(treatment protocol) that applies to the condition.Ĭo-payments – in the case of PMB, co-payments apply if patients prefer not to use
Medihelp necesse 2015 code#
PMB code – this code indicates the specific PMB condition and the listed treatment Receive the normal benefits in terms of your benefit option and are subject to limits/Ĭhronic Diseases List (CDL) – a list of 26 chronic conditions listed in the Regulations Non-PMB casesĪuthorisation schedule – a list of all approved services/medicine items approved for Non-PMB cases – cases where the illness, emergency or diagnosis does not qualifyįor PMB in terms of the criteria published in the Medical Schemes Act. Some of the terms that appear in this document are explained below: A formulary (list of medicine) applies to the Prime network options and the MHRP list from our website at or phone our call centre onĠ86 0100 678. PMB ensure that all medical scheme members have that contains the same molecule in the same therapeutic class, and Medihelp applies anĪccess to continuous care to maintain optimal health, and Medihelp will support you on average benefit amount for that specific medicine’s therapeutic class. Doctors and pharmacies may prescribe or provide medicine Minimum benefits (PMB) on all the benefit options offered to members, in terms of the Medihelp’s benefit options. In the event of a dispute, the registered Rules of Medihelp will apply, subject to approval by the Registrar of Medical Schemes.All registered medical schemes in South Africa must cover a set of defined prescribed Medihelp Reference Price (MHRP) – the MHRP applies to all PMB medicine on all Please refer to the complete brochure for more information. Terms, conditions, protocols and pre-authorisation requirements might apply to certain benefits. This is only a summary of the benefit option for 2013. Services must be obtained from a dentist in the Denis networkīenefits are available per 24-month cycle per beneficiary, 1 per beneficiaryĬlear single vision or clear Aquity bifocal lenses R2,240 per beneficiary to a maximum of R3,180 per family per year Specialist consultations on referral by a network GP PMB medicine Prescribed by a network doctor and approved by Medihelp R200 per beneficiary per year, maximum R68 per event Over-the-counter (OTC) medicine obtained without a prescription from a pharmacy in the Medihelp Preferred Pharmacy Network
Prescribed by a network doctor and obtained from a dispensing network GP or a pharmacy in the Medihelp Preferred Pharmacy Network Medicine and services rendered by a non-network doctor
General practitioner services within the Necesse networkĬonsultations – (pre-authorisation must be obtained from the 9th consultation per family onwards) General radiology, pathology and medical technology (during hospitalisation)ĭialysis During and not during hospitalisation Subject to pre-authorisationĬonfinement (non-PMB cases) Caesarean section not clinically indicated (elective)Ģ0% co-payment if not pre-authorised of if admitted to a hospital outside the network
Specialised radiology MRI and CT scans and angiography Hospitalisation, theatre fees, intensive and high-care wards State and private hospitals and day clinics in the Necesse networkĢ0% co-payment if not pre-authorised or if admitted to a hospital outside the network % of contracted/scheme tariff/cost/medicine price These are 2013 rates for Medihelp Plans: Necesse Major medical benefits
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