Medimed Medical Scheme

All four options cover Prescribed Minimum Benefits unlimited at a designated service provider, with no limits and no co-payments, provided the treatment is in terms of the scheme's managed care protocols. The brochures state this plainly and add one warning in bold: if a non-DSP is used voluntarily, the normal scheme benefits apply instead. That means the option's ordinary rand limit and its ordinary payment percentage, not full PMB cover. On Alpha that is the difference between a fully covered admission and one where you owe a levy of 25% to 40% on every doctor.

For chronic medicine, all four options pay 100% up to the Chronic Drug Amount set by the administrator, for conditions on the Chronic Disease List, on pre-authorisation and on formulary. Registration matters: the brochures state that beneficiaries who register the treatment and care of a CDL condition are the ones who get cover with no limits and no co-payments. Registration forms come from the administrator on 0861 777 660 or info@medimed.co.za.

Conditions that are not on the Chronic Disease List

This is where the options separate. An extended chronic benefit covers registered conditions outside the statutory list:

Alpha pays the largest extended chronic amount in the range but pays it at only 75% of the Chronic Drug Amount, so you fund a quarter of every non-CDL script. Medisave Essential publishes no extended chronic limit at all: its brochure records CDL cover on formulary and nothing beyond it. On Medisave Standard and Medisave Max, chronic medicine that has been approved as chronic is paid from the elective benefit rather than from your savings account, which is why the brochures advise registering regular medicine as chronic to make the savings account last.

Medimed does not publish the number of conditions on its Chronic Disease List in the 2026 benefit sheets, and its own website and its chronic application form have given different counts. Ask the scheme for the current CDL and the applicable formulary version before you rely on a specific condition being covered.

There are three completely different day-to-day designs in this range, and comparing the four options on price alone will mislead you.

1. Alpha has no savings account. Instead it gives you a list of fixed benefits with sub-limits, all sitting under an overall combined family limit of R18 000, and it pays 60% or 75% of the tariff on most of them. You fund the rest of every claim. The scheme pays the balance directly only where a provider submits in real time; otherwise you pay the provider and claim back.
2. Medisave Essential buys you care rather than money. Unlimited GP consultations, unlimited acute medicine and unlimited pathology and basic radiology come from the network, not from a fund. The savings account is only 10% of contributions, between R2 232 and R9 216 a year, and it exists to cover the things the network does not: casualty, out-of-town GP visits, over-the-counter medicine, appliances and auxiliary services.
3. Medisave Standard and Medisave Max are conventional savings plans. 25% of contributions goes into a savings account, paid at 100% of the Medimed Scheme Tariff on day-to-day claims. When that is empty, the elective benefit takes over: R6 000 a beneficiary and R12 000 a family on Standard, R7 500 and R15 000 on Max. When the elective benefit is also gone, day-to-day claims are yours.

Both savings options carry named sub-limits that apply regardless of how much savings you have left: optometry, appliances and over-the-counter medicine are capped separately. Certain authorised procedures done in a provider's rooms are paid from the in-hospital benefit instead of from savings, which preserves your day-to-day money, but you have to phone customer care to find out whether a planned procedure qualifies.

Both brochures publish the same six-point advice on making savings last: avoid unnecessary visits and purchases, do not go straight to a specialist, ask for generics, negotiate cash discounts, register regular medicine as chronic so it does not come out of savings, and keep diagnostic testing down by staying with one GP who holds your file.

The maternity benefit is identical on all four options and it is not automatic. You have to register on the Medimed maternity programme to get it. Registered beneficiaries receive, paid at 100% of the Medimed Scheme Tariff:

• Three antenatal visits.
• Two 2D scans.
• One paediatrician visit.
• One maternity bag per pregnancy.
• Antenatal vitamins at R100 a month for nine months, paid from the acute medication benefit, which on Alpha means at 60% and inside the R2 000 acute limit.

