Medshield Medical Scheme

Every option covers the 26 conditions on the statutory Chronic Disease List. What changes is whether anything is covered above that, and whether there is a rand limit at all.

You must register on the Chronic Medicine Management programme before the benefit starts. Your doctor or pharmacist calls Mediscor on 086 000 2120 or emails medshieldauths@mediscor.co.za with your membership number, the diagnosis and ICD-10 code, and the medicine name, strength and dosing. Medicine is supplied one month at a time. You can check whether your prescription is on the formulary for your option at mediscor.co.za before you register.

The additional conditions on MediBonus and PremiumPlus are the reason to buy those options if you are managing something outside the statutory list. They include osteoarthritis, osteoporosis, macular degeneration, generalised anxiety disorder, panic disorder, obsessive compulsive disorder, post-traumatic stress disorder, gout, psoriasis, urticaria and stroke. PremiumPlus adds attention deficit disorder, Barrett's oesophagus, gastro-oesophageal reflux disease, menopause, scleroderma and dermatitis on top of the MediBonus list.

For a PMB condition that is not on the CDL, Medshield runs a separate DTP PMB route through Mediscor. Your doctor completes the application form from the Medshield website and sends it to medshieldapmb@mediscor.co.za, and the care plan has to be renewed annually.

On every option, out-of-formulary medicine or a non-DSP pharmacy costs a 20% upfront co-payment. On MediValue the guide records this as 30% for a non-DSP or non-Medshield pharmacy network in the co-payment schedule, against 20% in the chronic medicine table of the same guide.

This is the sharpest line in the Medshield range. On MediCurve, MediPhila, MediValue and MediCore, oncology is Prescribed Minimum Benefits and PMB level of care only. There is no rand cancer limit on those four options, which between them cover every plan priced under R4 300 a month. Cover for a cancer that is not a PMB, or treatment beyond PMB level of care, is yours to fund.

All cancer cover runs through the Medshield Oncology Disease Management Programme with ICON as the designated service provider. You call 086 000 2121 on diagnosis, ask your doctor to refer you to an ICON oncologist, and the oncologist submits a treatment plan for authorisation. Post active treatment cover runs for 36 months. Continuing with a non-ICON oncologist after your treatment plan is renewed attracts a 40% upfront co-payment.

Breast reconstruction after an oncology event is R105 000 per family on every option. Integrated continuous cancer care, which is social worker psychological support during treatment, is 6 visits a family a year everywhere except MediPhila, where it is 4.

The exclusions list applies to cancer treatment too. Medicines that have not convincingly demonstrated a survival advantage of more than three months in metastatic malignancy are excluded unless they are PMB, with sorafenib for hepatocellular carcinoma and bevacizumab for colorectal and metastatic breast cancer named as examples. Trastuzumab beyond the 9-week ICON regimen for early breast cancer is excluded unless PMB. Gene sequencing is excluded.

Medshield uses four different day-to-day mechanisms across eight options, and they behave very differently.

1. Visit counts. MediCurve and MediCore. You get a fixed number of GP visits, not a pot of money. On MediCurve that is 5, 7 or 9 network GP visits by family size, plus unlimited virtual consultations. On MediCore it is 2 visits per beneficiary and 3 virtual consultations a family.
2. A risk-funded day-to-day limit. MediPhila, MediValue, MediPlus and MediBonus. The limit is set by family size, does not roll over, and is not your money. On MediBonus, PMB claims are paid from the day-to-day limit first and only from risk once it is depleted, which is unusual and worth knowing.
3. A savings account. MediSaver at 15% of contribution and PremiumPlus at 25%, both allocated 12 months in advance in January.
4. A threshold. PremiumPlus only.

Once the money is gone, the only common backstop is 2 extra network GP visits per beneficiary, on MediPlus, MediValue, MediSaver, MediBonus and PremiumPlus. MediCurve, MediPhila and MediCore do not have it. After that you self-fund, except on PremiumPlus where the Above Threshold Benefit takes over, and pharmacy advised therapy continues at R1 000 a family from that benefit.

Virtual GP consultations are worth knowing about because they are cheap for the scheme and generous for you: unlimited on MediCurve, 3 a family on MediPhila and MediCore, 5 a family on MediPlus, MediValue, MediSaver, MediBonus and PremiumPlus.

