maxima rates & benefits guide

Transcription

1 2016 maxima rates & benefits guide

2 01 Table of Contents Welcome 2 Our philosophy Care 3 Keeping it in the family 4 Unique s 5 2 Comprehensive options at a glance 7 Maxima Plus 8 Maxima Exec 13 Maxima Standard 19 Maxima Standard Elect 25 Quick Comparison 30 3 Saver options at a glance 31 Maxima Basis 32 Maxima Saver 35 Maxima EntrySaver 39 Quick Comparison 44 4 Hospital Plans at a glance 45 Maxima Core 46 Maxima EntryZone 49 Quick Comparison 53 5 Blue Door Plus at a glance 54 Blue Door Plus 55 6 Contributions Overview

3 our philosophy Family takes care of family Let us tell you a little bit more about our Fedhealth family. Established 79 years ago in 1936, our family tree has been growing strong ever since to include our members, business partners and service provider networks. Thanks to our proud heritage and thorough understanding of healthcare, we continue to look after South African families through a quality, value for money medical aid. What s more is that our consistently high Global Credit Rating of AA- (retained for 9 years straight), and reserves well over the required 25%, ensure that our family is financially sound and rated as one of the top medical aid schemes in South Africa. Sustainability is at the heart of everything we do, and we are always developing initiatives that benefit our members, partners and providers our extended family alike. Run by members for members, we re a scheme governed with a completely transparent approach where each member is important. It follows that our Board of Trustees operates with one objective only, namely to put the interests of our members first. Our family sure has come a long way and today our extensive option range and unique benefits, where we pay more from Risk than other schemes, prove that we re in it with your family for the long run. For us, it s more than service, it s support. Always. Welcome to the Fedhealth family. 02

4 Care 360 Care: Let the healing begin (with your FP) Do you recall there was a time when the family doctor treated Mom, Dad, the kids and Granny as well? He or she got to know the family inside and out, and was aware of all their ailments and allergies. This meant that everyone knew where to turn when they felt poorly a single medical professional they could trust for expert medical advice. This is the inspiration behind our 360 Care initiative, in which your family practitioner or FP as we like to call them becomes the coordinator of your care, working directly with you, the member, to ensure that your health needs are met safely, timeously and cost effectively. In a nutshell, this means that your FP, who will have the best understanding of your health status and treatment history, will refer you to the appropriate specialists to deliver the right care at the right time. We believe that 360 Care improves the quality of healthcare by facilitating access to the appropriate specialist care, and that it prevents unsafe combinations of treatments including medicines. It also prevents unnecessary duplication of costly clinical tests and treatments which contribute to rising health care costs and increases in members contributions. Finally, it will help us to introduce electronic health records which will allow the healthcare providers treating you to easily access and exchange your medical information. In addition, your FP will refer you and be able to make an appointment for you with a specialist much quicker than you might be able to do yourself. So, simply visit your Network FP (an unlimited benefit on most of our options) for a referral to the relevant specialist. Non-network FPs may also be consulted, but these visits will be paid from your Savings and may result in a co-payment from you. Under 360 Care, you will require an FP referral to visit: cardiologists, dermatologists, gastroenterologists, gynaecologists, neurologists, neurosurgeons, orthopaedic surgeons, otorhinolaryngologists (ENT), paediatric cardiologists, paediatricians, physicians, plastic and reconstructive surgeons, psychiatrists, pulmonologists, rheumatologists, surgeons and urologists. An FP referral is not necessary for: children under the age of two visiting a paediatrician, female members visiting a gynaecologist for their annual check-up, visits to oncologists, ophthalmologists, radiologists (general or specialised) or pathology services. Trusting your FP to coordinate your specialist care means having a healthcare practitioner with the information at hand to give you and your loved ones the best possible care. Just what your precious family deserves. 03

5 The support you deserve As a Fedhealth family member, you can enjoy the peace of mind that your Scheme is in the best hands, which means that you and your loved ones are too. Administration by Medscheme, a level 2 BBBEE Company and South Africa s largest managed care services provider and third largest medical scheme administrator, offers: An average claim turn-around time of 5 days An efficient and highly-rated ISO 9001:2008 certified Customer Contact Centre offering 90% one call query resolution, with an average 8-sec waiting time on calls. Family always keeps in touch It s really important for us to stay in touch with all our family members and we do this through: The Fedhealth Member Mobile App. Available for free to Apple and Android users, the App is a unique customer experience that enables members to enjoy direct access to their medical aid The FedChat Mobile App is also available as a free download to Apple, Android, Blackberry and Windows users. This dedicated Instant Messenger channel offers members the convenience of being able to communicate, in real time, with a Fedhealth service consultant during office hours, without the cost of a phone call or SMS The Fedhealth website. Fun and functional, yet always informative, the site carefully details the Fedhealth options without ever becoming complicated. It also has a blog section devoted to Living Fedhealthy, where users get to experience just what the Fedhealth world has to offer. Once on the Member Tools page, members are able to obtain hospital pre-authorisation, apply for chronic medication and learn how to submit a claim. Members can also locate Network Pharmacies and FPs using the locator tool. And once logged in, members can locate specialists, update personal information, conduct benefit enquiries and successfully track claim submissions and payments due to them. All brochure-ware, option selection forms and related documentation are available as easy-to-access PDF downloads. The website also features Live Chat an innovative feature that allows both members and non-members to raise important medical aid questions on the site during office hours. Skilled consultants then immediately answer these queries in a friendly, one-on-one capacity, without the person asking the question being left holding on the phone. Members may also obtain hospital and chronic disease authorisations on the site using Live Chat The bimonthly Fedhealthy Magazine our health publication is packed with articles and features to enrich every lifestyle. For Apple and Android users, the magazine is also available in e-format in the free Fedhealthy Magazine Mobile App. Something for our corporate family members We offer various initiatives to meet company-specific demands: Group Implementation and Training ensures a smooth transition from your previous scheme A dedicated Account Executive (AE) for each organisation with 25 or more staff members regular visits take place and the AE is always available to solve queries online A dedicated credit control person per organisation Tailor-made solutions with option mapping to cater directly to the organisation s staff. Keeping it in the family When you re feeling under the weather, all you want is a familiar face by your side. We understand this all too well, which is why our network partners are such valued members of our Fedhealth family. These healthcare professionals ensure that you get the very best, consistent care that is covered in full. Keeping it in the family really does have its benefits, as we cover treatment for Prescribed Minimum s (PMBs) and other conditions in full when you use our network partners. No surprise co-payments to catch you off guard! We use network service providers to: Provide members with price certainty and the assurance that the Scheme will cover their medical costs in full, if a partner s services are enlisted Focus on more effective health outcomes by providing quality care Ensure that treatment for PMB conditions is covered in full. Our Network family When it comes to giving our members quality healthcare they can trust, we partner with healthcare professionals with the same passion for healthcare. After all, only the best will do for our family! Over pharmacies nationwide currently belong to the Fedhealth Pharmacy Network (including all major retailers like Dis-Chem, Medi-Rite and Clicks Pharmacy and over independent pharmacies). This means that 90% of our principal members have access to a network pharmacy within a 10km radius of where they reside. We have over Family Practitioners currently contracted to the Fedhealth FP Network. As such 97% of our principal members have access to a Network Doctor within a 10km radius of where they live. And more than 81% of claiming beneficiaries on all comprehensive and saver options are already using Network Doctors. On most options, members have access to unlimited FP visits. We have over specialists from all disciplines contracted to the Fedhealth Specialist Network. Using a Fedhealth Network Specialist means no co-payments and truly unlimited benefits at cost for members in-hospital and price certainty out-of-hospital. We ve also established partnerships with hospitals across the country. Our Hospital Network ensures that Blue Door Plus, Maxima EntryZone and Maxima EntrySaver members have access to unlimited hospitalisation provided they make use of network facilities (as listed further on). This partnership provides immense financial peace of mind for members and allows the Scheme to provide comprehensive benefits at affordable rates. 04

6 01 Unique s UNIQUE BENEFITS Family goes the extra mile for you, and so do we There s probably nothing you wouldn t do for your family. Their wellbeing is your top priority and you love seeing them happy and healthy. We feel the same about you, which is why we offer you unique value-added benefits. With some of these tangible benefits we pay more from Risk than other schemes to ensure that your day-to-day medical spending not only goes further, but also works harder when you really need it. s unique to the Fedhealth Maxima option range: For unique benefits on our Blue Door Plus option, please see page 59 We realise that not all kids leave the parental nest at 18! That s why we offer child rates for financially dependent children up to the age of 27. This means student dependants pay rates applicable to children, provided they re unmarried and not earning more than the maximum social pension Within a single day, life can change. Whether you find out your family is expanding, or you re diagnosed with a dread disease. So with us, you re never locked into an option, and you can upgrade within 30 days of something dramatic happening that changes your circumstances during the year. *New premiums will apply 05

7 unique benefits Where we pay more from Risk than other schemes: Post-hospitalisation treatment for up to 30 days after discharge from hospital (physiotherapy, x-rays, pathology, etc) i.e. follow-up treatment for a full 30-day period is paid directly from Risk, to preserve your day-to-day benefit. Authorisation must be obtained 7 days of paid for take-home medication after discharge from hospital provided the medication is dispensed by the hospital and reflects on the original hospital account Specialised radiology like MRI and CT scans paid from Risk and never from Savings no matter what option you re on, whether performed in- or out-of-hospital. Authorisation must be obtained Trauma treatment at a casualty ward whether admitted to hospital or not, emergency treatment, like stitches, is always paid from Risk and never from Savings. Authorisation must be obtained Cover for female contraception including oral, patches, contraceptive rings, certain injectables as well as IUDs that include Mirena, on all Comprehensive and Saver options. On our two Hospital plans, Maxima Core and Maxima EntryZone, we cover oral contraception only subject to an approved list. *Must be prescribed by an FP or gynaecologist and not applicable to pills prescribed for acne The Screening with screenings for women s, children s, cardiac, as well as general health (like an annual flu vaccine) funded from Risk and not from your day-to-day benefit. From our family, with love to you: The Fedhealth Baby Programme 24-Hour Fedhealth Nurse Line FREE trauma counselling for practical and emotional support Emergency transport/response through Europ Assistance Comprehensive managed care programmes: - Aid for AIDS (AfA) for those living with HIV/AIDS, - AsthmaCare ensures that asthma patients lead a normal life, - DiabeticCare assists diabetics in managing their blood sugar, - CardioCare to prevent heart attacks in Coronary Heart Disease sufferers, and - Oncology Disease Management that supports cancer sufferers with comprehensive care including cover for chemotherapy, radiotherapy, approved medication, related consultations, pathology and general radiology. Plus, we also give our Fedhealth family members: Professional and extreme sports cover injuries sustained during sporting activities are covered within the benefits and rules of the Scheme, provided the treatment is received within the borders of South Africa In-hospital dentistry for children under 8 we cover the hospital and anaesthetist costs from the In-Hospital while the dentist s account comes from day-to-day benefits (OHEB and Savings) on the Comprehensive options. On Maxima Basis and Maxima Saver, the dentist s account will be paid from available savings and on Maxima Core the dentist s account will be paid from your own pocket. This benefit does not apply to Maxima EntrySaver and Maxima EntryZone Please note: The Authorisation Centre must be contacted at least 48 hours before the procedure. Authorisation will be granted provided no dental authorisation was granted for the same child within at least six months of the required admission date Easy membership for child dependants who go on to join Fedhealth in their personal capacity without delay no underwriting will be required for child dependants who are at an age and status to afford their own medical aid, and who join the Scheme directly after leaving their parents membership. 06

