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Medshield PremiumPlus Medical Aid Plan

Overall, the Medihelp PremiumPlus Medical Aid Plan is a trustworthy and comprehensive medical aid plan that offers 24/7 medical emergency assistance and SmartCare to up to 3 Family Members. The Medihelp PremiumPlus Medical Aid Plan starts from R7,842 ZAR.

👤 Main Member Contribution	R7,842
👥 Adult Dependent Contribution	R7,185
🍼 Child Dependent Contribution	R1,500
🔁 Gap Cover	None
🏥 Hospital Cover	Unlimited
💶 Prescribed Minimum Benefits	✅ Yes
💙 Maternity Benefits	✅ Yes
➡️ Home Care	✅ Yes
📉 Annual Limit	Unlimited Hospital Cover
🌎 International Cover	Only Organ Transplants

Medshield PremiumPlus Plan – 11 Key Point Quick Overview

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

Medshield PremiumPlus Plan Overview

The Medshield PremiumPlus medical aid plan is one of 11, starting from R7,842 and includes an emergency medical response by air and road, a medical savings account, chronic medicine, SmartCare, Day-to-Day benefits, and more. Gap Cover is not available on the Medshield PremiumPlus 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 PremiumPlus Plan Contributions and Medical Savings

Monthly Contributions

👤 Main Member	👥 +1 Adult Dependent	🍼 +1 Child Dependent
R7,842	R7,185	R1,500

READ more about the 5 Best Medical Aids under R500

Savings Account and Day-to-Day Benefits

🔎 Component	👤 Main Member	👥 Adult Dependent	🍼 Child Dependent
📌 Annual Personal Savings Account	R18,816	R17,244	R3,600
📍 Threshold	R22,500	R20,800	R4,200
🚩 Above Threshold Benefit (ATB)	R6,100	R4,400	R3,050*

Medshield PremiumPlus Plan Benefits and Cover Comprehensive Breakdown

PremiumPlus 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.

PremiumPlus Major Medical Benefits In-Hospital

🔎 Overall Annual Limit	There is no overall annual limit.
📌 Extended Benefit Cover of up to 200%	This only applies to specific services and procedures in hospitals.
🏥 Hospitalization	Unlimited cover. Subject to the relevant Management Healthcare Program. Pre-approval is needed for specialist services. Specialist visits and consults must be pre-authorized.
📍 Surgical Procedures	Covered as part of an authorized event. Unlimited cover provided. Extended Benefit Cover of up to 200%.
💊 Medicine upon discharge	Limited to R885 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 R148,280 limit per family yearly, subject to the hospitalization limit. DSPs must be used, or a 25% co-payment will apply for using a non-PremiumPlus Network Hospital. Terminal care is limited to R41,400 per family per year and is subject to the Alternatives to Hospitalisation Limit.
🩺 General, Medical, and Surgical Appliances	Limited to R6,995 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. 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. Extended Benefit cover of up to 200%.
📌 Refractive Surgery Includes the following: LASIK Radial Keratotomy Phakic Lens Insertion	Limited to R19,980 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. 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. Clinical protocols apply. 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 PMSA unless specific authorization is obtained.
🦾 Internal Prostheses and Devices	Subject to pre-authorization by the relevant Managed Healthcare Program. Only for surgically implanted devices. Limited to R69,945 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 R29,700 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	Unlimited cover. 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 R61,765 per family per year in and out-of-hospital. 25% upfront co-payment for non-Medshield Network Hospitals. DSP from Rand one applies for PMB and non-PMB admissions.
💊 Rehabilitation for Substance Abuse	Subject to the mental health limit. Limited to R16,480 per family per year.
👨‍⚕️ 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.

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PremiumPlus Oncology Benefits

1️⃣ Oncology Limit	Unlimited cover. There is a 40% co-payment if members use a non-DSP.
2️⃣ Active Treatment (Includes Stoma Therapy, Incontinence Therapy, and Brachytherapy)	Subject to the Oncology Limit. ICON Standard Protocols apply.
3️⃣ Oncology Medicine	Limited to R392,835 per family per year. Subject to the Oncology Limit. ICON Standard Protocols apply.
4️⃣ Radiology and Pathology	Subject to the Oncology Limit.
5️⃣ PET and PET-CT	Limited to 2 scans per family per annum. Subject to the Oncology Limit.
6️⃣ Integrated Continuous Cancer Care	Six visits per family per annum. Subject to the Oncology Limit
7️⃣ Specialized Drugs for Oncology, Non-Oncology, and Biological Drugs	Subject to the Oncology medicine limit. Pre-authorization is required from the Oncology Managed Healthcare provider. Clinical Protocols will apply. 20% upfront payment for non-PMBs.
8️⃣ Vitreoretinal Benefit	Subject to pre-approval. Specialized Drugs Limit applies.
9️⃣ 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.

