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Medshield MediPlus Prime Medical Aid Plan

Overall, the Medshield MediPlus Prime Medical Aid Plan is a trustworthy and comprehensive medical aid plan that offers 24/7 medical emergency assistance and a comprehensive wellness program to up to 3 Family Members. The Medshield MediPlus Prime Medical Aid Plan starts from R4,539 ZAR.

👤 Main Member Contribution	R4,539
👥 Adult Dependent Contribution	R3,240
🍼 Child Dependent Contribution	R1,07
📉 Annual Limit	Unlimited Hospital Cover
🏥 Hospital Cover	Unlimited
➡️ Oncology Cover	R282,350
💶 Prescribed Minimum Benefits	☑️ Yes
📊 Screening and Prevention	☑️ Yes
🤰 Maternity Benefits	☑️ Yes
💳 Medical Savings Account	None

Medshield MediPlus Prime Plan – 12 Key Point Quick Overview

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

Medshield MediPlus Prime Plan Overview

The Medshield MediPlus Prime medical aid plan is one of 11, starting from R4,539 and includes a comprehensive wellness program, mental health benefits, contraceptives, additional medical services, alternative and allied healthcare, HIV/AIDS cover, and more. Gap Cover is not available on the Medshield MediPlus Prime 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 MediPlus Prime Plan Contributions

👤 Main Member	👥 +1 Adult Dependent	🍼 +1 Child Dependent
R4,539	R3,240	R1,017

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Medshield MediPlus Prime Plan Benefits and Cover Comprehensive Breakdown

MediPlus Prime 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.