8 02 comprehensive options Our comprehensive options at a glance: Extensive medical cover, both in and out of hospital Maxima Plus, Maxima Exec, Maxima Standard and Maxima Standard Elect Peace of mind cover for growing families and individuals alike There comes a time in life when you don t want to leave you or your family s wellbeing and health to chance. That s the time to join our Fedhealth family, and experience our comprehensive cover for everyone, from baby to Mom or right through to the highpowered CEO. Our comprehensive options give you extensive cover for every phase of life, tailored around your changing medical needs. Every comprehensive option offers unlimited private hospitalisation and provides different levels of cover for day-to-day claims, such as medical consultations and prescribed medication. This cover is funded from a Savings Account, as well as the Out-of- Hospital Expenses and the Threshold. These plans also provide extensive chronic cover for members suffering from chronic conditions, with the range of conditions covered dependent on the option. Nothing is more important to us than looking after your family s health regardless of their life stage. So, trust our family to take care of yours with sound comprehensive cover! 07

9 Maxima Plus Ideal for: - Growing families What s in it for you? private hospitalisation Day-to-day claims for expenses like medical consultations funded first from a Savings Account, then from the Out-of-Hospital Expenses and then from a Threshold Extensive cover for 51 chronic conditions Oncology with generous cover for specialised medication Value adds like unlimited visits to Network FPs paid from Risk Major Medical RISK BENEFITS Chronic Disease Threshold OHEB Savings DAY-TO-DAY BENEFITS Cost Member Adult dependant Child dependant Risk R5 661 R4 817 R1 699 Savings R331 R281 R99 Total R5 992 R5 098 R1 798 Major Medical Please note: All reimbursements for treatment by healthcare professionals depend on the type of healthcare professional and the reimbursement rates agreed to by the Scheme. No overall annual limit Use any hospital of your choice If you use Fedhealth Network FPs and Specialists, you will be covered unlimited at cost If you use out-of-network specialists and FPs, the Scheme will cover you up to 100% of the for non-network FPs and up to 200% for non-network specialists. Any differences will have to be paid by you directly to the healthcare provider. Prescribed Minimum s (PMB) Treatment for PMB conditions can be funded in two ways: 1) To have the treatment for your PMB conditions covered in full, you will have to use Fedhealth Network FPs and Specialists. 2) Should you choose not to make use of network providers, the Scheme will only refund treatment at 100% of the for non-network FPs and 200% of the for non-network specialists. You will have a co-payment should the healthcare professional charge more. Also included in the Major Medical are: Healthcare Professionals in hospital - Fedhealth Network FPs and Specialists - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Alternatives to hospitalisation Sub-acute facilities, physical rehabilitation facilities Nursing services, private nurse practitioners & nursing agencies Ambulance Services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Immune deficiency related to HIV infection ALL LIMITS PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED cost 100% of 200% of 300% of with Europ Assistance We refer to General Practitioners (GP) as Family Practitioners (FP). 08

10 02 Maxima Plus Maternity - Fedhealth Network FPs and Specialists (eg. gynaecologists and paediatricians) - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Postnatal midwifery benefit Maxillo-facial surgery Including surgical extraction of impacted wisdom teeth Oncology: Oncologist consultations, visits, treatment and materials for chemotherapy and radiotherapy, approved medication, radiology and pathology at preferred provider* and subject to enhanced treatment protocols cost 100% of 200% of 300% of 4 consultations per pregnancy Specialised Medication for oncology (also see below) Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Prostheses - Internal - External Psychiatric services: Accommodation in a general ward, procedures, ECT, materials and hospital equipment, consultations and visits, medicines and injection material Renal dialysis (chronic): Consultations, visits, all services, materials and medicines associated with the cost of renal dialysis Specialised Medication (eg. biologicals) (oncology & non-oncology) Take-out medicines Terminal care benefit R R at 100% of the Various sub-limits apply, please see below R R at 100% of the R days medication for each hospital event R at 100% of the *Preferred provider is ICON - Independent Clinical Oncology Network Internal Prosthesis This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth. Hip and knee bilateral replacements will be allowed for up to double the amount for a single hip and knee replacement. Prostheses paid at cost subject to limits. Limits per family Aorta stent grafts R Detachable platinum coils R Cardiac stents R Cardiac valves R Cardiac pacemakers R Intraocular lenses (per lens) R2 958 Shoulder replacement R Elbow replacement R Hip replacement (see ICPS below) R Knee replacement (see ICPS below) R Total ankle replacement Bone lengthening devices Spinal plates and screws Carotid stents Peripheral arterial stent grafts Embolic protection devices Other approved spinal implantable devices *Combined benefit limit for all unlisted internal prosthesis R See combined benefit limit for all unlisted internal prosthesis* ICPS giving you a hip and a knee up You know us, we re all about the coordination of your care to ensure you recover quicker and more effectively. As such, we recommend our new Improved Clinical Pathway Services (ICPS) for members who need hip and knee replacements. A clinical pathway basically means that a network of the relevant healthcare professionals will oversee every step of your hip or knee replacement journey, from FP referral to surgery right through to your full rehabilitation. As the patient, you benefit since this coordinated approach has been proven to result in better health outcomes and patient satisfaction! So, you ll be back on your feet before you know it thanks to a managed process that includes your pre-op assessment, a rapid recovery plan with pre-operative strengthening, physiological anaesthesia, minimally traumatic surgery, and aggressive postoperative physiotherapy. It means peace of mind when you need it most. To find an ICPS surgeon, visit or call

11 Chronic Disease Medication for approved chronic diseases is covered from this benefit. Limit R per beneficiary, subject to an overall limit of R per family per year IN-BENEFIT (Lists 1 and 2 below) Conditions covered 51 conditions - See lists 1 and 2 below Formulary Comprehensive formulary Designated Service Provider (DSP) Service provider of choice OUT-OF-BENEFIT (List 1 below only) Formulary Comprehensive formulary Designated Service Provider (DSP) Service provider of choice HIV/ AIDS MEDICINE BENEFIT (including treatment for mother-to-child transmission, rape & post-exposure prophylaxis) Limit In-benefit means that you have not exhausted your Chronic Disease limit. Out-of-benefit means that you have exhausted your Chronic Disease limit. Non-compliance with formulary requirements will attract a co-payment of 40%. Where PMB conditions are concerned, the co-payment will not be refundable from Savings. All medicine claims are subject to the Medicine Price List (MPL), a generic reference price list, and the maximum negotiated dispensing fee. Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply. List 1 - PMB conditions: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy COPD/ Emphysema/ Chronic Bronchitis Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis List 2 Additional chronic conditions covered on Maxima Plus: Angina Ankylosing Spondylitis Anorexia Nervosa Attention Deficit Disorder (in children only) Barrett s Oesophagus Bulimia Nervosa Conn s Syndrome Cushing s Syndrome Deep Vein Thrombosis Depression Dermatomyositis Gastro-Oesophageal Reflux Disease Generalised Anxiety Disorder Narcolepsy Polyarteritis Nodosa Pulmonary Interstitial Fibrosis Obsessive Compulsive Disorder Panic Disorder Paraplegia/Quadriplegia (associated medicine) Post-Traumatic Stress Syndrome Scleroderma Thromboangitis Obliterans Thrombocytopaenic Purpura Tourette s Syndrome Valvular Heart Disease Zollinger-Ellison Syndrome Screening We believe that prevention is better than cure, and as such, Maxima Plus gives you access to screening and preventative programmes aimed at improving your health. The following procedures are covered: Women s health 1 mammogram every 3 years for females aged Pap smear every 3 years for females aged (liquid based cytology will be reimbursed up to the rate for a standard Pap smear) Children s health Complete immunisation programme as per state EPI Cardiac health 1 cholesterol screening (full lipogram) every 5 years for all members aged 20 and older Over 50 s 1 pneumococcal vaccination per lifetime for all members older than 65 1 bone densitometry test per lifetime for females older than 65 1 colorectal cancer screening test (faecal occult blood test) every 2 years for all members aged General 1 flu vaccination once a year for all members Health risk assessments 1 wellness screening (blood pressure, finger prick cholesterol and glucose tests) once a year for all members 1 preventative screening (waist-to-hip ratio, body fat %, flexibility, posture and fitness) once a year for all members Certain wearable devices (such as activity trackers) payable from Savings up to R750 per device for all members, as per approved list 10

12 02 Day-to-Day s Maxima Plus Day-to-day expenses are covered from available funds in the Savings Account, Out-of-Hospital Expenses (OHEB) and carry-over Savings. Limits may apply when calculating certain claims for accumulation to Threshold. These limits will also apply for refunds from OHEB and Threshold. The Threshold pays for certain day-to-day expenses once Savings and OHEB have been depleted and claims have accumulated up to the required level. The Threshold Level is reached through the accumulation of claims paid from Savings, OHEB and the member s own pocket through the year at the, unless otherwise specified. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from Threshold. Day to day medical expense Additional medical services: Audiology, dietetics, genetic counselling, hearing aid acoustics, occupational therapy, orthoptics, podiatry, private nursing*, psychologists, speech therapy, social workers Alternative healthcare: Acupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including medicines prescribed by alternative healthcare professionals) Antenatal scans Appliances, external accessories and orthotics: Hearing aids, wheelchairs etc. Limits Limit of R per family per year for the total of all additional medical services How the Savings Account covers the expense At cost How the Out-of-Hospital Expenses covers the expense Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available How the expense adds up towards the threshold level Fedhealth Rate to the maximum of the limit No limit At cost Up to the Does not add up to threshold level Two 2D antenatal scans per person per year Limit of R per family per year. Sub-limit of R3 910 per person for foot orthotics At cost At cost Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Fedhealth Rate to the maximum of the limit Fedhealth Rate to the maximum of the limit Biokinetics, Chiropractics No limit At cost Up to the Dentistry (Advanced): Inlays, crowns, bridges, mounted study models, metal base partial dentures, osseo-integrated implants, orthognathic surgery, oral surgery, orthodontic treatment, periodontists, prosthodontists and dental technicians Limit of R6 740 per person per year, up to an overall limit of R per family per year At cost Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Fedhealth Rate to the maximum of the limit Dentistry (Basic) No limit At cost Up to the Female contraception See cover for female contraception on page 6 Family Practitioners (Previously referred to as GPs) Fedhealth Network FPs No limit you are always covered even in the selfpayment gap. (This is because when the Out-of- Hospital Expenses is used up, the expenses will be covered by the Major Medical ) Non-Fedhealth Network FPs Never paid from savings At cost (set rate) set rate if refunded from OHEB No limit At cost Up to the How the Threshold covers the expense up to the limit Not covered up to the limit up to the limit up to the limit Covered from Major Medical * Private nursing that falls outside the Alternatives to Hospitalisation 11