PremiumPlus Chronic Medicine Benefits

🅰️ Members must use a DSP Provider on PremiumPlus	Limited to R16,490 per beneficiary and R32,980 per family per year. Medications will be approved per the Medshield Formulary and will be available beginning with Phase one.
🅱️ Supply of Medication (One month in advance)	Limited to R16,490 per beneficiary and R32,980 per family per year. Medications will be approved per the Medshield Formulary and will be available beginning with Phase one.

PremiumPlus Chronic Disease List

Medshield PremiumPlus covers 26 CDL conditions plus an additional 54, including but not limited to:

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

and many more.

PremiumPlus Dentistry Benefits

🅰️ Basic Dentistry: In-Hospital	Unlimited cover provided. The in-hospital cover is only for kids under 6 for comprehensive Basic Dental). Medshield private rates of up to 200% will apply to the dentist’s account for procedures performed under conscious sedation in the practitioner’s room. Subject to Managed Healthcare Program pre-authorization. Treatment without authorization incurs a 20% penalty. PremiumPlus members must use the Medshield 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 R20,360 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 Medshield private rates of up to 200% will apply to the dentist’s account for procedures performed under conscious sedation in the practitioner’s room. An R900 co-payment is required for wisdom teeth extraction in a Day Clinic. An upfront co-payment of R2,000 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. Medshield private rates of up to 200% will apply to the dentist’s account for procedures performed under conscious sedation in the practitioner’s room.
💙 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.	Subject to funds available in the PMSA. Threshold and Above Threshold will Apply.
😊 Maxillo-facial Surgery	Limited to R20,360 per family yearly. Extended benefit cover of up to R200%. 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 Medshield Hospital Network. It might be subject to using the Medshield specialist network.

PremiumPlus 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.

Get an better understanding of maternity benefits

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. Extended benefit cover of up to 200%.
👨‍⚕️ 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 Medshield 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.

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.

PremiumPlus SmartCare Services and Benefits

SmartCare gives access to Videomed and telephone 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.

🅰️ Pharmacy/clinic private nurse practitioner consultations	Unlimited cover.
🅱️ 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.
©️ WhatsApp doc advice line	Unlimited cover.

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PremiumPlus Day-to-Day Benefits

PremiumPlus includes a Personal Medical Savings Account (PSA) and an Over Threshold Benefit in its Day-to-Day benefit categories. Family Practitioner (FP) Consultations, Optical Services, Specialist Consultations, and Acute Medication are among the claims that can be paid with the benefits.

🔎 Component	👤 Main Member	👥 Adult Dependent	🍼 Child Dependent
💶 Annual Personal Savings Account	R17,280	R15,828	R3,300
📉 Threshold	R21,100	R19,450	R3,960
💙 Above Threshold Benefit (ATB)	R5,730	R4,135	R2,865

Using Daily Benefits and how they can be accessed by PremiumPlus members:

1️⃣ Step 1 Personal Savings Account	Access to Personal Savings Account (PSA) – 20% of monthly contributions, allocated annually in advance (January to December). PSA allocation is determined by family size. PSA covers Day-to-Day benefits. Above Threshold Benefit is available once PSA is exhausted and the Threshold amount set by Scheme is reached. Above Threshold Benefit applies to you and your dependents.
2️⃣ Step 2 Self-Payment Gap or SPG	Certain benefit category claims aggregate to the Scheme’s annual Threshold amount. If your savings run out before your Threshold, you will enter a Self-Payment Gap. Self-Payment Gap means paying day-to-day medical expenditures from your pocket or PSA until you hit a threshold. Not all PSA or Day-to-Day benefit claims contribute to your threshold and Self-Payment Gap. The SPG will only accumulate on the Scheme tariff. Family size determines the Self-Payment Gap up to a limit. Even at the Self-Payment Gap stage, you must submit claims for your payments to reflect on the system and accumulate. You can get Above Threshold Benefits after reaching the threshold.
3️⃣ Step 3 Above Threshold Benefits (ATB)	After reaching your threshold, you can access Above Threshold Benefits. The Above Threshold Benefit will cover Day-to-Day medical expenses up to a limit, not Savings. Claim payments will follow the Scheme tariff. Family size affects Above Threshold Benefit limits. After exhausting your Above Threshold Benefit, your savings will pay your claim.
4️⃣ ATB Payments	ATB covers the following: Medical Specialists Family Practitioners (FP) Acute Medicines (excluding OTC) Basic and Specialised Dentistry