Confinement in hospital is unlimited on every option, as is delivery by a GP or specialist and confinement in a registered birthing unit. A registered midwife is paid at Medshield Private Rates up to 200%. Hire of a water bath and oxygen cylinder is unlimited.

Caesarean co-payments are the thing to check. MediCurve charges R10 000 upfront for an elective caesarean, MediPhila R5 000 for a voluntary caesarean and MediValue R2 500. MediCore, MediPlus, MediSaver, MediBonus and PremiumPlus publish none. On the network options, confinement in a non-network facility carries the usual 30% upfront co-payment, and a designated service provider applies from rand one.

3D and 4D pregnancy scans are named in the exclusions list on MediCurve and MediPhila, which matches those options covering 2D scans only.

Medshield runs a MedshieldMOM service at medshieldmom.co.za where you register your pregnancy by week. You can request a complimentary baby bag in the third trimester by emailing medshieldmom@medshield.co.za with your membership number and delivery address. Register a newborn as a dependant within 60 days of birth.

Mental health is one of the widest gaps between the top and bottom of the range, from statutory minimum cover to R100 000 a family.

An admission by a general practitioner rather than a psychiatrist is capped at 3 days on every option. Substance abuse rehabilitation is one programme per beneficiary a year, PMB level of care on the cheaper options, R19 350 a family on MediSaver, and inside the mental health limit on MediPlus, MediBonus and PremiumPlus. On the network options, a mental health admission to a non-network hospital carries the same 30% upfront co-payment as any other admission.

The MediCore guide contradicts itself on mental health: the major medical table gives R46 000 per family in and out of hospital, and the day-to-day table on the same option says PMB only. Get the answer in writing before you rely on it.

SmartCare nurse and virtual GP consultations specifically exclude mental health, so the free primary care route is not available for it.

Dentistry runs through the Medshield Dental Network with Denis handling authorisations. Failing to pre-authorise dental treatment that needs it costs a 20% penalty.

Specialised dentistry covers implants, orthodontics, crowns, bridges, inlays, mounted study models, partial metal base dentures and periodontics. On MediCurve all of those are excluded outright, and MediCore has no specialised dentistry benefit either.

Orthodontic treatment is excluded for anyone younger than 9 or older than 18, along with orthodontic re-treatment and any orthodontics for cosmetic reasons. Wisdom teeth in a day clinic cost R800 upfront, or R1 800 on MediCurve and MediPhila. In hospital the co-payment is R2 000 on MediBonus, R3 500 on MediPlus and MediSaver, and R4 000 on MediCurve, MediPhila and MediValue. There is no co-payment if the procedure is done under conscious sedation in the practitioner's rooms.

General anaesthetic and hospitalisation for dental work are excluded except for patients under 6 or for bony impaction of third molars. Conservative dental treatment in hospital, meaning fillings, extractions and root canals, is not covered under general anaesthetic for children over 6 or adults. Admission because of dental fear or anxiety is excluded.

Optical benefits run on a rolling 24-month optical service date cycle through the Medshield optical network, with Iso Leso Optics administering claims. An eye test is one per beneficiary a year on every option that has a benefit.

Readers are R220 per beneficiary a year on every option that has an optical benefit, if supplied by a registered optometrist, ophthalmologist, supplementary optical practitioner or pharmacy. On MediCurve and MediPhila, bifocal, multifocal and contact lenses are excluded, so a member who needs varifocals pays for them.

MediCore has no optical benefit in its 2026 benefit tables at all, even though the same guide carries a page headed "How to Check and Submit Your Optical Claims" and lists Iso Leso as the optical DSP. Confirm this with the scheme before buying MediCore for anyone who wears glasses.

Refractive surgery, where it exists, is separate from the optical limit: R36 500 a family on PremiumPlus, R31 350 on MediBonus, R22 000 on MediPlus and R21 000 on MediSaver. MediValue records it as no benefit, and MediCurve, MediPhila and MediCore have no refractive surgery benefit in their tables and list it in their exclusions unless specifically provided for.

Wellness cover is subject to the relevant pharmacy network and, on most options, to the overall annual limit and then to the day-to-day limit or savings. The core screening set is the same across the range.