13 Day to day medical expense Limits How the Savings Account covers the expense Optometry: Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, Readers and optometric examinations Over-the-counter medication Limit of R3 010 per person per year, up to an overall limit of R9 170 per family per year Paid out only from Savings (not from Out-of-Hospital Expenses or Threshold ) At cost How the Out-of- Hospital Expenses covers the expense Up to the Fedhealth Rate until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available How the expense adds up towards the threshold level to the maximum of the limit At cost Not covered Does not add up to threshold level Pathology No limit At cost Up to the Fedhealth Rate Physiotherapy No limit At cost Up to the Fedhealth Rate Prescribed medication Limit of R8 980 per person per year, up to an overall limit of R per family per year At cost Up to the MPL until the benefit limit is reached. Amounts spent above limit may be paid out of carryover Savings if there are funds available Radiology (General) No limit At cost Up to the Fedhealth Rate Radiology (Specialised) Specialists excluding Psychiatrists Fedhealth Network No limit Specialists Non-Fedhealth Network Specialists Specialists - Psychiatrists Fedhealth Network Psychiatrists Non-Fedhealth Network Psychiatrists the MPL to the maximum of the limit Paid from the Major Medical if pre-authorised Up to set rate At cost (set rate) No limit At cost Up to the Fedhealth Rate The Additional Medical Services limit of R per family per year applies (combined limit) The Additional Medical Services limit of R per family per year applies (combined limit) Up to set rate At cost At cost (set rate) until the benefit limit is reached. Amounts spent above limit may be paid out of carryover Savings if there are funds available Up to the Fedhealth Rate until the benefit limit is reached. Amounts spent above limit may be paid out of carryover Savings if there are funds available set rate set rate to the maximum of the limit to the maximum of the limit How the Threshold covers the expense Fedhealth Rate up to the limit Not covered Fedhealth Rate Fedhealth Rate Covered up to MPL up to the limit Fedhealth Rate set rate (Fedhealth Network Specialists will only charge the set rate) set rate up to the limit (Fedhealth Network Specialists will only charge the set rate) Fedhealth Rate up to the limit You will have the following funds available for the year: Member: R Adult dependant: R9 042 Child dependant: R2 928 Call the doctor Once the Out-of-Hospital Expenses has run out of funds, Fedhealth gives unlimited cover for FP consultations, as long as you use an FP who is on the Fedhealth Network. Oh baby! Welcoming a teeny tiny baby into your family must be one of life s happiest moments! We like to make this special event even more joyful by not only ensuring that your day-to-day benefits cover all your pregnancy costs, but also offering you the value-adding Fedhealth Baby Programme. We pay pregnancy costs from Savings and OHEB if you have funds available. Consultations with a Fedhealth Network gynaecologist will be covered in full at the agreed rate from your Savings and OHEB. Consultations with nonnetwork gynaecologists will be covered at cost from your Savings and up to 100% of the from OHEB. Just remember, non-network gynaecologists may charge more for consultations, which will result in your day-to-day funds being depleted sooner. We ll be with you every step of the way nine months and beyond! UNIQUE BENEFITS Plus, for more value-added support benefits paid from Risk to make your day-to-day medical spending go further, like specialised radiology, please go to page 5 of this brochure. 12

14 02 Maxima Exec Maxima Exec Ideal for: - Established professionals - Executives What s in it for you? private hospitalisation Day-to-day claims for expenses like medical consultations funded first from a Savings Account, then from the Out-of-Hospital Expenses and then from a Threshold Extensive cover for 51 chronic conditions All day-to-day expenses covered thanks to a generous Savings Account and Out-of-Hospital Expenses Value adds like unlimited visits to Network FPs paid from Risk Major Medical RISK BENEFITS Chronic Disease Threshold OHEB Savings DAY-TO-DAY BENEFITS Cost Member Adult dependant Child dependant Risk R3 374 R2 875 R1 007 Savings R265 R225 R79 Total R3 639 R3 100 R1 086 Major Medical Please note: All reimbursements for treatment by healthcare professionals depend on the type of healthcare professional and the reimbursement rates agreed to by the Scheme. No overall annual limit Use any hospital of your choice If you use Fedhealth Network FPs and Specialists, you will be covered unlimited at cost If you use out-of-network specialists and FPs, we will cover you up to 100% of the for non-network FPs, and up to 200% for non-network specialists. Any differences will have to be paid by you directly to the healthcare provider. Prescribed Minimum s (PMB) Treatment for PMB conditions can be funded in two ways: 1) To have the treatment for your PMB conditions covered in full, you will have to use Fedhealth Network FPs and Specialists. 2) Should you choose not to use network providers, the Scheme will only refund the treatment at 100% of the for non-network FPs and 200% of the for non-network specialists. You will have a co-payment should the healthcare professional charge more. Also included in the Major Medical are: Healthcare Professionals in hospital - Fedhealth Network FPs and Specialists - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Alternatives to hospitalisation Sub-acute facilities, physical rehabilitation facilities Nursing services, private nurse practitioners & nursing agencies Ambulance Services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Immune deficiency related to HIV infection ALL LIMITS PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED cost 100% of 200% of 200% of with Europ Assistance 13 We refer to General Practitioners (GP) as Family Practitioners (FP).

15 Maternity - Fedhealth Network FPs and Specialists (eg. gynaecologists and paediatricians) - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Postnatal midwifery benefit Maxillo-facial surgery - Surgical extraction of impacted wisdom teeth Oncology: Oncologist consultations, visits, treatment and materials for chemotherapy and radiotherapy, approved medication, radiology and pathology at preferred provider* and subject to enhanced treatment protocols. DSP* above limit cost 100% of 200% of 200% of 4 consultations per pregnancy You pay a co-payment of R3 500 on the hospital bill R Specialised Medication for oncology (also see below) Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Prostheses - Internal - External Psychiatric services: Accommodation in a general ward, procedures, ECT, materials and hospital equipment, consultations and visits, medicines and injection material Renal dialysis (chronic): Consultations, visits, all services, materials and medicines associated with the cost of renal dialysis Specialised Medication (eg. biologicals) (oncology & non-oncology) Take-out medicines Terminal care benefit *Preferred provider and DSP is ICON - Independent Clinical Oncology Network R R R at 100% of the Various sub-limits apply, please see below R R R at 100% of the R days medication for each hospital event R at 100% of the Internal Prosthesis This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth. Hip and knee bilateral replacements will be allowed for up to double the amount for a single hip and knee replacement. Prostheses paid at cost subject to limits. Aorta stent grafts R Limits per family Detachable platinum coils R Cardiac stents R Cardiac valves R Cardiac pacemakers R Intraocular lenses (per lens) R2 958 Shoulder replacement R Elbow replacement R Hip replacement (See ICPS on page 15) R Knee replacement (See ICPS on page 15) R Total ankle replacement Bone lengthening devices Spinal plates and screws Carotid stents Peripheral arterial stent grafts Embolic protection devices Other approved spinal implantable devices *Combined benefit limit for all unlisted internal prosthesis R See combined benefit limit for all unlisted internal prosthesis* Procedures with a R2 000 co-payment on the hospital/facility bill: Colonoscopy, Upper GI endoscopy, Arthroscopic procedures: hip, wrist, Other arthroscopic procedures Procedures with a R3 500 co-payment on the hospital/facility bill: Surgical extraction of impacted wisdom teeth, Balloon sinuplasty, Spinal surgery, Joint replacements (See ICPS on page 15), All laparoscopic procedures, Rhizotomies & facet pain block (limited to 1 of either procedures per beneficiary per year) 14

16 02 Maxima Exec ICPS giving you a hip and a knee up without a co-payment You know us, we re all about the coordination of your care to ensure you recover quicker and more effectively. As such, we recommend our new Improved Clinical Pathway Services (ICPS) for members who need hip and knee replacements. A clinical pathway basically means that a network of the relevant healthcare professionals will oversee every step of your hip or knee replacement journey, from FP referral to surgery right through to your full rehabilitation. As the patient, you benefit since this coordinated approach has been proven to result in better health outcomes and patient satisfaction! So, you ll be back on your feet before you know it thanks to a managed process that includes your pre-op assessment, a rapid recovery plan with pre-operative strengthening, physiological anaesthesia, minimally traumatic surgery, and aggressive postoperative physiotherapy. Another great advantage is that if you use ICPS, you won t have any co-payment on your hip or knee replacement. It therefore makes sense to avoid co-payments by using ICPS. Simply visit or call to find an ICPS surgeon. Chronic Disease Medication for approved chronic diseases is covered from this benefit. Limit R6 430 per beneficiary, subject to an overall limit of R per family per year IN-BENEFIT (Lists 1 and 2 below) Conditions covered 51 conditions - See lists 1 and 2 below Formulary Comprehensive formulary Designated Service Provider (DSP) Service provider of choice OUT-OF-BENEFIT (List 1 below only) Formulary Comprehensive formulary Designated Service Provider (DSP) Medi-Rite pharmacy and Pharmacy Direct HIV/ AIDS MEDICINE BENEFIT (including treatment for mother-to-child transmission, rape & post-exposure prophylaxis) Limit In-benefit means that you have not exhausted your Chronic Disease limit. Out-of-benefit means that you have exhausted your Chronic Disease limit. Non-compliance with DSP and/or formulary requirements will attract a co-payment of 40%. Where PMB conditions are concerned, the co-payment will not be refundable from Savings. All medicine claims are subject to the Medicine Price List (MPL), a generic reference price list, and the maximum negotiated dispensing fee. Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply. List 1 - PMB conditions: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy COPD/ Emphysema/ Chronic Bronchitis Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis List 2 Additional chronic conditions covered on Maxima Exec: Angina Ankylosing Spondylitis Anorexia Nervosa Attention Deficit Disorder (in children only) Barrett s Oesophagus Bulimia Nervosa Conn s Syndrome Cushing s Syndrome Deep Vein Thrombosis Depression Dermatomyositis Gastro-Oesophageal Reflux Disease Generalised Anxiety Disorder Narcolepsy Polyarteritis Nodosa Pulmonary Interstitial Fibrosis Obsessive Compulsive Disorder Panic Disorder Paraplegia/Quadriplegia (associated medicine) Post-Traumatic Stress Syndrome Scleroderma Thromboangitis Obliterans Thrombocytopaenic Purpura Tourette s Syndrome Valvular Heart Disease Zollinger-Ellison Syndrome Screening We believe that prevention is better than cure, and as such, Maxima Exec gives you access to screening and preventative programmes aimed at improving your health. The following procedures are covered: Women s health 1 mammogram every 3 years for females aged Pap smear every 3 years for females aged (liquid based cytology will be reimbursed up to the rate for a standard Pap smear) Children s health Complete immunisation programme as per state EPI Cardiac health 1 cholesterol screening (full lipogram) every 5 years for all members aged 20 and older 15

17 Over 50 s 1 pneumococcal vaccination per lifetime for all members older than 65 1 bone densitometry test per lifetime for females older than 65 1 colorectal cancer screening test (faecal occult blood test) every 2 years for all members aged General 1 flu vaccination once a year for all members Health risk assessments 1 wellness screening (blood pressure, finger prick cholesterol and glucose tests) once a year for all members 1 preventative screening (waist-to-hip ratio, body fat %, flexibility, posture and fitness) once a year for all members Certain wearable devices (such as activity trackers) payable from Savings up to R750 per device for all members, as per approved list Day-to-Day s Day-to-day expenses are covered from available funds in the Savings Account, Out-of-Hospital Expenses (OHEB) and carry-over Savings. Limits may apply when calculating certain claims for accumulation to Threshold. These limits will also apply for refunds from OHEB and Threshold. The Threshold pays for certain day-to-day expenses once Savings and OHEB have been depleted and claims have accumulated up to the required level. The Threshold Level is reached through the accumulation of claims paid from Savings, OHEB and the member s own pocket through the year at the, unless otherwise specified. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from Threshold. A 10% co-payment will apply to all claims paid from the Threshold on Maxima Exec. No co-payment will apply to FP or specialist consultations in network. Day to day medical expense Additional medical services: Audiology, dietetics, genetic counselling, hearing aid acoustics, occupational therapy, orthoptics, podiatry, private nursing*, psychologists, speech therapy, social workers Alternative healthcare: Acupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including medicines prescribed by alternative healthcare professionals) Antenatal scans Appliances, external accessories and orthotics: Hearing aids, wheelchairs etc. Limits Limit of R per family per year for the total of all additional medical services How the Savings Account covers the expense At cost How the Out-of-Hospital Expenses covers the expense Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available How the expense adds up towards the threshold level Fedhealth Rate to the maximum of the limit No limit At cost Up to the Does not add up to threshold level Two 2D antenatal scans per person per year Limit of R per family per year. Sub-limit of R3 910 per person for foot orthotics At cost At cost Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Fedhealth Rate to the maximum of the limit Fedhealth Rate to the maximum of the limit Biokinetics, Chiropractics No limit At cost Up to the Dentistry (Advanced): Inlays, crowns, bridges, mounted study models, metal base partial dentures, osseointegrated implants, orthognathic surgery, oral surgery, orthodontic treatment, periodontists, prosthodontists and dental technicians Limit of R6 740 per person per year, up to an overall limit of R per family per year At cost Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Fedhealth Rate to the maximum of the limit Dentistry (Basic) No limit At cost Up to the Female contraception See cover for female contraception on page 6 * Private nursing that falls outside the Alternatives to Hospitalisation How the Threshold covers the expense up to the limit Not covered up to the limit up to the limit up to the limit 16