MediPlus Prime Major Medical Benefits In-Hospital

📈 Overall Annual Limit	There is no overall annual limit. Members must use the Prime Hospital Network.
🏥 Hospitalization	Unlimited cover. Subject to the relevant Management Healthcare Program. Pre-approval is needed for specialist services. Members must use the Prime Hospital Network.
🚑 Surgical Procedures	Covered as part of an authorized event. Unlimited cover provided.
💊 Medicine upon discharge	Limited to R610 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. There is an R70,420 limit per family yearly, subject to the hospitalization limit. DSPs must be used, or a 25% co-payment will apply for using a non-MediPlus Prime Network Hospital. Terminal care is limited to R41,145 per family per year and is subject to the overall annual limit.
✅ General, Medical, and Surgical Appliances	Limited to R10,320 per family per year. Pre-approval is required. Services must be obtained from a DSP, Network Provider, or Preferred Provider.
📌 Peak Flow Meters, Nebulizers, Glucometers, and Blood Pressure Monitors (needs motivation)	Limited to R885 per beneficiary yearly. Subject to the Appliance Limit
🦻 Hearing Aids (including repairs)	Subject to the Appliance Limit
👩🏻‍🦼 Wheelchairs (including repairs)	Subject to the Appliance Limit
➡️ Stoma Products and Incontinence Sheets relating to Stoma Therapy	Unlimited if pre-approved.
💤 CPAP Apparatus for Sleep Apnea	Subject to the Appliance Limit
⚕️ Oxygen Therapy Equipment	Unlimited cover. Subject to pre-authorization and the relevant Managed Healthcare Program. Clinical Protocols will apply.
🔁 Home Ventilators	Unlimited cover. Subject to pre-authorization and the relevant Managed Healthcare Program. Clinical Protocols will apply.
🩸 Blood, Blood Equivalents, and Blood Products	Unlimited cover. Subject to pre-authorization and the relevant Managed Healthcare Program. Must use the Prime Hospital Network. Clinical Protocols will apply.
👩‍⚕️ Medical Practitioner Consultations and Visits during hospital admission	Unlimited cover. Forms part of an authorized event during hospitalization and includes Medical and Dental Specialists or FPs.
✔️ Refractive Surgery Includes the following: LASIK Radial Keratotomy Phakic Lens Insertion	Limited to R10,360 per family per year. The benefit includes hospitalization. Without pre-authorization, the account will be settled from daily benefits limits. Subject to pre-authorization by the relevant Managed Healthcare Program. Services must be obtained from the Medshield Hospital Network, and the Medshield Specialist Network might be required.
😴 Sleep Studies Diagnostic Polysomnograms	Unlimited Cover Subject to pre-authorization by the relevant managed healthcare program. Clinical protocols will apply.
⚠️ CPAP Titration	Unlimited cover. Subject to pre-authorization by the relevant managed healthcare program. Clinical protocols will apply.
❤️ Organ, Tissue, and Haemopoietic Stem Cell (Bone Marrow) Transplants Immuno-Suppressive Medication Post Transplantation biopsies and scans. Related radiology and pathology	Subject to the relevant managed healthcare program. Limited to R164,705 per family per annum. 25% upfront co-payment for the use of a non-Prime Network Hospital. Organ harvesting is limited to the Republic of South Africa. Workup costs for the donor in Solid Organ Transplants are included. No benefits for international donor search costs. Hemopoietic stem cell (bone marrow) transplantation is limited to allogenic grafts and autologous grafts derived 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	Unlimited cover. The Preferred Provider Network applies. Must be part of an authorized event but excludes allergy and Vitamin D testing.
🦵 Physiotherapy	Limited to R2,955 per beneficiary yearly. Once this is exhausted, the benefit is subject to the day-to-day limit unless specific authorization is obtained. Subject to the hospitalization limit and then the daily limit unless pre-approved.
🦾 Internal Prostheses and Devices	Subject to pre-authorization by the relevant Managed Healthcare Program. Only for surgically implanted devices. Limited to R40,620 per family yearly. 25% co-payment unless related to PMB. Hips and knees sub-limit: R35,510 per beneficiary.
➡️ External Prostheses	Must be pre-approved. Treatment can only be obtained from a DSP, Network Provider, or Preferred provider. The benefit includes Ocular Prostheses. Clinical protocols apply. Subject to prostheses and devices’ internal limit. There are no co-payments on external prostheses.
☑️ Long Leg Callipers	Subject to prostheses and devices’ internal limit. There are no co-payments on external prostheses.
✅ Basic Radiology	Unlimited cover. Clinical protocols will apply.
📌 Specialized Radiology	Limited to R14,150 per family yearly for in- and out-of-hospital. Subject to pre-authorization by the Managed Healthcare Program. Services must be obtained from the Medshield DSP or Network Provider.
📍 CT Scans, MUGA Scans, MRI Scans, Radio Isotope Studies	Subject to the Specialised Radiology Limit. Clinical protocols will apply.
✳️ CT Colonography (Virtual colonoscopy)	There is no co-payment on this benefit. Clinical protocols apply.
✔️ Interventional Radiology replacing Surgical Procedures	Unlimited cover, but clinical protocols apply.
👩‍⚕️ Chronic Renal Dialysis Hemodialysis and Peritoneal Dialysis include the following: Material Medication Related Radiology and Pathology	Limited to R205,885 per family yearly. A non-DSP will incur a 35% upfront co-payment. Use of a DSP with Rand one for PMB and non-PMB.
👨‍⚕️ Non-Surgical Procedures and Tests	Unlimited cover. It must be as part of an authorized event. Members must use the Medshield Specialist Network.
🧠 Mental Health	Limited to R34,625 per family per year in and out-of-hospital. 25% upfront co-payment for non-Prime Network Hospitals. DSP from Rand one applies for PMB and non-PMB admissions. There is a limit of R39,290 per family yearly.
💊 Rehabilitation for Substance Abuse	There is one rehabilitation program available per beneficiary yearly. Subject to PMB and PMB level of care.
🚩 Consultations and Visits, Procedures, Assessments, Therapy, Treatment, or Counselling	Subject to the mental health limit.
🅰️ HIV and Aids	According to the Managed Healthcare Protocols. Pre-authorization and Managed Healthcare Program registration are required.
🅱️ Anti-retroviral and related medicines HIV/AIDS-related Pathology and Consultations National HIV Counselling and Testing (HCT)	Voluntary out-of-formulary or PMB medication from a non-DSP supplier requires a 35% upfront co-payment.
😊 Infertility Interventions and Investigations	Clinical Protocols apply. Limited to interventions and investigations only. Pre-authorization and Managed Healthcare Program registration are required.