The delivery itself

For an in-hospital delivery the obstetrician or gynaecologist is funded at 200% of the Medimed Scheme Tariff on every option, including Alpha. This is the only benefit in the whole range where all four options pay double tariff, and it exists because obstetric fees are the classic source of a shortfall.

For a home delivery, a registered midwife is funded at 100% of tariff, limited to R12 000 per pregnancy, and that figure is conditional on there being no admission. If you plan a home birth and end up being admitted, the benefit drops to R1 200 and the hospital admission is covered under the ordinary hospital benefit instead.

Three antenatal visits is thin. Most South African antenatal schedules run to eight or more consultations, so on any Medimed option expect to fund the rest from savings, from the day-to-day limits, or yourself.

Cancer treatment on every option is authorised through ICON and paid at 100% of the Medimed Scheme Tariff, on pre-authorisation. What differs is how much of it there is, and the spread across the range is very wide.

Read the Medisave Essential row carefully. On that option oncology, radiation therapy, dialysis and organ transplants all draw on one shared limit of R50 000 a family. Prescribed Minimum Benefit treatment remains unlimited at a designated service provider, and most cancers are PMBs, so this is not the same as having no cancer cover. But any treatment that falls outside the PMB level of care, and any dialysis for a family that has already used the limit, has R50 000 behind it. Medisave Essential is the cheapest option in the range and this is the largest single reason why.

Alpha's R200 000 is also low by open scheme standards for a plan at R2 100 an adult. Medisave Max at R400 000 is the only figure in the range that would carry a full course of modern treatment without hitting the ceiling, and it is also the only option with a biological medicine benefit, at R200 000 subject to prior application and approval by the scheme's designated agent.

Cancer screening on Medisave Standard and Medisave Max is paid from the oncology benefit rather than from savings: mammogram for breast cancer, Pap smear for cervical cancer, PSA for prostate cancer and faecal occult blood tests for colorectal cancer. On Alpha, screening sits inside the R1 500 preventative care benefit. On Medisave Essential no screening benefit is published.

HIV and Aids is unlimited on all four options, subject to managed care protocols. Oxygen is R4 000 a family on Standard and R6 000 a family on Max, and is not published as a benefit on Alpha or Medisave Essential.

This is the weakest area of the range and the 2026 documents are honest about it. There is no separate out-of-hospital psychology benefit with its own rand limit on Alpha, Medisave Standard or Medisave Max. Psychology falls under auxiliary benefits, which means it competes with physiotherapy and chiropractic for the same money.

Psychiatric admission needs pre-authorisation on every option, and the stated limit includes hospitalisation and all other in-hospital providers' costs, so the psychiatrist's fee comes out of the same figure as the bed. A R6 000 limit covering both is a few days, not a course of treatment. Beyond it you are relying on Prescribed Minimum Benefits, which cover a defined set of psychiatric conditions at a designated service provider and nothing else.

The one genuine outlier is Medisave Essential, where psychology is unlimited on referral from your selected GP because it is bought from the practitioner association rather than paid from a fund. On the cheapest option in the range, out-of-hospital mental health cover is the strongest.

The scheme also runs a mental health lifestyle coaching programme through its wellbeing team on 086 010 3228. It is coaching for stress and anxiety management, and the scheme states that it does not diagnose or treat mental illness. Do not count it as cover.

In-hospital dentistry is covered on all four options but tightly fenced: it is limited to impacted wisdom teeth and children under 12 everywhere in the range, and the limit includes the hospital account and every other in-hospital provider's cost.

Note the difference between per family and per beneficiary. Alpha and Medisave Essential cap in-hospital dentistry across the whole membership, so two children needing wisdom teeth out in the same year share R12 000 or R10 000. Medisave Standard and Medisave Max apply the limit to each beneficiary.

On Alpha the dentist is paid at 60% of the Medimed Scheme Tariff even inside hospital, so a member pays 40% of the dentist's account plus anything charged above tariff. Medisave Essential includes one set of plastic dentures every two years within its R1 000 denture allowance. Orthodontics is not named as a benefit in any 2026 Medimed brochure.