18 02 Maxima Exec Day to day medical expense Limits How the Savings Account covers the expense Family Practitioners (Previously referred to as GPs) Fedhealth Network FPs No limit you are always covered even in the self-payment gap. (This is because when the Out-of- Hospital Expenses is used up, the expenses will be covered by the Major Medical ) Never paid from savings How the Outof-Hospital Expenses covers the expense At cost (set rate) Non-Fedhealth Network FPs No limit At cost Up to the Optometry: Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, Readers and optometric examinations Over-the-counter medication Limit of R3 010 per person per year, up to an overall limit of R9 170 per family per year Paid out only from Savings (not from Out-of-Hospital Expenses or Threshold ) At cost Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available How the expense adds up towards the threshold level set rate if refunded from OHEB to the maximum of the limit At cost Not covered Does not add up to threshold level Pathology No limit At cost Up to the Physiotherapy No limit At cost Up to the Prescribed medication Limit of R8 980 per person per year, up to an overall limit of R per family per year At cost Up to the MPL until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Radiology (General) No limit At cost Up to the Radiology (Specialised) Specialists excluding Psychiatrists Fedhealth Network No limit Specialists Non-Fedhealth Network Specialists Specialists - Psychiatrists Fedhealth Network Psychiatrists Non-Fedhealth Network Psychiatrists the MPL to the maximum of the limit Paid from the Major Medical if pre-authorised Up to set rate At cost (set rate) No limit At cost Up to the The Additional Medical Services limit of R per family per year applies (combined limit) The Additional Medical Services limit of R per family per year applies (combined limit) Up to set rate At cost At cost (set rate) until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available set rate set rate to the maximum of the limit to the maximum of the limit How the Threshold covers the expense Covered from Major Medical Fedhealth Rate Fedhealth Rate up to the limit Not covered Fedhealth Rate Fedhealth Rate Covered up to MPL up to the limit Fedhealth Rate set rate (Fedhealth Network Specialists will only charge the set rate) set rate up to the limit (Fedhealth Network Specialists will only charge the set rate) Fedhealth Rate up to the limit 17

19 You will have the following funds available for the year: Member: R8 570 Adult dependant: R6 900 Child dependant: R1 648 Call the doctor Once the Out-of-Hospital Expenses has run out of funds, Fedhealth gives unlimited cover for FP consultations, as long as you use an FP who is on the Fedhealth Network. Oh baby! Welcoming a teeny tiny baby into your family must be one of life s happiest moments! We like to make this special event even more joyful by not only ensuring that your day-to-day benefits cover all your pregnancy costs, but also offering you the value-adding Fedhealth Baby Programme. We pay pregnancy costs from Savings and OHEB if you have funds available. Consultations with a Fedhealth Network gynaecologist will be covered in full at the agreed rate from your Savings and OHEB. Consultations with nonnetwork gynaecologists will be covered at cost from your Savings and up to 100% of the from OHEB. Just remember, non-network gynaecologists may charge more for consultations, which will result in your day-to-day funds being depleted sooner. We ll be with you every step of the way nine months and beyond! UNIQUE BENEFITS Plus, for more value-added support benefits paid from Risk to make your day-to-day medical spending go further, like specialised radiology, please go to page 5 of this brochure. 18

20 02 Maxima Standard Maxima Standard Ideal for: - Young, growing families - Single professionals What s in it for you? private hospitalisation Day-to-day claims for expenses like medical consultations first funded from a Savings Account, then from the Out-of-Hospital Expenses and then a Threshold Extensive cover for 39 chronic conditions Risk benefits like unlimited visits to Network FPs Major Medical RISK BENEFITS Chronic Disease Threshold OHEB Savings DAY-TO-DAY BENEFITS Cost Member Adult dependant Child dependant Risk R2 476 R2 109 R741 Savings R217 R185 R65 Total R2 693 R2 294 R806 Major Medical Please note: All reimbursements for treatment by healthcare professionals depend on the type of healthcare professional and the reimbursement rates agreed to by the Scheme. No overall annual limit Use any hospital of your choice If you use Fedhealth Network FPs and Specialists, you will be covered unlimited at cost If you use out-of-network specialists and FPs, we will cover you up to 100% of the and any differences will have to be paid by you directly to the healthcare provider. Prescribed Minimum s (PMB) Treatment for PMB conditions can be funded in two ways: 1) To have the treatment for your PMB conditions covered in full, you will have to use Fedhealth Network FPs and Specialists. 2) Should you choose not to use network providers, the Scheme will only refund the treatment at 100% of the and you will have a co-payment should the healthcare professional charge more. Also included in the Major Medical are: 19 Healthcare Professionals in hospital - Fedhealth Network FPs and Specialists - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Alternatives to hospitalisation Nursing services, private nurse practitioners & nursing agencies Sub-acute facilities, physical rehabilitation facilities Ambulance Services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Immune deficiency related to HIV infection Maternity - Fedhealth Network FPs and Specialists (eg. gynaecologists and paediatricians) - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Postnatal midwifery benefit ALL LIMITS PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED cost 100% of 100% of 200% of Covered up to PMB level of care with Europ Assistance cost 100% of 100% of 200% of 4 consultations per pregnancy

21 Maxillo-facial surgery - Surgical extraction of impacted wisdom teeth Oncology: Oncologist consultations, visits, treatment and materials for chemotherapy and radiotherapy, approved medication, radiology and pathology at preferred provider* and subject to standard treatment protocols. DSP* above limit Specialised Medication for oncology (also see below) Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Prostheses - Internal - External Psychiatric services: Accommodation in a general ward, procedures, ECT, materials and hospital equipment, consultations and visits, medicines and injection material Renal dialysis (chronic): Consultations, visits, all services, materials and medicines associated with the cost of renal dialysis Specialised Medication (eg. biologicals) (oncology & non-oncology) Take-out medicines Terminal care benefit *Preferred provider and DSP is ICON - Independent Clinical Oncology Network You pay a co-payment of R3 500 on the hospital bill R No benefit R R at 100% of the Various sub-limits apply, please see below R R R at 100% of the No benefit 7 days medication for each hospital event R at 100% of the Internal Prosthesis This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth. Hip and knee bilateral replacements will be allowed for up to double the amount for a single hip and knee replacement. Prostheses paid at cost subject to limits. Aorta stent grafts R Limits per family Detachable platinum coils R Cardiac stents R Cardiac valves R Cardiac pacemakers R Intraocular lenses (per lens) R2 958 Shoulder replacement R Elbow replacement R Hip replacement (See ICPS on page 21) R Knee replacement (See ICPS on page 21) R Total ankle replacement Bone lengthening devices Spinal plates and screws Carotid stents Peripheral arterial stent grafts Embolic protection devices Other approved spinal implantable devices *Combined benefit limit for all unlisted internal prosthesis R See combined benefit limit for all unlisted internal prosthesis* Procedures with a co-payment on the hospital/facility bill: Colonoscopy, Upper GI endoscopy R2 000 Surgical extraction of impacted wisdom teeth R3 500 Rhizotomies & facet pain block R3 500 (limited to 1 of either procedures per beneficiary per year) Balloon sinuplasty R3 500 Spinal surgery R3 500 Joint replacements (See ICPS on page 21) R3 500 Arthroscopic procedures: hip, wrist R2 000 Other arthroscopic procedures R2 000 All laparoscopic procedures R3 500 We refer to General Practitioners (GP) as Family Practitioners (FP). 20

22 02 Maxima Standard ICPS giving you a hip and a knee up without a co-payment You know us, we re all about the coordination of your care to ensure you recover quicker and more effectively. As such, we recommend our new Improved Clinical Pathway Services (ICPS) for members who need hip and knee replacements. A clinical pathway basically means that a network of the relevant healthcare professionals will oversee every step of your hip or knee replacement journey, from FP referral to surgery right through to your full rehabilitation. As the patient, you benefit since this coordinated approach has been proven to result in better health outcomes and patient satisfaction! So, you ll be back on your feet before you know it thanks to a managed process that includes your pre-op assessment, a rapid recovery plan with pre-operative strengthening, physiological anaesthesia, minimally traumatic surgery, and aggressive postoperative physiotherapy. Another great advantage is that if you use ICPS, you won t have any co-payment on your hip or knee replacement. It therefore makes sense to avoid co-payments by using ICPS. Simply visit or call to find an ICPS surgeon. Chronic Disease Your medication for approved chronic diseases is covered from this benefit. Limit R5 120 per beneficiary, subject to an overall limit of R per family per year IN-BENEFIT (Lists 1 and 2 below) Conditions covered 39 conditions - See lists 1 and 2 below Formulary Restrictive formulary Designated Service Provider (DSP) Service provider of choice OUT-OF-BENEFIT (List 1 below only) Formulary Restrictive formulary Designated Service Provider (DSP) Medi-Rite pharmacy and Pharmacy Direct HIV/ AIDS MEDICINE BENEFIT (including treatment for mother-to-child transmission, rape & post-exposure prophylaxis) Limit In-benefit means that you have not exhausted your Chronic Disease limit. Out-of-benefit means that you have exhausted your Chronic Disease limit. Non-compliance with DSP and/or formulary requirements will attract a co-payment of 40%. Where PMB conditions are concerned, the co-payment will not be refundable from Savings. All medicine claims are subject to the Medicine Price List (MPL), a generic reference price list, and the maximum negotiated dispensing fee. Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply. List 1 - PMB conditions: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy COPD/ Emphysema/ Chronic Bronchitis Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis List 2 Additional chronic conditions covered on Maxima Standard: Ankylosing Spondylitis Anorexia Nervosa Attention Deficit Disorder (in children only) Bulimia Nervosa Depression Dermatomyositis Generalised Anxiety Disorder Narcolepsy Obsessive Compulsive Disorder Panic Disorder Paraplegia/Quadriplegia (associated medicine) Post-Traumatic Stress Syndrome Scleroderma Tourette s Syndrome Screening We believe that prevention is better than cure, and as such, Maxima Standard gives you access to screening and preventative programmes aimed at improving your health. The following procedures are covered: Women s health 1 mammogram every 3 years for females aged Pap smear every 3 years for females aged (liquid based cytology will be reimbursed up to the rate for a standard Pap smear) Children s health Complete immunisation programme as per state EPI Cardiac health 1 cholesterol screening (full lipogram) every 5 years for all members aged 20 and older General 1 flu vaccination once a year for all members Health risk assessments 1 wellness screening (blood pressure, finger prick cholesterol and glucose tests) once a year for all members 1 preventative screening (waist-to-hip ratio, body fat %, flexibility, posture and fitness) once a year for all members Certain wearable devices (such as activity trackers) payable from Savings up to R750 per device for all members, as per approved list 21