PremiumPlus Day-to-Day Benefits Table

👨‍⚕️ Family Practitioner (FP) Consultations and Visits Out-of-Hospital	Subject to the Personal Savings Account. Threshold and Above Threshold Benefits apply.
👩‍⚕️ Medshield Family Practitioner Network (Consults and Visits out-of-hospital)	Two visits per beneficiary, according to the OAL, once the medical savings account is depleted.
📌 Extended FP visits for emergency and chronic FP consultations (In-person only)	Registration in the Disease Management Program is required. Pre-approval is needed. Chronic Disease List and Clinical Protocols Apply. Unlimited once savings and Care Plan FP visits have been depleted. There is a limit of one FP consultation per beneficiary.
📍 Medical Specialist Consultations and Visits	Must use the Medshield Specialist Network. Subject to the day-to-day limit. Subject to the Personal Savings Account.
⚠️ Casualty and emergency visits	Subject to the day-to-day limit. Subject to the Personal Savings Account.
💊 Acute Medicine	Subject to the Personal Savings Account.
⚕️ Pharmacy Advised Therapy (PAT)	Subject to the day-to-day limit. Limited to R250 per script and one script per beneficiary daily. A co-payment will apply if a non-Medshield Network Pharmacy is used.
🤓 Optometry	Subject to the Personal Savings Account.
👁️ Optometric Refraction Eye Tests	One test per beneficiary per 24-month optical cycle. Subject to the Personal Savings Account.
👁️‍🗨️ Spectacles or Contact Lenses (Single Vision Lenses, Bifocal Lenses, Multifocal Lenses, Contact Lenses)	Subject to the Personal Savings Account.
👓 Frame or lens enhancement	Subject to the Personal Savings Account.
📖 Reading Glasses	There is a limit of R190 per beneficiary. Subject to the Personal Savings Account. Must be supplied by a registered Optometrist, Ophthalmologist, Supplementary Optical Practitioner, or a registered Pharmacy.
🧪 Pathology and Medical Technology	Subject to the Personal Savings Account. Subject to the relevant Pathology Managed Healthcare program and protocols.
😷 Covid-19 PCR/Antigen Test	The 1st test is included in the OAL and then subject to the savings account unless there is a positive result. In such cases, it is subject to PMB.
🏈 Physiotherapy, Biokinetics, and chiropractics	Subject to the Personal Savings Account.
📈 Basic Radiology	Subject to the Personal Savings Account. 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.
📉 Specialized Radiology	Limited to R29,700 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 Personal Savings Account. Threshold and ATB will apply. The use of the Medshield Specialist Network will apply.
🅰️ Procedures and Tests performed in the Practitioner’s rooms	Unlimited cover. Medshield Private Rate covers up to 200%.
🅱️ 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. Medshield Private Rate covers up to 200%. 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	Limited to R5,550 per family yearly. Limited to (and included in) the day-to-day limit of R61,765.
🩺 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	Subject to the Personal Savings Account. Threshold and ATB will apply.
➡️ Alternative Healthcare Service (Only applies to Acupuncturists, Homeopaths, Naturopaths, Osteopaths, and Phytotherapists)	Subject to the Savings Account.

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PremiumPlus 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 R1,795 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)

PremiumPlus 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.

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PremiumPlus Prescribed Minimum Benefits

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.

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.

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 PremiumPlus 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 PremiumPlus Option Payment for PMB conditions	Member contributions fund Personal Medical Savings Accounts, so Risk pays for care plan care directly. The Scheme can reprocess claims if a member pays out of pocket for approved Care Plan services. This only applies to services on the approved Care Plan.
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 or 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. PremiumPlus covers either a PCR or an antigen test, but not both.

PremiumPlus 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).

PremiumPlus Plan Exclusions and Waiting Periods

PremiumPlus Exclusions

PremiumPlus does not cover some of the following:

⛔ Cosmetic crown and bridge procedures, as well as the accompanying laboratory fees
⛔ Crown and bridge procedures with minimal tooth structural loss and accompanying laboratory costs
⛔ Rehabilitation of the occlusion and the related laboratory expenditures
⛔ Provisional crowns, as well as the accompanying laboratory fees
⛔ Emergency crowns that are not inserted immediately to safeguard a tooth after an injury, as well as the related laboratory expenditures
⛔ Gold, precious metal, semi-precious metal, and platinum foil prices
⛔ Fees for laboratory delivery
⛔ Unless expressly authorized and unless PMB level of care, orthopedic shoes, and boots
⛔ TENS and APS pain relief machines
⛔ Stethoscopes
⛔ Procedures for sinus lift
⛔ When claimed in conjunction with impacted teeth, closing an oral-antral opening
⛔ Orthognathic (jaw correction) surgery, as well as any associated hospital expenditures and laboratory fees
⛔ Aortic stents are covered until the Prescribed Minimum Benefits level of care (DSP) is met
⛔ Peripheral vascular stents are covered unless the Prescribed Minimum Benefits level of care (DSP) is met
⛔ Mineral trioxide cost
⛔ Enamel micro-abrasion
⛔ Dental procedures or equipment that is not deemed clinically necessary or desirable by the applicable Managed Healthcare Program

PremiumPlus Waiting Periods

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.