Four options, four completely different approaches, and one of them gives you nothing towards glasses.

• Alpha: one optometric examination per beneficiary per year at 100% of the Medimed Scheme Tariff. Frames and prescription lenses: no benefit. Contact lenses: no benefit. The brochure states this in as many words. If you wear glasses, Alpha will pay for the eye test and nothing else.
• Medisave Essential: a two year benefit for either contact lenses or glasses, delivered through the PPN network. The eye test is 100% of cost in network or R380 at a non-network provider. Frames R330. Single vision lenses R215. Bifocal and base multifocal lenses R460. Contact lenses R845 a beneficiary, with multifocal contact lenses paid up to the value of bifocals.
• Medisave Standard: R3 800 a beneficiary to a maximum of R7 600 a family, every second year, paid from savings then the elective benefit.
• Medisave Max: R4 400 a beneficiary to a maximum of R8 800 a family, every second year, paid from savings then the elective benefit.

The Medisave Essential figures are the amounts the scheme pays, not the amounts a practice charges. R330 towards a frame and R215 towards single vision lenses will buy you the network's entry level range and nothing more. The Standard and Max amounts are considerably more usable, but they come out of your own savings money rather than being funded by the risk pool.

Basic radiology is unlimited on every option, though on Alpha it is paid at only 75% of tariff. Specialised radiology, meaning MRI, CT and similar, needs pre-authorisation on every option and applies in and out of hospital.

Internal prosthesis limits are per family per year on every option, not per beneficiary. A joint replacement, a stent or a spinal fusion will use most or all of a family's annual prosthesis allowance in one admission. On Medisave Essential the whole family has R20 000 for the year, which will not cover one hip. On Alpha a joint replacement also attracts a R10 000 co-payment on top.

Alternatives to hospitalisation covers step-down services, and compassionate care covers home-based palliative care, pain management and family support. Both need pre-authorisation.

Three of the four options carry a preventative care benefit paid at 100% of the Medimed Scheme Tariff, in addition to savings and day-to-day limits:

• Alpha: R1 500 a beneficiary to R3 000 a family, covering flu vaccination, Pap smear, bone density scan, cholesterol test, one dental consultation, blood sugar test and HIV test.
• Medisave Standard: R1 500 a beneficiary to R3 000 a family, covering flu vaccination, bone density scan, cholesterol test, blood glucose tests, dental consultation and HIV test.
• Medisave Max: R1 600 a beneficiary to R3 200 a family, same list.
• Medisave Essential: no preventative care benefit is published in the 2026 brochure.

Beyond that the scheme runs programmes rather than benefits, through its wellbeing team on 086 010 3228 and wellbeing@medimed.co.za: an HIV and Aids programme covering registration, authorisation, education, counselling, post-exposure prophylaxis and pre-exposure prophylaxis, chronic lifestyle coaching for members with registered chronic conditions, mental health lifestyle coaching, oncology case management through ICON, the maternity programme, compassionate home-based care, and a smoking cessation booklet. These come from medimed.co.za rather than from the 2026 benefit sheets.

Child immunisation is now covered on Medisave Standard and Medisave Max, but from the acute medication benefit, so it draws down your savings account rather than being risk funded.

Each benefit sheet carries the same disclaimer: it is a summary for information purposes only, it does not supersede the rules of the scheme, and where the two differ the rules prevail. The following are absent from the 2026 benefit and contribution sheets, so treat anything you read elsewhere as unverified until Medimed confirms it in writing:

• A hospital network list, or any named hospital group arrangement on Alpha, Medisave Standard or Medisave Max.
• The identity of the preferred provider hospitals on Medisave Essential, which are named only on the scheme website.
• A specialist network, a GP network list for the Essential option, or a find-a-provider tool of any kind.
• A list of general exclusions.
• Waiting periods and late-joiner penalties, which appear in the scheme rules rather than the benefit sheets.
• The Chronic Drug Amount, the current CDL and non-CDL formularies, and the number of chronic conditions covered.
• Any international travel, evacuation or out-of-country benefit. There is no evidence one exists on any option.
• Any orthodontic benefit.
• An oxygen benefit on Alpha or Medisave Essential.
• Call centre operating hours.