MediPlus Prime Oncology Benefits

📌 Oncology Limit	Limited to R282,350 per family per year. 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	Six visits per family per annum. Subject to the Oncology Limit
📌 Specialized Drugs for Oncology, Non-Oncology, and Biological Drugs	Limited to R130,630 per family yearly. Subject to the Oncology medicine limit. Pre-authorization is required from the Oncology Managed Healthcare provider. Clinical Protocols will apply. 15% upfront payment for non-PMBs.
📍 Vitreoretinal Benefit	Subject to pre-approval. Specialized Drugs Limit applies.
☑️ Breast Reconstruction (only after an oncology event)	Subject to pre-authorization. Clinical protocols apply. The benefit is only for Post Mastectomy (all stages) Services must be obtained from a DSP network or provider. Member must use the Medshield Specialist Network. Limited to R94,105 per family yearly and limited to (and included) in the hospitalization limit. Co-payments and prostheses limits will not apply for Breast Reconstruction.

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MediPlus Prime Chronic Medicine Benefits

Members must use a DSP Provider on MediPlus Prime:

Limited up to R7,465 per recipient per year, up to a maximum of R14,930 per family per year.
Medications will be approved per the Medshield Formulary and will be available beginning with Phase one.
Members must use a Medshield Pharmacy Network from Rand one.

Supply of Medication (One month in advance):

Limited up to R7,465 per recipient per year, up to a maximum of R14,930 per family per year.
Medications will be approved per the Medshield Formulary and will be available beginning with Phase one.
Members must use a Medshield Pharmacy Network from Rand one.

MediPlus Prime Chronic Disease List

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

and many more!

MediPlus Prime Dentistry Benefits

🦷 Basic Dentistry: In-Hospital	Unlimited cover provided. The in-hospital cover is only for kids under 6 for comprehensive Basic Dental). Subject to Managed Healthcare Program pre-authorization. Treatment without authorization incurs a 20% penalty. MediPlus Prime members must use the Prime Hospital Network.
🪥 Basic Dentistry: Out-of-Hospital	Unlimited cover provided. According to the Dental Managed Healthcare Program, protocols. Members must use the Medshield Dental Network. Pre-authorization is required for plastic dentures. A 20% penalty will be imposed if permission is not obtained before treatment.
🅰️ Specialized Dentistry	There is a limit of R13,870 per family yearly. All services are subject to pre-approval by the applicable Managed Healthcare Program. A 20% penalty will be imposed if permission is not obtained before treatment. Protocols and the Medshield Dental Network apply according to the Dental Managed Healthcare Program.
🅱️ Impacted Teeth, Wisdom Teeth, and Apicectomy 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 apply. Dental Managed Healthcare Programs, Protocols, and Medshield Dental Network apply. Pre-authorization for general anesthesia and conscious sedation pre-authorization, in- and out-of-hospital. No authorization is needed for local anesthetic apicectomy, impacted tooth removal, or wisdom tooth removal.	The Specialist Dentistry Restriction applies. An R1,575 co-payment is required for wisdom teeth extraction in a Day Clinic. An upfront co-payment of R4,500 is required if the procedure is performed in-hospital. There is no co-payment if the procedure is performed under conscious sedation in the Practitioners’ rooms.
📌 Dental Implants Covers implant-related services. Must be pre-approved. The Dental Managed Healthcare Programme, Protocols, and Medshield Dental Network apply.	The Specialist Dentistry Limit applies.
📍 Orthodontic Treatment Pre-approval is required. Protocols and the Medshield Dental Network apply according to the Dental Managed Healthcare Program.	The Specialist Dentistry Limit applies.
👑 Crowns, Bridges, Inlays, Mounted Study Models, Partial Chrome Cobalt Frame Base Dentures, and Periodontics Includes consultations, visits, and treatment for all types of dentistry, including technician fees. Pre-approval is required. Protocols and the Medshield Dental Network apply according to the Dental Managed Healthcare Program.	The Specialist Dentistry Limit applies.
🙂 Maxillo-facial Surgery	Limited to R17,870 per family yearly. Subject to pre-approval. The benefit is only for non-elective surgery. Subject to the Dental Management Healthcare Program and Protocols. Must use a provider from the Prime Hospital Network. It might be subject to using the Medshield specialist network.