Often, there is a waiting period for pre-existing conditions. This is to prevent new members from abusing medical insurance for a brief period to finance pricey procedures and cancel their membership shortly after.

Medshield PremiumPlus Plan vs. Similar Plans from other Medical Schemes

🔎 Medical Aid Plan	🥇 Medshield PremiumPlus	🥈 Momentum Summit Plan	🥉 Discovery Health Executive Plan
🌎 International Cover	Only Organ Transplants	R9 million	Up to US$1 million
👤 Main Member Contribution	R7,842	R13,573	R10,303
👥 Adult Dependent Contribution	R7,185	R10,855	R10,303
🍼 Child Dependent Contribution	R1,500	R3,118	R1,969
💶 Annual Limit	Unlimited Hospital Cover	Unlimited	Unlimited
➡️ Oncology Cover	Unlimited	Unlimited	R500,000

Our Verdict on The PremiumPlus Plan

Medshield’s PremiumPlus plan is the most comprehensive and highest-tier plan offered by the medical aid scheme. It provides the most extensive cover, both in and out-of-hospital, with higher medical savings, fewer co-payments and limitations, and additional benefits not included in the lower tier plans. With PremiumPlus, members can access unlimited private hospital coverage, chronic medication, preventive care, wellness programs, and specialized medical procedures. PremiumPlus also offers a comprehensive range of benefits for maternity, dental, optometry, and mental health services. One of the few disadvantages of this plan is its higher monthly premiums, which may be less affordable for some individuals. Overall, if you are looking for a plan that offers the most comprehensive cover and benefits, PremiumPlus is the best choice. However, if you are on a tight budget, you may consider the lower-tier plans, which may offer less coverage but are more affordable.

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

PremiumPlus Plan Frequently Asked Questions

What is Medshield PremiumPlus?

PremiumPlus is the most comprehensive and highest-tier plan offered by Medshield, a medical aid scheme in South Africa. It provides extensive in and out-of-hospital cover, higher medical savings, fewer co-payments, and additional benefits not included in the lower-tier plans.

What is the PremiumPlus medical savings account?

The medical savings account is 20% of the monthly contributions allocated to members in advance for healthcare expenses. This account can cover medical expenses like doctor visits, medication, and tests.

What are examples of chronic medications covered by PremiumPlus?

Chronic medications covered by PremiumPlus refer to medications used to treat ongoing medical conditions, such as high blood pressure, diabetes, and asthma. The plan, subject to certain limitations and conditions, covers these medications.

What are preventive care and wellness programs with PremiumPlus?

Preventive care and wellness programs included in PremiumPlus refer to services and programs designed to help members maintain good health and prevent illnesses. These include regular check-ups, screenings, vaccinations, and lifestyle counseling.

What are the maternity benefits of PremiumPlus?

The maternity benefits with PremiumPlus cover the costs of prenatal, delivery, and postnatal care for pregnant women. These benefits may include consultations with gynecologists and midwives, ultrasound scans, blood tests, and hospitalization.

What are the dental and optometry benefits of PremiumPlus?

The dental and optometry benefits with PremiumPlus cover the costs of routine dental and eye care services, such as check-ups, cleanings, fillings, and glasses or contact lenses.

What are mental health services offered by PremiumPlus?

Mental health services covered by PremiumPlus include the costs of consultations with psychiatrists and psychologists, as well as inpatient and outpatient treatment for mental illnesses.

What is private hospital cover provided by PremiumPlus?

Private hospital cover with PremiumPlus refers to the plan’s coverage of hospitalization costs in private hospitals, which typically offer higher quality care and better amenities than public hospitals.

What are the specialized medical procedures covered by PremiumPlus?

Specialized medical procedures refer to medical treatments requiring specialized equipment or expertise, such as organ transplants, cancer treatments, and complex surgeries.

What are the monthly premiums with PremiumPlus?

Monthly premiums in PremiumPlus are the monthly payments that members make to the medical aid scheme to maintain their healthcare coverage. The premiums for PremiumPlus are typically higher than those for lower-tier plans, starting from R7,200 for the main member.

Are there more affordable healthcare options than PremiumPlus?

Yes, Medshield offers several lower-tier plans that may be more affordable for individuals on a tight budget. These plans offer less coverage than PremiumPlus but may still provide adequate healthcare coverage for many people.

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.