23 Day-to-Day s Day-to-day expenses are covered from available funds in the Savings Account, Out-of-Hospital Expenses (OHEB) and carry-over Savings. Limits may apply when calculating certain claims for accumulation to Threshold. These limits will also apply to refunds from OHEB and Threshold. The Threshold pays for certain day-to-day expenses once Savings and OHEB have been depleted and claims have accumulated up to the required level. The Threshold Level is reached through the accumulation of claims paid from Savings, OHEB and the member s own pocket through the year at the, unless otherwise specified. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from Threshold. A 20% co-payment will apply to all claims paid from the Threshold on Maxima Standard. No co-payment will apply to FP or specialist consultations in network. Day to day medical expense Additional medical services: Audiology, dietetics, genetic counselling, hearing aid acoustics, occupational therapy, orthoptics, podiatry, private nursing*, psychologists, speech therapy, social workers Alternative healthcare: Acupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including medicines prescribed by alternative healthcare professionals) Antenatal scans Appliances, external accessories and orthotics: Hearing aids, wheelchairs etc. Limits Limit of R per family per year for the total of all additional medical services How the Savings Account covers the expense At cost How the Out-of-Hospital Expenses covers the expense Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available How the expense adds up towards the threshold level Fedhealth Rate to the maximum of the limit No limit At cost Up to the Does not add up to threshold level Two 2D antenatal scans per person per year Limit of R per family per year. Sub-limit of R3 910 per person for foot orthotics At cost At cost Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Fedhealth Rate to the maximum of the limit Fedhealth Rate to the maximum of the limit Biokinetics, Chiropractics No limit At cost Up to the Dentistry (Advanced): Inlays, crowns, bridges, mounted study models, metal base partial dentures, osseointegrated implants, orthognathic surgery, oral surgery, orthodontic treatment, periodontists, prosthodontists and dental technicians Limit of R6 740 per person per year, up to an overall limit of R per family per year At cost Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Fedhealth Rate to the maximum of the limit Dentistry (Basic) No limit At cost Up to the Female contraception See cover for female contraception on page 6 Family Practitioners (Previously referred to as GPs) Fedhealth Network FPs No limit you are always covered even in the self-payment gap. (This is because when the Out-of-Hospital Expenses is used up, the expenses will be covered by the Major Medical ) Non-Fedhealth Network FPs Never paid from savings At cost (set rate) set rate if refunded from OHEB No limit At cost Up to the * Private nursing that falls outside the Alternatives to Hospitalisation How the Threshold covers the expense up to the limit Not covered up to the limit up to the limit up to the limit Covered from Major Medical 22

24 02 Maxima Standard Day to day medical expense Limits How the Savings Account covers the expense Optometry: Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, Readers and optometric examinations Over-the-counter medication Limit of R3 010 per person per year, up to an overall limit of R9 170 per family per year Paid out only from Savings (not from Out-of-Hospital Expenses or Threshold ) At cost How the Outof-Hospital Expenses covers the expense Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available How the expense adds up towards the threshold level to the maximum of the limit At cost Not covered Does not add up to threshold level Pathology No limit At cost Up to the Physiotherapy No limit At cost Up to the Prescribed medication Limit of R8 980 per person per year, up to an overall limit of R per family per year At cost Up to the MPL until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Radiology (General) No limit At cost Up to the Radiology (Specialised) Specialists excluding Psychiatrists Fedhealth Network No limit Specialists Non-Fedhealth Network Specialists Specialists - Psychiatrists Fedhealth Network Psychiatrists Non-Fedhealth Network Psychiatrists the MPL to the maximum of the limit Paid from the Major Medical if pre-authorised Up to set rate At cost (set rate) No limit At cost Up to the The Additional Medical Services limit of R per family per year applies (combined limit) The Additional Medical Services limit of R per family per year applies (combined limit) Up to set rate At cost At cost (set rate) until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available set rate set rate to the maximum of the limit to the maximum of the limit How the Threshold covers the expense Fedhealth Rate up to the limit Not covered Fedhealth Rate Fedhealth Rate Covered up to MPL up to the limit Fedhealth Rate set rate (Fedhealth Network Specialists will only charge the set rate) set rate up to the limit (Fedhealth Network Specialists will only charge the set rate) Fedhealth Rate up to the limit 23

25 You will have the following funds available for the year: Member: R6 754 Adult dependant: R5 220 Child dependant: R1 192 Call the doctor Once the Out-of-Hospital Expenses has run out of funds, Fedhealth gives unlimited cover for FP consultations, as long as you use an FP who is on the Fedhealth Network. Oh baby! Welcoming a teeny tiny baby into your family must be one of life s happiest moments! We like to make this special event even more joyful by not only ensuring that your day-to-day benefits cover all your pregnancy costs, but also offering you the value-adding Fedhealth Baby Programme. We pay pregnancy costs from Savings and OHEB if you have funds available. Consultations with a Fedhealth Network gynaecologist will be covered in full at the agreed rate from your Savings and OHEB. Consultations with nonnetwork gynaecologists will be covered at cost from your Savings and up to 100% of the from OHEB. Just remember, non-network gynaecologists may charge more for consultations, which will result in your day-to-day funds being depleted sooner. We ll be with you every step of the way nine months and beyond! UNIQUE BENEFITS Plus, for more value-added support benefits paid from Risk to make your day-to-day medical spending go further, like specialised radiology, please go to page 5 of this brochure. 24

26 02 Maxima Standard Elect Maxima Standard Elect Ideal for: - Young, growing families - Single professionals What s in it for you? private hospitalisation at Fedhealth Network Hospitals Day-to-day claims for expenses like medical consultations funded first from a Savings Account, then from the Out-of-Hospital Expenses and then a Threshold Extensive cover for 39 chronic conditions Risk benefits like unlimited visits to Network FPs Major Medical RISK BENEFITS Chronic Disease Threshold OHEB Savings DAY-TO-DAY BENEFITS Cost Member Adult dependant Child dependant Risk R1 889 R1 610 R565 Savings R164 R140 R50 Total R2 053 R1 750 R615 Major Medical Please note: All reimbursements for treatment by healthcare professionals depend on the type of healthcare professional and the reimbursement rates agreed to by the Scheme. No overall annual limit Use Maxima Standard Elect Network Hospitals for full cover at the negotiated tariff. A R co-payment will apply should you choose to use a non-network hospital If you use Fedhealth Network FPs and Specialists, you will be covered unlimited at cost If you use out-of-network specialists and FPs, we will cover you up to 100% of the and any differences will have to be paid by you directly to the healthcare provider. Prescribed Minimum s (PMB) Treatment for PMB conditions can be funded in two ways: 1) To have the treatment for your PMB conditions covered in full, you will have to use Fedhealth Network Hospitals, FPs and Specialists. 2) Should you choose not to use network providers, the Scheme will only refund the treatment at 100% of the and you will have a co-payment should the healthcare professional charge more. Should you not make use of a network hospital, a R co-payment will apply. Also included in the Major Medical are: Healthcare Professionals in hospital - Fedhealth Network FPs and Specialists - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Alternatives to hospitalisation - Nursing services, private nurse practitioners & nursing agencies - Sub-acute facilities, physical rehabilitation facilities Ambulance Services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Immune deficiency related to HIV infection Maxillo-facial surgery - Surgical extraction of impacted wisdom teeth ALL LIMITS PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED cost 100% of 100% of 200% of Covered up to PMB level of care with Europ Assistance You pay a co-payment of R3 500 on the hospital bill 25 We refer to General Practitioners (GP) as Family Practitioners (FP).

27 Maternity - Fedhealth Network FPs and Specialists (eg. gynaecologists and paediatricians) - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Postnatal midwifery benefit Oncology: Oncologist consultations, visits, treatment and materials for chemotherapy and radiotherapy, approved medication, radiology and pathology at preferred provider* and subject to standard treatment protocols. DSP* above limit Specialised Medication for oncology (also see below) Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Prostheses - Internal - External Psychiatric services: Accommodation in a general ward, procedures, ECT, materials and hospital equipment, consultations and visits, medicines and injection material Renal dialysis (chronic): Consultations, visits, all services, materials and medicines associated with the cost of renal dialysis Specialised Medication (eg. biologicals) (oncology & non-oncology) Take-out medicines Terminal care benefit *Preferred provider and DSP is ICON - Independent Clinical Oncology Network cost 100% of 100% of 200% of 4 consultations per pregnancy R No benefit R R at 100% of the Various sub-limits apply, please see below R R R at 100% of the No benefit 7 days medication for each hospital event R at 100% of the MAXIMA STANDARD Elect NETWORK HOSPITALS PROVINCE SUBURB Life St Mary s Private Hospital Eastern Cape Umtata Life Queenstown Private Hospital Eastern Cape Queenstown Riemland Clinic Free State Frankfort St Helena Hospital Free State Welkom Botshilu Private Hospital Gauteng Soshanguve Clinix Lesedi Private Hospital Gauteng Southdale Clinix Tshepo-Themba Private Hospital Gauteng Dobsonville Clinix Botshelong-Empilweni Private Hospital Gauteng Vosloorus Clinix Naledi-Nkanyezi Private Hospital Gauteng Sebokeng Louis Pasteur Private Hospital Gauteng Pretoria Folateng Pretoria West Hospital Gauteng Pretoria West Folateng Helen Joseph Hospital Gauteng Auckland Park Folateng Sebokeng Hospital Gauteng Sebokeng Zamokuhle Private Hospital Gauteng Tembisa MAXIMA STANDARD Elect NETWORK HOSPITALS PROVINCE SUBURB La Verna Private Hospital KwaZulu-Natal Ladysmith Shifa Private Hospital KwaZulu-Natal Durban Pongola Hospital KwaZulu-Natal Pongola Zoutpansberg Private Hospital Limpopo Polokwane Mediclinic Tzaneen Limpopo Tzaneen Clinix Phalaborwa Private Hospital Mpumalanga Phalaborwa Life Piet Retief Hospital Mpumalanga Piet Retief Clinix Itokolle - Victoria Private Hospital North West Mafikeng Vryburg Private Hospital Northern Cape Vryburg Lenmed Health Kathu Private Hospital Northern Cape Kathu Melomed Mitchells Plain Medical Centre Western Cape Mitchells Plain Ceres Private Hospital Western Cape Ceres Melomed Bellville Medical Centre Western Cape Bellville Internal Prosthesis This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth. Hip and knee bilateral replacements will be allowed for up to double the amount for a single hip and knee replacement. Prostheses paid at cost subject to limits. Limits per family Aorta stent grafts R Detachable platinum coils R Cardiac stents, Cardiac valves, Cardiac pacemakers, Shoulder replacement, Elbow replacement R Intraocular lenses (per lens) R2 958 Hip replacement, Knee replacement (See ICPS on page 27) R Total ankle replacement, Bone lengthening devices, Spinal plates and screws, Carotid stents, Peripheral arterial stent grafts, Embolic protection devices, Other approved spinal implantable devices *Combined benefit limit for all unlisted internal prosthesis R See combined benefit limit for all unlisted internal prosthesis* Procedures with a R2 000 co-payment on the hospital/facility bill: Colonoscopy, Upper GI endoscopy, Arthroscopic procedures: hip, wrist, Other arthroscopic procedures Procedures with a R3 500 co-payment on the hospital/facility bill: Surgical extraction of impacted wisdom teeth, Balloon sinuplasty, Spinal surgery, Joint replacements (See ICPS on page 27), All laparoscopic procedures, Rhizotomies & facet pain block (limited to 1 of either procedures per beneficiary per year) 26