• Mammogram, one a year for a female beneficiary aged 30 and over, on every option. Medshield lowered the age to 30 for 2026.
• Pap smear, one a year for every female beneficiary, excluding the consultation fee.
• PSA screening, one a year for a male beneficiary aged 40 and over.
• Health risk assessment, one a year for a beneficiary aged 18 and over, at a pharmacy or GP, covering cholesterol, blood glucose, blood pressure and body mass index.
• Flu vaccination, one a year from age 18. Pneumococcal vaccination, one a year for high risk beneficiaries and everyone aged 60 and over.
• Bone density scan, one every three years from age 50, on MediPlus, MediValue, MediSaver, MediBonus, MediCore and PremiumPlus.
• Diabetic AI retinal screening, R250 a beneficiary a year for a diabetic aged 40 and over registered on the Diabetic Disease Management Programme.
• Contraceptive medicine, up to 13 prescriptions a year for a female beneficiary aged 14 to 55, at R185 a script on MediCurve and R235 on MediBonus.
• Intrauterine devices, one per female beneficiary, covering any brand up to the price of a Mirena. Mirena or Kyleena every 5 years, Implanon every 3, copper devices every 2. Only if no contraceptive medicine is used.
• Childhood vaccinations follow the Department of Health schedule from birth to age 12.

MediCurve is the outlier: no HPV vaccination, no TB test and no adult vaccination benefit. MediPhila has no adult vaccination benefit. Adult vaccination elsewhere is R520 or R550 a family, rising to R2 100 a family including travel vaccination on MediBonus and PremiumPlus.

The exclusions list is identical in structure across all eight guides. The headline items are these.

• Cosmetic operations, medicines, treatments and procedures, and anything for personal reasons not directly caused by illness, accident or disease.
• Medicines for chronic conditions that are not on your option's list of covered diseases.
• Assisted reproduction. In vitro fertilisation, ICSI, intra-uterine insemination, GIFT, ZIFT, donor sperm, ovarian drilling and reversal of tubal ligation or vasectomy are all excluded. Infertility cover is limited to the statutory investigations and interventions in Addendum A.
• Erectile dysfunction and loss of libido treatment, slimming preparations for obesity, tonics, multivitamins and most nutritional supplements.
• Alternative healthcare including aromatherapy, art therapy, ayurvedics, herbalists, iridology, reflexology and therapeutic massage.
• Continuous glucose monitoring devices and consumables, except the specific MediBonus benefit for beneficiaries under 18 with type 1 diabetes. Insulin pumps and CPAP machines unless specifically authorised.
• Wearable monitoring devices, exercise machines, electric toothbrushes, humidifiers, air purifiers, beds, mattresses, pillows, back rests, TENS and APS pain machines, and orthopaedic shoes unless specifically authorised.
• Gene sequencing, allergy testing and vitamin D testing in hospital.
• Examinations, reports and tests for insurance, employment, visas, immigration, travel, pilot and driver's licences, and school readiness tests.
• Appointments you fail to keep, autopsies, cryo-storage of foetal stem cells and sperm, and accommodation in spas, health resorts and places of rest.
• Accommodation in a geriatric hospital, old age home or frail care facility, unless specifically provided for.
• Orthognathic jaw correction surgery and sinus lift procedures unless PMB.
• Tooth whitening, fissure sealants from age 16, oral hygiene instruction and evaluation, and nutritional and tobacco counselling.

The full exclusions run to several pages in each guide and the registered Scheme Rules govern in all cases. If a specific device, drug or procedure matters to you, ask for the current rules before you sign.

The Medical Schemes Act allows an open scheme to apply a general waiting period of up to 3 months, a condition-specific waiting period of up to 12 months on a pre-existing condition, and a permanent late-joiner penalty of up to 75% of the risk contribution for an applicant aged 35 or older who cannot show unbroken South African medical scheme membership. Whether Medshield applies any of these, and at what level, is not in the documents.

Ask the scheme in writing what it intends to apply to you before you sign anything, and check the answer against the counter-offer you receive. Do the same for the Scheme Rules, which govern in all cases and are not reproduced in the benefit guides.