• General waiting period of up to 3 months, applied to applicants who do not have at least 90 days of prior medical scheme cover.
• Condition-specific waiting period of up to 12 months on a pre-existing condition, meaning one for which medical advice, diagnosis, care or treatment was recommended or received in the 12 months before you applied.
• No waiting periods are imposed for a change of employment, an employer changing schemes, a transfer between Medimed options, or newborn and adopted children.
• Late-joiner penalty if you are 35 or older when you apply and cannot show continuous cover since 1 April 2001, with breaks of up to three months allowed. The penalty is a permanent loading on your contribution.

• Evidence required. You and each dependant must provide satisfactory evidence of age, income, state of health and any prior membership. Where the scheme requires medical tests or examinations, the scheme pays for them.
• Income proof matters more here than at most schemes, because three of the four options are banded and the gap between the bottom and top band on Medisave Essential is R1 250 a month for an adult.
• Employer groups need a minimum of 20 eligible employees to participate.
• Dependants: a spouse or partner, children under 21, children 21 to 25 who are unmarried full-time students, children with disabilities regardless of age, and other immediate family members you support. Every dependant other than a spouse or partner must not earn more than the social pension threshold.
• Changing option takes effect only from 1 January, in writing, with at least 30 days notice, unless the board announces a mid-year change or exercises its discretion.
• Resigning requires three months written notice from a member, and six months from an employer terminating participation. Retiring employees stay on automatically unless they ask to be removed.

Claims must be submitted within four months of the date of service. Medimed cannot process an account unless it carries all of the following, so check before you send it:

• The provider's name and practice number.
• Your name, initials, address and medical aid number.
• The patient's name.
• The service date.
• An ICD-10 diagnosis code.
• Tariff codes for the services provided.
• NAPPI codes for any medicine dispensed.
• The amount charged on each line item.

Who gets paid

• Acute medicine: prescribed medicine from a pharmacy is paid directly to the pharmacy if the pharmacy submits it in real time. You settle your own portion at the counter.
• Claims below R1 000 per service: refunded to you. No receipt needs to be attached, but mark the claim as paid.
• Claims of R1 000 or more per service: paid to the provider if the provider submits. If you submit and mark it paid, you are refunded.
• A service means a single provider and beneficiary event. Scheme approved rates, levies and exclusions all apply to what is actually reimbursed.

Submit claims by email to claims@medimed.co.za and providerclaims@medimed.co.za as a clear scanned image, by post to Medimed Claims, PO Box 1672, Port Elizabeth, 6000, or by hand to Momentum Thebe Ya Bophelo, 7 Lutman Street, Richmond Hill, Port Elizabeth, 6000.

Pre-authorisation is required for hospitalisation on every option, and separately for alternatives to hospitalisation, auxiliary services, prostheses, psychiatric admission, specialised radiology, appliances, chronic medicine, oncology, dialysis, transplants and biological medicine. In practice, if a benefit in the tables above carries a rand limit, assume it needs authorising first.

Medimed publishes an ex gratia policy, which is more than most schemes do. Ex gratia is a discretionary payment where the scheme believes an exceptional situation warrants funding. The policy is explicit that it is not a benefit defined in the scheme rules and should not be used to replace or supplement existing benefits.

Applications are evaluated by an Ex Gratia Committee appointed by the Board of Trustees, on their merits, at the committee's sole discretion, guided by the rules of the scheme. Enquiries go to ex-gratia@medimed.co.za.