28 02 Maxima Standard Elect ICPS giving you a hip and a knee up without a co-payment You know us, we re all about the coordination of your care to ensure you recover quicker and more effectively. As such, we recommend our new Improved Clinical Pathway Services (ICPS) for members who need hip and knee replacements. A clinical pathway basically means that a network of the relevant healthcare professionals will oversee every step of your hip or knee replacement journey, from FP referral to surgery right through to your full rehabilitation. As the patient, you benefit since this coordinated approach has been proven to result in better health outcomes and patient satisfaction! So, you ll be back on your feet before you know it thanks to a managed process that includes your pre-op assessment, a rapid recovery plan with pre-operative strengthening, physiological anaesthesia, minimally traumatic surgery, and aggressive postoperative physiotherapy. Another great advantage is that if you use ICPS, you won t have any co-payment on your hip or knee replacement. It therefore makes sense to avoid co-payments by using ICPS. Simply visit or call to find an ICPS surgeon. Chronic Disease Your medication for approved chronic diseases is covered from this benefit. Limit R5 120 per beneficiary, subject to an overall limit of R per family per year IN-BENEFIT (Lists 1 and 2 below) Conditions covered 39 conditions - See lists 1 and 2 below Formulary Restrictive formulary Designated Service Provider (DSP) Medi-Rite pharmacy and Pharmacy Direct OUT-OF-BENEFIT (List 1 below only) Formulary Restrictive formulary Designated Service Provider (DSP) Medi-Rite pharmacy and Pharmacy Direct HIV/ AIDS MEDICINE BENEFIT (including treatment for mother-to-child transmission, rape & post-exposure prophylaxis) Limit In-benefit means that you have not exhausted your Chronic Disease limit. Out-of-benefit means that you have exhausted your Chronic Disease limit. Non-compliance with DSP and/or formulary requirements will attract a co-payment of 40%. Where PMB conditions are concerned, the co-payment will not be refundable from Savings. All medicine claims are subject to the Medicine Price List (MPL), a generic reference price list, and the maximum negotiated dispensing fee. Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply. List 1 - PMB conditions: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy COPD/ Emphysema/ Chronic Bronchitis Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis List 2 Additional chronic conditions covered on Maxima Standard Elect : Ankylosing Spondylitis Anorexia Nervosa Attention Deficit Disorder (in children only) Bulimia Nervosa Depression Dermatomyositis Generalised Anxiety Disorder Narcolepsy Obsessive Compulsive Disorder Panic Disorder Paraplegia/Quadriplegia (associated medicine) Post-Traumatic Stress Syndrome Scleroderma Tourette s Syndrome Screening We believe that prevention is better than cure, and as such, Maxima Standard Elect gives you access to screening and preventative programmes aimed at improving your health. The following procedures are covered: 27 Women s health 1 mammogram every 3 years for females aged Pap smear every 3 years for females aged (liquid based cytology will be reimbursed up to the rate for a standard Pap smear) Children s health Complete immunisation programme as per state EPI Cardiac health 1 cholesterol screening (full lipogram) every 5 years for all members aged 20 and older General 1 flu vaccination once a year for all members Health risk assessments 1 wellness screening (blood pressure, finger prick cholesterol and glucose tests) once a year for all members 1 preventative screening (waist-to-hip ratio, body fat %, flexibility, posture and fitness) once a year for all members Certain wearable devices (such as activity trackers) payable from Savings up to R750 per device for all members, as per approved list

29 Day-to-Day s Day-to-day expenses are covered from available funds in the Savings Account, Out-of-Hospital Expenses (OHEB) and carry-over Savings. Limits may apply when calculating certain claims for accumulation to Threshold. These limits will also apply to refunds from OHEB and Threshold. The Threshold pays for certain day-to-day expenses once Savings and OHEB have been depleted and claims have accumulated up to the required level. The Threshold Level is reached through the accumulation of claims paid from Savings, OHEB and the member s own pocket through the year at the, unless otherwise specified. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from Threshold. A 20% co-payment will apply to all claims paid from the Threshold on Maxima Standard Elect. No co-payment will apply to FP or specialist consultations in network. Day to day medical expense Additional medical services: Audiology, dietetics, genetic counselling, hearing aid acoustics, occupational therapy, orthoptics, podiatry, private nursing*, psychologists, speech therapy, social workers Alternative healthcare: Acupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including medicines prescribed by alternative healthcare professionals) Antenatal scans Appliances, external accessories and orthotics: Hearing aids, wheelchairs etc. Limits Limit of R per family per year for the total of all additional medical services How the Savings Account covers the expense At cost How the Out-of-Hospital Expenses covers the expense Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available How the expense adds up towards the threshold level Fedhealth Rate to the maximum of the limit No limit At cost Up to the Does not add up to threshold level Two 2D antenatal scans per person per year Limit of R per family per year. Sub-limit of R3 910 per person for foot orthotics At cost At cost Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Fedhealth Rate to the maximum of the limit Fedhealth Rate to the maximum of the limit Biokinetics, Chiropractics No limit At cost Up to the Dentistry (Advanced): Inlays, crowns, bridges, mounted study models, metal base partial dentures, osseointegrated implants, orthognathic surgery, oral surgery, orthodontic treatment, periodontists, prosthodontists and dental technicians Limit of R6 740 per person per year, up to an overall limit of R per family per year At cost Up to the until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available Fedhealth Rate to the maximum of the limit Dentistry (Basic) No limit At cost Up to the Female contraception See cover for female contraception on page 6 Family Practitioners (Previously referred to as GPs) Fedhealth Network FPs No limit you are always covered even in the self-payment gap. (This is because when the Out-of-Hospital Expenses is used up, the expenses will be covered by the Major Medical ) Non-Fedhealth Network FPs Never paid from savings At cost (set rate) set rate if refunded from OHEB No limit At cost Up to the * Private nursing that falls outside the Alternatives to Hospitalisation How the Threshold covers the expense up to the limit Not covered up to the limit up to the limit up to the limit Covered from Major Medical 28

30 02 Maxima Standard Elect Day to day medical expense Limits How the Savings Account covers the expense Optometry: Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, Readers and optometric examinations Over-the-counter medication Limit of R3 010 per person per year, up to an overall limit of R9 170 per family per year Paid out only from Savings (not from Out-of-Hospital Expenses or Threshold ) At cost How the Out-of- Hospital Expenses covers the expense Up to the Fedhealth Rate until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available How the expense adds up towards the threshold level to the maximum of the limit At cost Not covered Does not add up to threshold level Pathology No limit At cost Up to the Fedhealth Rate Physiotherapy No limit At cost Up to the Fedhealth Rate Prescribed medication Limit of R8 980 per person per year, up to an overall limit of R per family per year At cost Up to the MPL until the benefit limit is reached. Amounts spent above limit may be paid out of carryover Savings if there are funds available Radiology (General) No limit At cost Up to the Fedhealth Rate Radiology (Specialised) Specialists excluding Psychiatrists Fedhealth Network No limit Specialists Non-Fedhealth Network Specialists Specialists - Psychiatrists Fedhealth Network Psychiatrists Non-Fedhealth Network Psychiatrists the MPL to the maximum of the limit Paid from the Major Medical if pre-authorised Up to set rate At cost (set rate) No limit At cost Up to the Fedhealth Rate The Additional Medical Services limit of R per family per year applies (combined limit) The Additional Medical Services limit of R per family per year applies (combined limit) Up to set rate At cost At cost (set rate) until the benefit limit is reached. Amounts spent above limit may be paid out of carryover Savings if there are funds available Up to the Fedhealth Rate until the benefit limit is reached. Amounts spent above limit may be paid out of carry-over Savings if there are funds available set rate set rate to the maximum of the limit to the maximum of the limit How the Threshold covers the expense up to the limit Not covered Covered up to MPL up to the limit set rate (Fedhealth Network Specialists will only charge the set rate) set rate up to the limit (Fedhealth Network Specialists will only charge the set rate) up to the limit You will have the following funds available for the year: Member: R6 118 Adult dependant: R4 680 Child dependant: R1 012 Call the doctor Once the Out-of-Hospital Expenses has run out of funds, Fedhealth gives unlimited cover for FP consultations, as long as you use an FP who is on the Fedhealth Network. Oh baby! Welcoming a teeny tiny baby into your family must be one of life s happiest moments! We like to make this special event even more joyful by not only ensuring that your day-to-day benefits cover all your pregnancy costs, but also offering you the value-adding Fedhealth Baby Programme. We pay pregnancy costs from Savings and OHEB if you have funds available. Consultations with a Fedhealth Network gynaecologist will be covered in full at the agreed rate from your Savings and OHEB. Consultations with nonnetwork gynaecologists will be covered at cost from your Savings and up to 100% of the from OHEB. Just remember, non-network gynaecologists may charge more for consultations, which will result in your day-to-day funds being depleted sooner. We ll be with you every step of the way nine months and beyond! UNIQUE BENEFITS Plus, for more value-added support benefits paid from Risk to make your day-to-day medical spending go further, like specialised radiology, please go to page 5 of this brochure. 29

31 comprehensive options Quick Comparison Major Medical Hospitalisation Network FPs and Specialists Non-network FPs Non-network Specialists Other healthcare professionals Oncology maxima plus From R5 992pm maxima exec From R3 639pm cover at cost with Fedhealth Network FPs and Specialists Up to 300% of No overall annual limit Up to 200% of Up to 100% of R Up to 200% of maxima standard maxima standard elect From R2 053pm No overall annual limit Network hospitals only on maxima standard elect Up to 100% of R Organ transplant R R Renal dialysis R R Specialised medication R R No benefit Chronic Disease 51 Conditions R per beneficiary R per family 51 Conditions R6 430 per beneficiary R per family 39 Conditions R5 120 per beneficiary R per family Member Maxima Plus Adult dependant Day-to-Day Maxima Exec Maxima Standard Maxima StandardElect Child Adult Child dependant Member Member Adult Child dependant dependant dependant dependant Member Adult dependant Child dependant OHEB Savings Total Threshold* Self-payment gap R7 850 R5 670 R1 740 R5 390 R4 200 R700 R4 150 R3 000 R412 R4 150 R3 000 R412 R3 972 R3 372 R1 188 R3 180 R2 700 R948 R2 604 R2 220 R780 R1 968 R1 680 R600 R R9 042 R2 928 R8 570 R6 900 R1 648 R6 754 R5 220 R1 192 R6 118 R4 680 R1 012 R R9 460 R3 280* R R7 680 R2 580* R R7 680 R2 580* R R7 680 R2 580* R478 R418 R352 R1 430 R780 R932 R3 246 R2 460 R1 388 R3 882 R3 000 R1 568 *Up to a maximum of three children. specialised radiology paid from the Major Medical if pre-authorised 30

32 03 saver options Our saver options at a glance hospitalisation Day-to-day cover Chronic cover Maxima Basis, Maxima Saver and Maxima EntrySaver The perfect fit for your young family It s so important to make the right decisions for your unique family. Whether family means just you, you and your partner, or the tiny baby you ve just welcomed home. Our three saver options look after single, young professionals and young families alike, by giving you superb hospital cover AND covering day-to-day healthcare spending. On Maxima Saver and Maxima Basis, you have access to unlimited hospitalisation at all private hospitals, whilst Maxima EntrySaver gives you unlimited hospitalisation at Network Hospitals only. Plus, once your savings is depleted, you can still enjoy certain Scheme Funded s on each option. All three options allow all beneficiaries to visit a Network FP for unlimited consultations covered from Risk 365 days a year on Maxima Saver and Maxima EntrySaver you have to visit a nominated Network FP to use the benefit. All these options also provide a Chronic Disease that covers 25 chronic conditions at 100% of the Medicine Price List. Trust our saver options to take care of you and/or your young family because that s what families do! 31