MediPlus Prime 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	Twelve Consultations per pregnancy. It might be subject to the use of the Medshield Specialist Network.
🤰 Antenatal Classes and Postnatal Midwife Consults	Eight Visits per event.
📉 Scans	Two 2D scans per pregnancy.
📈 Amniocentesis Tests	One per pregnancy
📊 Confinement In-Hospital	Unlimited cover when using a Prime Network Hospital.
👩‍⚕️ Delivery by a Family Practitioner or Medical Specialist	Unlimited cover.
🚑 Confinement in a registered birthing unit or out-of-hospital	Unlimited cover Must use a Prime Network.
💙 Delivery by a registered Midwife or a Practitioner	Covered up to 200% of the Medshield Private rates (only for a registered Midwife).
🛁 Hire of a water bath and oxygen cylinder	Unlimited cover.

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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 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 continue 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.

MediPlus Prime 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.

MediPlus Prime Day-to-Day Benefits

📌 Day-to-Day Limits	Limited to the following: Main Member – R9,380 Main Member +1 – R13,100 Main Member +2 – R14,650 Main Member +3 – R16,485 Main Member +4> – R18,090
📍 Family Practitioner (FP) Consultations and Visits Out-of-Hospital FP consults and visits are available in person, over the phone, and remotely. Each beneficiary is required to select one Family Practitioner from the Prime Family Practitioner (FP) Network. From Rand one, the Prime FP Network is applicable.	Each beneficiary can nominate a limit of one FP from the Contact FP Network. Subject to daily limits for the nominated FP.
☑️ Non-Nominated FP/Emergency visits	Limited to two visits per family. Included in the day-to-day limit.
✅ Additional FP Consultations and visits to a nominated provider	This benefit is only active once your daily limit has been exhausted. There is a limit of 2 visits per beneficiary from the OAL after daily limits are depleted. This benefit is subject to the Prime FP Network.
👩‍⚕️ Extended FP visits for emergency and chronic FP consultations	Registration in the Disease Management Program is required. Pre-approval is needed. Chronic Disease List and Clinical Protocols Apply. Unlimited cover if the daily limit and Care Plan FP visits have been depleted. Members must use a nominated FP on the Prime network. There is a limit of one FP consultation per beneficiary.
👨‍⚕️ Medical Specialist Consultations and Visits	Two visits per family, subject to referral authorization by the Network FP of choice. The Overall Yearly Limit is both limited and inclusive. After that, you are restricted to the Day-to-Day Limit.
⚠️ Casualty and emergency visits	Subject to the day-to-day limit.
💊 Acute Medicine	Subject to the daily limit.
🩺 Pharmacy Advised Therapy (PAT)	Subject to the day-to-day limit. Limited to R250 per script and one script per beneficiary daily.
🤓 Optometry	Subjected to applicable Optometry Managed Healthcare Program and Procedures. One set of Optical Lenses and a frame or contact lenses per beneficiary every two years. Benefit determined by the Optical Service Date Cycle.
👁️ Optometric Refraction Eye Tests	One test per beneficiary per 24-month optical cycle. Subject to the OAL.
👓 Spectacles or Contact Lenses (Single Vision Lenses, Bifocal Lenses, Multifocal Lenses, Contact Lenses)	Subject to the OAL and Optical Limit.
➡️ Frame or lens enhancement	Subject to the OAL and the Optical Limit.
☑️ Reading Glasses	There is a limit of R190 per beneficiary. Subject to OAL. Must be supplied by a registered Optometrist, Ophthalmologist, Supplementary Optical Practitioner, or a registered Pharmacy.
📌 Pathology and Medical Technology	Subject to the day-to-day limit. Subject to the relevant Pathology Managed Healthcare program and protocols.
📍 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.
☑️ Physiotherapy, Biokinetics, and chiropractics	Subject to the day-to-day limit.
✅ Basic Radiology	Subject to the day-to-day limit. There is a limit of one bone densitometry scan per beneficiary yearly in or out-of-hospital. Subject to the Radiology Managed Healthcare Program and Protocols. Subject to the Medshield Basic Radiology formulary. Only covered when referred by a Network GP.
📈 Specialized Radiology	Limited to R14,150 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	Subject to the day-to-day limit.
📊 Procedures and Tests performed in the Practitioner’s rooms	Unlimited cover.
🔎 Routine diagnostic Endoscopic Procedures performed in the Practitioner’s rooms	If done in practitioner’s rooms, it is limited to and included in the overall annual limit. There is an R1,500 upfront co-payment applicable if done In-Hospital. In-Hospital co-payment is not required for children aged 8 and under.
🧠 Mental Health Includes the following: Consultations and Visits Procedures Assessments Therapy Treatment or Counselling	Members must use the Medshield Specialist Network. Limited to (and included in) the day-to-day limit. Limited to R34,625 per family yearly.
✔️ 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.
🧪 Additional Medical Services Including the following: Audiology Genetic Counselling Hearing Aid Acoustics Occupational Therapy Orthoptics Podiatry Speech Therapy and Private Nurse Practitioners Dietetics	An in-Hospital referral is subject to authorization. Subject to the day-to-day limit.
🚑 Alternative Healthcare Service (Only applies to Acupuncturists, Homeopaths, Naturopaths, Osteopaths, and Phytotherapists)	Subject to the day-to-day limit.

