila FP Network. Consultations subject to the General Practitioner Consultations and Visits Limit. Medicine limited to the Acute Medicine Limit and the Day-to-Day Limit. |
| 🏥 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. M+0= R1,850 M+1 = R2 560 M2+ = R2 950 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 R300 per script and one script per beneficiary daily. |
| 🤓 Optometry | R2 400 per beneficiary per 24 month Optical Service Date Cycle. The use of a Medshield Network Provider applies. |
| 👁️ 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) | 1 pair of Optical Lenses per beneficiary, every 24 months. Single vision (excludes Bifocal Lenses, Multifocal Lenses and Contact Lenses) Subject to Optical Limit. |
| 🤓 Frames | R950 per beneficiary included in the Optical Limit. • Readers If supplied by a registered Optometrist, Ophthalmologist, Supplementary Optical Practitioner or a Registered Pharmacy. • R220 per beneficiary per annum. |
| 👓 Reading Glasses | There is a limit of R220 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 R8,600 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 | GP Network - unlimited. Test & Procedures not specified - No Benefit. Refer to Addendum C for a list of services on Brochure. |
| 🚩 Non-Surgical Procedures and Tests: Non-FP Network | GP Network - unlimited. Subject to the Day-to-Day Limit. Test & Procedures not specified - No Benefit. Refer to Addendum C for a list of services of Medshield Brochure. |
| 🔎Mental Health Medicine | R5 850 per beneficiary. Subject to the medicine formulary and Chronic DSP from Rand one. 20% upfront co-payment for the use of out-of-formulary medicine and/or for using a non-DSP. |
| 📌 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 R155 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. |
| ✅ Mammogram (Breast Screening) | 1 per female beneficiary 30+ years old, per annum |
| ✳️ 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 9 + years old. Subject to qualifying criteria. |
| ☑️ PSA Screening for Male Beneficiaries | 1 test per male beneficiary 40+ years old, per annum |
| ✅ 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) 3-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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MediPhila Plan vs. Similar Plans from other Medical Schemes
| 🔎 Medical Aid Plan | 🥇 Medshield MediPhila (2026) | 🥈 Medihelp MedVital Elect (2026) | 🥉 Bankmed Basic |
| 👤 Main Member Contribution | R2 145 | R2,412 | R1,320 – 2,538 ZAR |
| 👥 Adult Dependent Contribution | R2 145 | R1,752 | R987 – 1,902 ZAR |
| 🍼 Child Dependent Contribution | R558 | R1,014 | R332 – 636 ZAR |
| 🌎 International Cover | Yes, Scheme Tariff | Scheme Tariff | Members pay costs and claim back |
| 📈 Annual Limit | Unlimited Hospital Cover | Unlimited | 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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