What the committee weighs

1. The clinical appropriateness and medical necessity of the treatment, including whether alternative treatments exist for the condition.
2. Whether the cost would cause you undue financial hardship.
3. Your benefit usage and any previous ex gratia claims you have made.
4. The financial position of the scheme.

What it will not consider at all

• Stale claims, meaning anything older than four months.
• Costs under R1 000.
• Charges above scheme tariff. This is the important one. If your shortfall is because a surgeon billed above the Medimed Scheme Tariff, ex gratia is not the route, and the whole shortfall is yours.
• Treatment of a cosmetic nature.
• Legal costs incurred because you did not settle an account.

The practical reading is that ex gratia exists for a benefit limit that ran out on a clinically necessary treatment, not for balance billing. Apply early, apply within four months, and expect the committee to look at what you have already claimed.

The benefit sheets set out the first step and the last. The middle steps come from the scheme rules.

1. Complain in writing to the scheme at info@medimed.co.za, or to the administrator at escalations@medimed.co.za. The rules require a written response within 30 days of receipt.
2. Unresolved matters go to a disputes committee of three members, appointed annually, which holds a hearing on not less than 21 days notice.
3. Appeal to the Council for Medical Schemes, by affidavit, not later than three months after the date of the decision concerned. Lodging the appeal suspends the operation of the disputed decision until the Council determines it.
4. You may report a dispute to the Council at any stage. Share call 0861 123 267, email complaints@medicalschemes.com, or write to Private Bag X34, Hatfield, 0028.

The three month appeal window is a real deadline. If you have a final decision from the scheme that you want to challenge, diarise it the day you receive it.

Between R1 860 and R5 230 a month for an adult, and between R580 and R920 for a child, depending on the option and on what you earn. Alpha is a flat R2 100 an adult and R740 a child regardless of income. Medisave Essential runs from R1 860 to R3 110, Medisave Standard from R2 600 to R3 480, and Medisave Max from R4 460 to R5 230. The principal member and an adult dependant pay the same rate, so a couple is exactly double a single member. Rates took effect on 1 January 2026 and the scheme says the average increase was 7.79%.

Because three of Medimed's four options are income banded on the principal member's gross monthly income. The benefits are identical inside an option, so a member earning R10 000 and a member earning R30 000 get exactly the same Medisave Standard cover but pay R2 600 and R3 480 for it. You have to provide satisfactory evidence of income when you apply, along with evidence of age, state of health and prior membership. Only Alpha ignores what you earn, which is why Alpha can be the more expensive choice for a low earner and the cheaper one for a high earner.

Not for most people. Medisave Essential costs R1 860 an adult in the bottom band, which is R240 less than Alpha. And Alpha at R2 100 is only R500 less than Medisave Standard at R2 600 for a low earner, while giving you no savings account, a hard R18 000 family day-to-day ceiling, sub-limits of R3 500 a person for doctors and R2 000 a person for acute medicine, and a scheme payment of only 60% or 75% of tariff on most day-to-day claims. Alpha suits someone who wants a flat rate and claims very little out of hospital.

The Medimed Scheme Tariff is a rate the scheme sets and pays up to. Every benefit in every 2026 brochure is expressed against it. Doctors, surgeons, anaesthetists and pathologists are free to charge above it, and where they do the difference is yours. Only Medisave Max pays in-hospital GPs and specialists at 200% of the tariff. On Medisave Essential and Medisave Standard the brochures publish no rate above the tariff at all, and on Alpha in-hospital doctors are paid at 100% for a PMB admission and 75% otherwise. Medimed's own advice is to ask your doctor to charge at the scheme tariff and, if they will not, to ask how much above it they charge before the procedure.

Medimed does not publish a hospital network list, and no 2026 document names Netcare, Life Healthcare, Mediclinic or the National Hospital Network. On Alpha, Medisave Standard and Medisave Max the benefit sheets say hospital cover is unlimited on pre-authorisation and impose no named network. On Medisave Essential the account is paid at 100% at preferred providers and 80% at non-preferred providers, and the scheme website names Mercantile Hospital and Cuyler Clinic as those preferred providers. There is no find-a-provider tool, so if this matters to you, get the answer from customer care in writing before you join.