MediPlus Prime 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.

💉 Adult Vaccination	Limited to R445 per family per annum. After the limit is reached, it is taken from the daily benefit.
💊 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 R200 limit per prescription. Subject to Acute Medical Benefit Limit. Only relevant in the absence of intrauterine devices and alternatives.
🦴 Bone Density Testing for Osteoporosis and bone fragmentation	One per beneficiary 50 years> every three years.
😷 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. After that, it is paid from the daily benefit.
📌 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>
🔁 Pneumococcal Vaccination	One per annum for high-risk individuals and beneficiaries 60 years>.
☑️ 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.
⚕️ Mammogram (Breast Screening)	One per female beneficiary 40 years> every 2 years.
📊 PSA Screening for male beneficiaries	Subject to the day-to-day limit.
🧪 Tuberculosis Test	One test per beneficiary.

Wellness Benefits – Child Immunisations

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

❤️ 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)

MediPlus Prime 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.

Medshield Emergency Medical Services:

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

MediPlus Prime Prescribed Minimum Benefits

Medshield members are entitled to cover 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.

1️⃣ 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.
2️⃣ Out-of-Hospital treatment and managing PMBs	Members diagnosed with any 26 CDL conditions covered by Medshield and MediPlus Prime 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. After using the Care Plan, the member and their treating provider must fill out a PMB Application form to seek clearance for further treatment. If approved, a revised Care Plan will include the additional treatment.
3️⃣ MediPlus Prime Option Payment for PMB conditions	The Day-to-Day limit on your benefit option or plan is a risk allocation made available to members. As a result, a PMB will pay from your Day-to-Day limit until it is empty, then pay from Risk until the services on your Care Plan have been used. If you require additional services not included in your Care Plan, you and your treating provider must complete a new PMB Application form (Clinical Procedures are followed).
4️⃣ 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 Savings will pay for treatment. The Care Plan (treatment plan) will list the covered treatments for the condition after clinical assessment and approval.
5️⃣ 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. MediPlus Prime covers either a PCR or an antigen test, but not both.

MediPlus Prime 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).