• Every admission needs pre-authorisation from Medshield Hospital Benefit Management on 086 000 2121 or by email to preauth@medshield.co.za.
• You need your membership number, the patient's name and date of birth, the ICD-10 and tariff codes from your doctor, the date and time of the procedure, the admitting doctor's and hospital's details, and the estimated length of stay.
• Confirm the hospital is on your network first. The authorisation does not waive the 30% non-network co-payment.
• Failing to authorise costs a 20% penalty on top of any co-payment, on every option, emergencies excepted.
• Additional services during an admission, such as physiotherapy, a dietician, prosthetics or an MRI or CT scan, may need separate authorisation. Not obtaining it leaves you out of pocket.
• If the admission is postponed, cancelled or repeated for the same condition, you have to contact Medshield to update or cancel the authorisation.
• The emergency window is stated three different ways in the same guides. The how-to page says retrospective pre-authorisation within 48 hours of admission. The day-to-day casualty benefit says retrospective authorisation within 72 hours. The MediPhila in-hospital access page says the first working day following an emergency admission. Treat 48 hours as the safe assumption and phone as soon as you can.

• Hospital claims. Medscheme, 086 000 2121, hospitalclaims@medshield.co.za, weekdays 08:00 to 17:00.
• Chronic medicine. Mediscor, 086 000 2120, medshieldauths@mediscor.co.za, weekdays 07:30 to 17:00.
• DTP PMB applications. medshieldapmb@mediscor.co.za, with annual renewal.
• Oncology. ICON and Medscheme, 086 000 2121, oncology@medshield.co.za. ICON oncologists are listed at cancernet.co.za.
• Dentistry. Denis, 086 000 2121. Periodontics perio@denis.co.za, orthodontics ortho@denis.co.za, crowns, bridges and implants crowns@denis.co.za, in-hospital dental hospitalenq@denis.co.za, specialised dentistry and plastic dentures customercare@denis.co.za. Have the practice number, dental codes, tooth numbers, ICD-10 codes, treatment date and X-ray results ready.
• Optical. Iso Leso, 011 340 9200 or medshield@isoleso.co.za to confirm benefits, medshieldclaims@isoleso.co.za to claim. The claim must show the optometrist's practice number, the optical codes for frames and lenses, the ICD-10 codes and the date of treatment.
• HIV. HaloCare, 086 014 3258, medshield@halocare.co.za, weekdays 07:30 to 16:00. Medicine through Pharmacy Direct on 086 002 7800.
• Turnaround times for claims payment are not published in the 2026 benefit guides.

Claims are processed at the Scheme tariff and only while your membership is in good standing with contributions paid up to date.

1. Start with the contact centre on 086 000 2120, or WhatsApp on 060 042 7274.
2. Lodge a formal complaint by email to complaints@medshield.co.za.
3. Escalate an appeal or dispute to the Principal Officer at POqueries@medshield.co.za. Medshield says these are handled in line with its complaints and disputes escalation procedures.
4. Take it to the Council for Medical Schemes. You have a statutory right to complain to the regulator at any stage. Complaints Unit, Block A, Eco Glades 2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion 0157. Phone 086 112 3267 or 012 431 0500, or email complaints@medicalschemes.co.za or information@medicalschemes.co.za. From there the route runs to the CMS Appeal Committee, the Appeal Board and ultimately the High Court.

Separately, suspected fraud, waste or abuse goes to the Whistle Blowers Ethics Hotline, not to Medshield: toll-free 0800 112 811, SMS 33490, WhatsApp 031 308 4664, whistleblowing.co.za, information@whistleblowing.co.za, fax 0800 212 689, or Freepost KZN665, Musgrave, 4062. Reports can be anonymous.

MediCurve at R1 821 a month for a main member, R1 821 for an adult dependant and R483 a child. It gives you unlimited hospital cover in the Compact Hospital Network and between 5 and 9 network GP visits a year, but cancer and chronic medicine are Prescribed Minimum Benefits only, there is no specialised dentistry, the specialised radiology limit is R6 450 for the whole family, and an elective caesarean carries a R10 000 upfront co-payment.

No. None of the eight 2026 benefit guides contains an income band. Every option has one price for a main member, one for an adult dependant and one for a child, regardless of what you earn. That makes Medshield relatively good value at higher incomes and relatively poor value at low ones compared with schemes that band their entry plans.

On every option except MediBonus and PremiumPlus, voluntarily using a hospital outside your network means you pay 30% of the hospital account upfront, before the scheme pays anything. It is a percentage of the bill, not a fixed rand amount, and the benefit guides publish no ceiling on it, so a R400 000 admission would cost you R120 000. The same 30% applies to a non-network mental health admission and to a non-network organ or bone marrow transplant. Check the hospital is on the Prime or Compact list, whichever applies to your option, before you accept a booking.