Yes. Your selected GP is described by the scheme as the manager of all your healthcare, and you need a referral from that GP for specialists, pathology, radiology, physiotherapy and psychology. In return, consultations with that GP and acute medicine prescribed or dispensed by that GP are unlimited, on formulary. The after-hours casualty facilities at private hospitals are not affiliated to the option, so you must consult your selected GP unless it is a genuine life-threatening emergency. You may change GP twice a year, and move between GP groups such as PEGP and ECIPA only at the start of a year.

R400 000 a family on Medisave Max, R250 000 on Medisave Standard and R200 000 on Alpha, all authorised through ICON. On Medisave Essential there is no separate oncology limit: oncology and radiation therapy share a combined R50 000 family limit with dialysis and organ transplants. Prescribed Minimum Benefit cancer treatment stays unlimited at a designated service provider on every option, and most cancers are PMBs, but anything outside the PMB level of care runs off the limits above. Medisave Max is also the only option with a biological medicine benefit, at R200 000 on prior approval.

On Medisave Standard and Medisave Max an elective benefit takes over: R6 000 a beneficiary and R12 000 a family on Standard, R7 500 and R15 000 on Max. Total day-to-day money, savings plus elective, runs from R13 800 for a single member on the lowest Standard band to R51 900 for a family of four on the top Max band. Once the elective benefit is gone too, day-to-day claims are your own. Medisave Essential has only a small savings account of 10% of contributions and no elective benefit, because its primary care comes from the network instead. Alpha has no savings account at all.

It depends entirely on the option. Alpha pays for one eye test a year and has no benefit whatsoever for frames, prescription lenses or contact lenses. Medisave Essential pays through the PPN network on a two year cycle: R330 for frames, R215 for single vision lenses, R460 for bifocal and base multifocal, or R845 for contact lenses. Medisave Standard gives R3 800 a beneficiary and R7 600 a family every second year, and Medisave Max R4 400 and R8 800, both paid from your savings account and then the elective benefit rather than from the risk pool.

You can apply for an ex gratia payment, in writing to ex-gratia@medimed.co.za. An Ex Gratia Committee appointed by the Board of Trustees decides each application on its merits, weighing the clinical necessity of the treatment, whether the cost would cause you undue financial hardship, your benefit usage and previous ex gratia claims, and the financial position of the scheme. It will not consider claims older than four months, costs under R1 000, treatment of a cosmetic nature, legal costs from an unsettled account, or charges above scheme tariff. That last exclusion matters: if your shortfall is because a specialist billed above the Medimed Scheme Tariff, ex gratia is not the answer.

A general waiting period of up to three months if you do not have at least 90 days of prior medical scheme cover, and a condition-specific waiting period of up to 12 months on a pre-existing condition. No waiting period applies for a change of employment, an employer changing schemes, a transfer between Medimed options, or newborn and adopted children. If you are 35 or older when you apply and cannot show continuous cover since 1 April 2001, a permanent late-joiner penalty of 5%, 25%, 50% or 75% is loaded onto your contribution depending on how many years of creditable cover you are missing. These come from the scheme rules, not from the 2026 benefit sheets.

At scheme level, yes. Solvency was 87.84% at the end of 2024 against a statutory minimum of 25%, on gross contributions of R305.7 million, and the scheme states reserves above R270 million. The qualification is that its 2024 annual general meeting report discloses that three of the four options, Medisave Essential, Medisave Max and Medisave Standard, each ran an insurance service deficit that year, a section 33(2) concern about the soundness of individual options, with Medisave Standard carrying 88 high-cost cases worth R31.7 million. The board's position is that the options remain viable. 2025 figures had not been published when this page was checked.