33 Maxima Basis Ideal for: - Young couples thinking of starting a family What s in it for you? private hospitalisation Medical Savings Account consultations at a Network FP (paid from Risk) once Savings is depleted Optometry benefit every two years Dentistry benefit funded by the Scheme once Savings runs out Generous Maternity benefit Cover for 25 chronic conditions at 100% of the Medicine Price List Major Medical RISK BENEFITS Chronic Disease Scheme Funded Day-to-Day Savings DAY-TO-DAY BENEFITS Cost Member Adult dependant Child dependant Risk R1 889 R1 609 R569 Savings R334 R284 R101 Total R2 223 R1 893 R670 Major Medical Please note: All reimbursements for treatment by healthcare professionals depend on the type of healthcare professional and the reimbursement rates agreed to by the Scheme. No overall annual limit Use any hospital of your choice If you use Fedhealth Network FPs and Specialists, you will enjoy unlimited cover at cost If you use out-of-network specialists and FPs, we will cover you up to 100% of the and any differences will have to be paid by you directly to the healthcare provider. Prescribed Minimum s (PMB) Treatment for PMB conditions can be funded in two ways: 1) To have treatment for your PMB conditions covered in full, you have to use Fedhealth Network FPs and Specialists. 2) Should you choose not to use network providers, the Scheme will only refund the treatment at 100% of the and you will be responsible for a co-payment. Also included in the Major Medical are: Healthcare Professionals in hospital - Fedhealth Network FPs and Specialists - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Alternatives to hospitalisation - Nursing services, private nurse practitioners & nursing agencies - Sub-acute facilities, physical rehabilitation facilities Ambulance Services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Balloon sinuplasty Immune deficiency related to HIV infection ALL LIMITS PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED cost 100% of 100% of 200% of Covered up to PMB level of care with Europ Assistance No benefit We refer to General Practitioners (GP) as Family Practitioners (FP). 32

34 03 Maternity - Fedhealth Network FPs and Specialists (eg. gynaecologists and paediatricians) - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals cost 100% of 100% of 200% of Maxima Basis Postnatal midwifery benefit Maxillo-facial surgery - Surgical extraction of impacted wisdom teeth Oncology: Oncologist consultations, visits, treatment and materials for chemotherapy and radiotherapy, approved medication, radiology and pathology at designated service provider* and subject to standard treatment protocols Specialised Medication for oncology (also see below) Organ transplant including immunosuppression medication 4 consultations per pregnancy You pay a co-payment of R3 500 on the hospital bill R at an ICON specialist No benefit on this option R Corneal graft Pathology, radiology (general) Prostheses - Internal - External Psychiatric services: Accommodation in a general ward, procedures, ECT, materials and hospital equipment, consultations and visits, medicines and injection material Renal dialysis (chronic): Consultations, visits, all services, materials and medicines associated with the cost of renal dialysis Rhizotomies & facet pain block Specialised Medication (eg. biologicals) (oncology & non-oncology) Take-out medicines Terminal care benefit *Designated service provider is ICON - Independent Clinical Oncology Network No benefit at 100% of the Various sub-limits apply, please see below R R R at 100% of the No benefit No benefit 7 days medication for each hospital event R at 100% of the Internal Prosthesis This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth. Hip and knee bilateral replacements will be allowed for up to double the amount for a single hip and knee replacement. Prostheses paid at cost subject to limits. Limits per family Cardiac pacemakers PMBs only Aorta stent grafts R Carotid stents Peripheral arterial stent grafts Embolic protection devices Shoulder replacement Elbow replacement Hip replacement Knee replacement Bone lengthening devices Spinal plates and screws Other approved spinal implantable devices Intraocular lenses (per lens) R2 958 Detachable platinum coils R Cardiac stents PMBs only Cardiac valves PMBs only *Combined benefit limit for all unlisted internal prosthesis R Procedures with a co-payment on the hospital/facility bill: Colonoscopy, Upper GI endoscopy R3 500 Surgical extraction of impacted wisdom teeth R3 500 Open hiatus hernia surgery R3 500 Spinal surgery R5 000 Joint replacements R5 000 Arthroscopic procedures: hip, wrist R6 500 Other arthroscopic procedures R3 500 See combined benefit limit for all unlisted internal prosthesis* 33 All laparoscopic procedures R5 500

35 Chronic Disease Maxima Basis offers unlimited cover for medication for all 25 PMB chronic conditions as well as HIV/Aids. Cover is subject to a restrictive formulary of approved medications which must be obtained from a Medi-Rite Pharmacy or Pharmacy Direct, our Designated Service Providers (DSP). A 40% co-payment will apply when using medication not on the list or for using any other pharmacy except Medi-Rite or Pharmacy Direct for the dispensing of your medication. The following 25 chronic conditions are covered: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy COPD/Emphysema/Chronic Bronchitis Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis Screening We believe prevention is better than cure, and as such, Maxima Basis gives you access to screening and preventative programmes aimed at improving your health. The following procedures are covered: Women s health 1 mammogram every 3 years for females aged Pap smear every 3 years for females aged (liquid based cytology will be reimbursed up to the rate for a standard Pap smear) Children s health Complete immunisation programme as per state EPI Cardiac health 1 cholesterol screening (full lipogram) every 5 years for all members aged 20 and older General 1 flu vaccination once a year for all members Health risk assessments 1 wellness screening (blood pressure, finger prick cholesterol and glucose tests) once a year for all members 1 preventative screening (waist-to-hip ratio, body fat %, flexibility, posture and fitness) once a year for all members Certain wearable devices (such as activity trackers) payable from Savings up to R750 per device for all members, as per approved list Day-to-Day s Your day-to-day expenses like visits to doctors and specialists, short-term courses of medicine, x-rays and dentistry will be paid directly out of your Savings. You have the following funds available for the year: Member: R4 008 Adult dependant: R3 408 Child dependant: R1 212 Once your Savings has been depleted, you will have to pay for your day-to-day expenses from your own pocket. Call the doctor Even if your current year s Savings has run out, you will enjoy unlimited cover for FP consultations, as long as you use an FP on the Fedhealth network. Looking after those pearly whites Even if your current year s Savings is depleted, the Scheme will pay for two annual dentist consultations per beneficiary including scaling and polishing provided you use one of our contracted dentists and the treatment falls within our list of approved dental procedures. Oh baby! Welcoming a teeny tiny baby into your family must be one of life s happiest moments! We like to make this special event even more joyful by not only ensuring that your day-to-day benefits cover all your pregnancy costs, but also offering you the value-adding Fedhealth Baby Programme. We pay pregnancy costs from Savings if you have funds available. Consultations with a gynaecologist will be covered at cost from your Savings, and if you use a Fedhealth Network gynaecologist, the costs will covered in full at the agreed rate. Just remember, non-network gynaecologists may charge more for consultations, which will result in your day-to-day funds being depleted sooner. We ll be with you every step of the way nine months and beyond! Should your current year s Savings run out, the Scheme will still pay for two 2D antenatal scans per year, antenatal classes up to R950 by a midwife, a total of six ante- or postnatal consultations or a mix thereof with a midwife, network gynaecologist or network FP, and one amniocentesis per year. But if babies can wait The Scheme pays for certain female contraceptives like the Pill, contraceptive rings, IUD (including the Mirena) and certain injectables, from the Major Medical. We keep a close eye Maxima Basis brings you optical benefits through an Optical Network Provider paid from the Major Medical. This benefit offers: one comprehensive consultation per beneficiary, one pair of single vision or bifocal lenses per beneficiary, and a frame to the value of R182 per beneficiary (Savings can be used to buy more expensive frames). This benefit runs over a 24-month period (in other words, it s available every two years). UNIQUE BENEFITS Plus, for more value-added support benefits paid from Risk to make your day-to-day medical spending go further, like specialised radiology, please go to page 5 of this brochure. 34

36 03 Maxima Saver Maxima Saver Ideal for: - Young professionals - Young families What s in it for you? private hospitalisation Medical Savings Account consultations at a nominated Network FP (paid from Risk) once Savings is depleted Non-Fedhealth Network providers funded at up to 100% of the Cover for 25 chronic conditions at 100% of the Medicine Price List Major Medical RISK BENEFITS Chronic Disease Scheme Funded Day-to-Day Savings DAY-TO-DAY BENEFITS Cost Member Adult dependant Child dependant Risk R1 571 R1 279 R453 Savings R277 R226 R80 Total R1 848 R1 505 R533 Major Medical Please note: All reimbursements for treatment by healthcare professionals depend on the type of healthcare professional and the reimbursement rates agreed to by the Scheme. No overall annual limit Use any hospital of your choice If you use Fedhealth Network FPs and Specialists, you will enjoy unlimited cover at cost If you use out-of-network specialists and FPs, we will cover you up to 100% of the and any differences will have to be paid by you directly to the healthcare provider. Prescribed Minimum s (PMB) Treatment for PMB conditions can be funded in two ways: 1) To have treatment for your PMB conditions covered in full, you have to use Fedhealth Network FPs and Specialists. 2) Should you choose not to use network providers, we will only refund the treatment at 100% of the and you will be responsible for a co-payment. Also included in the Major Medical are: Healthcare Professionals in hospital - Fedhealth Network FPs and Specialists - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Alternatives to hospitalisation - Nursing services, private nurse practitioners & nursing agencies - Sub-acute facilities, physical rehabilitation facilities Ambulance Services Appliances, external accessories, orthotics Blood, blood equivalents and blood products Balloon sinuplasty Immune deficiency related to HIV infection ALL LIMITS PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED cost 100% of 100% of 150% of Covered up to PMB level of care with Europ Assistance Subject to savings No benefit 35 We refer to General Practitioners (GP) as Family Practitioners (FP).

37 Joint replacements Maternity - Fedhealth Network FPs and Specialists (eg. gynaecologists and paediatricians) - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Postnatal midwifery benefit Maxillo-facial surgery - Surgical extraction of impacted wisdom teeth Oncology: Oncologist consultations, visits, treatment and materials for chemotherapy and radiotherapy, approved medication, radiology and pathology at designated service provider* and subject to standard treatment protocols Specialised Medication for oncology (also see below) Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Prostheses - Internal - External Psychiatric services: Accommodation in a general ward, procedures, ECT, materials and hospital equipment, consultations and visits, medicines and injection material Renal dialysis (chronic): Consultations, visits, all services, materials and medicines associated with the cost of renal dialysis Rhizotomies & facet pain block Specialised Medication (eg. biologicals) (oncology & non-oncology) Take-out medicines Terminal care benefit *Designated service provider is ICON - Independent Clinical Oncology Network Covered up to PMB level of care cost 100% of 100% of 150% of 4 consultations per pregnancy You pay a co-payment of R3 500 on the hospital bill R No benefit on this option R No benefit at 100% of the Covered up to PMB level of care R9 940 R R at 100% of the No benefit No benefit 7 days medication for each hospital event R at 100% of the Procedures with a co-payment on the hospital/facility bill: All open hernia surgery R3 500 Back & neck pain procedures R5 000 Spinal surgery R5 000 Bunion procedures R5 000 Cataract surgery R5 000 Elective caesarean sections R5 000 Gastritis/ dyspepsia/ heartburn R5 000 Hysterectomy (unless for cancer) R5 000 Nasal procedures R5 000 Colonoscopy, Upper GI endoscopy R3 500 Cystoscopy R5 000 Skin biopsy/ excision R5 000 Tonsil/ adenoid procedures R5 000 Varicose vein procedures R5 000 Dental admissions R5 500 Surgical extraction of impacted wisdom teeth R3 500 Arthroscopic procedures: hip & wrist R6 500 Other arthroscopic procedures R3 500 Laparoscopic procedures R