Only MediPlus and MediValue come in both. Medshield states the benefits are identical and that two things change. First, the hospital network: Prime is the wider list, Compact the narrower one. Second, on Compact you must use a network GP and that GP must refer you before you see a specialist or a paediatrician, and going without a referral adds a 20% upfront co-payment. Compact saves a main member R498 a month on MediPlus and R300 a month on MediValue.

Four of the eight. PremiumPlus is unlimited, MediBonus is R632 200 per family a year, MediSaver R428 000 and MediPlus R326 000. On MediCurve, MediPhila, MediValue and MediCore, oncology is Prescribed Minimum Benefits and PMB level of care only, with no rand limit of its own. All cancer treatment runs through the ICON network, and using a non-ICON oncologist after your treatment plan is renewed costs a 40% upfront co-payment.

Two. MediSaver allocates 15% of your contribution, which is R9 672 a year for a main member, R8 016 for an adult and R2 364 for a child. PremiumPlus allocates 25%, which is R28 464, R26 076 and R5 448. Both release the full year's savings in advance in January, so joining mid-year gets you less. MediPhila, MediValue, MediPlus and MediBonus use a risk-funded day-to-day limit instead, and MediCurve and MediCore give you a fixed number of GP visits with no fund at all.

PremiumPlus is the only Medshield option with a Threshold and an Above Threshold Benefit. A main member has to accumulate R33 500 of day-to-day claims in a year before the Above Threshold Benefit starts, and that benefit is then worth R7 500. Your savings account of R28 464 covers most of the R33 500, so the self-payment gap is about R5 000. For an adult dependant the threshold is R32 000 with R5 500 above it. Accumulation counts a maximum of three children.

On every option, but in very different ways. MediCurve gives 5 to 9 network GP visits a year by family size, MediPhila 8 to 11, MediCore 2 per beneficiary. MediValue, MediPlus and MediBonus pay them from a risk-funded day-to-day limit of R8 500 to R27 200. MediSaver and PremiumPlus pay them from your savings account. On top of that, every option has unlimited registered nurse consultations at a SmartCare pharmacy, and virtual GP consultations are unlimited on MediCurve and 3 or 5 a family elsewhere.

Almost certainly a procedure co-payment. Medshield charges fixed upfront amounts for a defined list of procedures on every option except PremiumPlus: R5 000 for a hysterectomy or a Nissen fundoplication, R3 000 for a hernia repair, R4 000 to R8 000 for back and neck surgery, R2 000 to R4 000 for laparoscopy or arthroscopy, and R20 000 on MediPlus for spinal surgery if you did not complete the Conservative Back and Neck Rehabilitation programme first. Authorisation does not remove these. Ask what the co-payment is when you authorise.

Medshield does not publish them. None of the eight 2026 benefit guides mentions a general waiting period, a condition-specific waiting period or a late-joiner penalty. The Medical Schemes Act allows an open scheme to apply up to 3 months general, up to 12 months on a pre-existing condition, and a permanent late-joiner penalty of up to 75% for applicants aged 35 and over without unbroken cover. Ask the scheme in writing what it will apply to you and get the answer in the counter-offer before you sign.

Start with the contact centre on 086 000 2120. If that does not resolve it, email complaints@medshield.co.za. To escalate an appeal or a dispute, email the Principal Officer at POqueries@medshield.co.za. At any stage you may complain to the Council for Medical Schemes on 086 112 3267 or 012 431 0500, or at complaints@medicalschemes.co.za, and from there to the CMS Appeal Committee, the Appeal Board and the High Court. Suspected fraud goes separately to the Whistle Blowers Ethics Hotline on 0800 112 811 and can be reported anonymously.

The 2025 results put its solvency ratio at 53%, against a statutory minimum of 25%, with accumulated funds of R2.62 billion on insurance revenue of R4.21 billion, and GCR rates it AA with a stable outlook. Membership grew 4.5% in 2025. On the merger: Medshield and Fedhealth did propose an amalgamation and the Competition Commission recommended approval, but both boards announced on 10 November 2025 that they had mutually agreed to terminate the discussions after independent actuarial evaluations. Medshield remains a standalone scheme.