MediPlus Prime Plan Exclusions and Waiting Periods

MediPlus Prime Exclusions

MediPlus Prime does not cover the following:

Beneficiaries between the ages of 5 and 13 can only receive professionally applied fluoride. Oral hygiene teaching and evaluation are also provided.
Whitening one’s teeth
Advice on healthy eating and quitting smoking
Price of medicated products like Corsodyl and other mouthwashes and ointments
Fissure sealants for those aged 16 and over
Dental fillings to repair teeth worn down by fluoride, abrasion, erosion, and wear
Restorations requiring resin bonding are billed as an additional service
Surface finishing of restorations; Gold-foiling of restorations
Therapy with ozone

and more.

READ more about Health Insurance for Travel

MediPlus Prime 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.

Medshield MediPlus Prime Plan vs. Similar Plans from other Medical Schemes

🔎 Medical Aid Plan	🥇 Medshield MediPlus Prime	🥈 Discovery Health Classic Smart Comprehensive	🥉 Bestmed Pace 1
🌎 International Cover	Only Organ Transplants	R5 million	R500,000 – R3 million
👤 Main Member Contribution	R4,539	R7,163	R5,061
👥 Adult Dependent Contribution	R3,240	R6,611	R3,555
🍼 Child Dependent Contribution	R1,017	R1,671	R1,277
🏥 Hospital Cover	☑️ Yes	☑️ Yes	☑️ Yes
💶 Prescribed Minimum Benefits	✅ Yes	✅ Yes	✅ Yes
📉 Screening and Prevention	☑️ Yes	☑️ Yes	☑️ Yes
💙 Medical Savings Account	None	None	✅ Yes
🔁 Gap Cover	None	☑️ Yes	None

Our Verdict on The MediPlus Prime Plan

MediPlus Prime plan from Medshield is a comprehensive medical aid plan offering its members a range of benefits and features. One of its significant advantages is the absence of a 40% co-payment required in the MediPlus Compact plan. Additionally, the plan provides additional maternity cover and more scans and tests, additional preventative care, higher overall limits, and more day-to-day benefits that save on out-of-pocket expenses. However, it is important to note that the plan’s premiums may be higher than those of other plans, making it less affordable for some members. Therefore, the MediPlus Prime plan is a good option for those seeking comprehensive medical cover without the added co-payments and wanting higher benefits.

You might also like the following plans MedShield has to offer:

MediPlus Prime Plan Frequently Asked Questions

What are the advantages of MediPlus Prime?

The advantages of MediPlus Prime include additional maternity cover and more scans and tests, additional preventative care, higher overall limits, and more day-to-day benefits that save on out-of-pocket expenses.

What is the difference between MediPlus Prime and MediPlus Compact plan?

The main difference between MediPlus Prime and MediPlus Compact plans is the absence of a 40% co-payment in the former. Additionally, MediPlus Prime starts from R4,539 while MediPlus Prime Compact starts from R4,125.

What are the out-of-pocket expenses associated with MediPlus Prime?

Out-of-pocket expenses with MediPlus Prime could occur when members have used all existing daily limits.

What is the cost of MediPlus Prime?

MediPlus Prime costs R4,146 for the main member, R2,958 for each adult dependent, and R930 for child dependents.

What is covered under MediPlus Prime?

MediPlus Prime covers a range of medical expenses, including hospitalization, doctor visits, prescription medication, preventative care, and maternity care, among many other treatments, procedures, and services.

Can I change my medical aid plan to Medshield?

Yes, members can change their plan with Medshield during open enrollment periods or as needed based on their changing healthcare needs.

How do I become a member of MediPlus Prime?

To become a member of MediPlus Prime, you can visit the Medshield website or contact them directly to start the application process.

What is the process for filing a claim with MediPlus Prime?

To file a claim with MediPlus Prime, you must provide the necessary documentation, such as medical bills, doctor’s notes, and prescriptions. The claims process can be initiated online or through the Medshield app.

Are there any network provider restrictions with MediPlus Prime?

Yes, MediPlus Prime has a network of preferred providers under its Prime Network. Members may be required to choose healthcare services from members registered in this network to avoid costly co-payments.

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.