38 03 Chronic Disease Maxima Saver Maxima Saver offers unlimited cover for medication for all 25 PMB chronic conditions as well as HIV/Aids. Cover is subject to a restrictive formulary of approved medications which must be obtained from a Medi-Rite Pharmacy or Pharmacy Direct, our Designated Service Providers (DSP). A 40% co-payment will apply when using medication not on the list or for using any other pharmacy except Medi-Rite or Pharmacy Direct for the dispensing of your medication. The following 25 chronic conditions are covered: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy COPD/Emphysema/Chronic Bronchitis Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis Screening We believe prevention is better than cure, and as such, Maxima Saver gives you access to screening and preventative programmes aimed at improving your health. The following procedures are covered: Women s health 1 mammogram every 3 years for females aged Pap smear every 3 years for females aged (liquid based cytology will be reimbursed up to the rate for a standard Pap smear) Children s health Complete immunisation programme as per state EPI Cardiac health 1 cholesterol screening (full lipogram) every 5 years for all members aged 20 and older General 1 flu vaccination once a year for all members Health risk assessments 1 wellness screening (blood pressure, finger prick cholesterol and glucose tests) once a year for all members 1 preventative screening (waist-to-hip ratio, body fat %, flexibility, posture and fitness) once a year for all members Certain wearable devices (such as activity trackers) payable from Savings up to R750 per device for all members, as per approved list Day-to-Day s Your day-to-day expenses like visits to doctors and specialists, short-term courses of medicine, optometry and dentistry will be paid directly out of your Savings. You have the following funds available for the year: Member: R3 324 Adult dependant: R2 712 Child dependant: R960 Once your Savings has been depleted, you will have to pay for your day-to-day expenses from your own pocket. Call the doctor Even if your current year s Savings has run out, you will enjoy unlimited cover for FP consultations, as long as you use a nominated FP on the Fedhealth network. Let s talk about contraception If you re not ready for the pajama drill quite just yet, there s no need to worry. The Scheme will pay for certain female contraceptives such as the Pill, contraceptive rings, IUD (including the Mirena) and certain injectables, from the Major Medical, giving you the freedom to plan your family. Looking after those pearly whites Even if your current year s Savings is depleted, the Scheme will pay for two annual dentist consultations per beneficiary including scaling and polishing provided you use one of our contracted dentists and the treatment falls within our list of approved dental procedures. Oh baby! Welcoming a teeny tiny baby into your family must be one of life s happiest moments! We like to make this special event even more joyful by not only ensuring that your day-to-day benefits cover all your pregnancy costs, but also offering you the value-adding Fedhealth Baby Programme. We pay pregnancy costs from Savings if you have funds available. Consultations with a gynaecologist will be covered at cost from your Savings, and if you use a Fedhealth Network gynaecologist, the costs will covered in full at the agreed rate. Just remember, non-network gynaecologists may charge more for consultations, which will result in your day-to-day funds being depleted sooner. We ll be with you every step of the way nine months and beyond! UNIQUE BENEFITS Plus, for more value-added support benefits paid from Risk to make your day-to-day medical spending go further, like specialised radiology, please go to page 5 of this brochure. 37

39

40 03 Maxima EntrySaver Maxima EntrySaver Ideal for: - Young professionals - Young families What s in it for you? hospitalisation at Fedhealth Network Hospitals Medical Savings Account consultations at a nominated Network FP (paid from Risk) once Savings is depleted Treatment by Fedhealth Network Specialists covered at cost for in-hospital procedures Cover for 25 chronic conditions at 100% of the Medicine Price List Major Medical RISK BENEFITS Chronic Disease Scheme Funded Day-to-Day Savings DAY-TO-DAY BENEFITS Cost Member Adult dependant Child dependant Risk R1 224 R881 R392 Savings R235 R169 R75 Total R1 459 R1 050 R467 Major Medical Please note: All reimbursements for treatment by healthcare professionals depend on the type of healthcare professional and the reimbursement rates agreed to by the Scheme. No overall annual limit Use Maxima EntrySaver Network Hospitals for full cover at the negotiated tariff. A R5 270 co-payment will apply should you choose to use a non-network hospital If you use Fedhealth Network FPs and Specialists, you will be covered unlimited at cost If you use out-of-network specialists and FPs, we will cover you up to 100% of the, and any differences will have to be paid by you directly to the healthcare provider. Prescribed Minimum s (PMB) Treatment for PMB conditions can be funded in two ways: 1) To have treatment for your PMB conditions covered in full, you have to use Fedhealth Network Hospitals, FPs and Specialists. 2) Should you choose not to use network providers, the Scheme will only refund the treatment at 100% of the and you will have a co-payment. Should you not make use of a network hospital, a R5 270 co-payment will apply. Also included in the Major Medical are: Healthcare Professionals in hospital - Fedhealth Network FPs and Specialists - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Alternatives to hospitalisation - Nursing services, private nurse practitioners & nursing agencies - Sub-acute facilities, physical rehabilitation facilities Ambulance Services Appliances, external accessories, orthotics Blood, blood equivalents and blood products Arthroscopic procedures: hip & wrist Balloon sinuplasty Dental admissions ALL LIMITS PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED cost 100% of 100% of 100% of Covered up to PMB level of care with Europ Assistance Subject to savings No benefit No benefit No benefit 39 We refer to General Practitioners (GP) as Family Practitioners (FP).

41 Immune deficiency related to HIV infection Joint replacements Maternity - Fedhealth Network FPs and Specialists (eg. gynaecologists and paediatricians) - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Postnatal midwifery benefit Maxillo-facial surgery Oncology: Oncologist consultations, visits, treatment and materials for chemotherapy and radiotherapy, approved medication, radiology and pathology at designated service provider* and subject to standard treatment protocols Specialised Medication for oncology (also see below) Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Prostheses - Internal - External Psychiatric services: Accommodation in a general ward, procedures, ECT, materials and hospital equipment, consultations and visits, medicines and injection material Renal dialysis (chronic): Consultations, visits, all services, materials and medicines associated with the cost of renal dialysis Rhizotomies & facet pain block Specialised Medication (eg. biologicals) (oncology & non-oncology) Take-out medicines Terminal care benefit Covered up to PMB level of care cost 100% of 100% of 100% of 4 consultations per pregnancy No benefit for surgical extraction of impacted wisdom teeth Covered up to PMB level of care at an ICON specialist No benefit on this option Covered up to PMB level of care in state facilities No benefit at 100% of the Covered up to PMB level of care Covered up to PMB level of care Covered up to PMB level of care Covered up to PMB level of care in state facilities No benefit No benefit 7 days medication for each hospital event R at 100% of the *Designated service provider is ICON - Independent Clinical Oncology Network 40

42 03 Maxima EntrySaver Fedhealth has an agreement with a list of facilities for this option. It s always best to use a facility in the network, as it means your hospital account is covered in full. If you use any other hospital, you will need to pay R5 270 of the cost of the hospital account. MAXIMA ENTRYSAVER NETWORK HOSPITALS PROVINCE SUBURB Life Beacon Bay Hospital Eastern Cape East London Life Mercantile Hospital Eastern Cape Korsten Life St George s Hospital Eastern Cape Centrahill Life St James Hospital Eastern Cape Southernwood Life St Mary's Private Hospital Eastern Cape Umtata Netcare Settlers Hospital Eastern Cape Grahamstown Netcare Cuyler Hospital Eastern Cape Uitenhage Horizon Eye Care Centre Free State Bloemfontein Life Pasteur Hospital Free State Bloemfontein Life Rosepark Hospital Free State Bloemfontein Mediclinic Hoogland Free State Bethlehem Netcare Kroon Hospital Free State Kroonstad Botshilu Private Hospital Gauteng Soshanguve Arwyp Medical Centre Gauteng Kempton Park Clinix Selby Park Hospital Gauteng Marshalltown Clinix Tshepo - Themba Private Hospital Gauteng Dobsonville Cormed Clinic Gauteng Vanderbijlpark Ahmed Kathrada Private Hospital Gauteng Lenasia Lenmed Health Randfontein Private Hospital Gauteng Randfontein Lesedi Private Hospital Gauteng Southdale Leslie Williams Memorial Private Hospital Gauteng Carletonville Life Bedford Gardens Hospital Gauteng Gardenview Life Brenthurst Clinic Gauteng Johannesburg Life Carstenhof Clinic Gauteng Midrand Life Dalview Clinic Gauteng Brakpan Life Faerie Glen Hospital Gauteng Faerie Glen Life Flora Clinic Gauteng Roodepoort Life Fourways Hospital Gauteng Fourways Gardens Life The Glynnwood Gauteng Benoni Life Robinson Private Hospital Gauteng Randfontein Life Roseacres Clinic Gauteng Primrose Life Wilgeheuwel Hospital Gauteng Honeydew Louis Pasteur Hospital Gauteng Pretoria Central Mediclinic Emfuleni Gauteng Vanderbijlpark Mediclinic Legae Gauteng Mabopane Mediclinic Midstream Gauteng Midstream Midvaal Private Hospital Gauteng Three Rivers Netcare Akasia Hospital Gauteng Akasia Netcare Bougainville Hospital Gauteng Hercules Netcare Clinton Hospital Gauteng Alberton Netcare Mulbarton Gauteng Mulbarton Vaalpark Hospital Gauteng Vaalpark Hibiscus Private Hospital KwaZulu-Natal Port Shepstone Hillcrest Private Hospital KwaZulu-Natal Pinetown Kokstad Private Hospital KwaZulu-Natal Kokstad La Verna Private Hospital KwaZulu-Natal Ladysmith Life Chatsmed Garden Hospital KwaZulu-Natal Chatsworth Life Empangeni Garden Clinic KwaZulu-Natal Richards Bay Life Entabeni Hospital KwaZulu-Natal Durban Life Mount Edgecombe Hospital KwaZulu-Natal Mount Edgecombe Life Westville Hospital KwaZulu-Natal Westville 41

43 MAXIMA ENTRYSAVER NETWORK HOSPITALS PROVINCE SUBURB Midlands Medical Centre KwaZulu-Natal Pietermaritzburg Netcare Alberlito Hospital KwaZulu-Natal Ballito Netcare Kingsway Hospital KwaZulu-Natal Amanzimtoti Netcare The Bay Hospital KwaZulu-Natal Richards Bay Mediclinic Limpopo Limpopo Polokwane Zoutpansberg Private Hospital Limpopo Polokwane Life Cosmos Hospital Mpumalanga Witbank Life Anncron Clinic North West Klerksdorp Life Peglerae Hospital North West Rustenburg Mooimed Private Hospital North West Potchefstroom Netcare Ferncrest Hospital North West Rustenburg Mediclinic Gariep Northern Cape Kimberley Life Bay View Private Hospital Western Cape Mossel Bay Netcare N1 City Hospital Western Cape Goodwood Netcare Kuils River Western Cape Kuils River Mediclinic Vergelegen Western Cape Somerset West Netcare Blaauwberg Hospital Western Cape Bloubergrant Mediclinic Cape Gate Western Cape Cape Gate Mediclinic Cape Town Western Cape Mill Street Ceres Private Hospital Western Cape Ceres Life Claremont Hospital Western Cape Claremont Life Kingsbury Hospital Western Cape Claremont Mediclinic Geneva Western Cape George Mediclinic George Western Cape George Mediclinic Stellenbosch Western Cape Die Boord Melomed Bellville Medical Centre Western Cape Bellville Melomed Gatesville Medical Centre Western Cape Gatesville Melomed Mitchells Plain Medical Centre Western Cape Cape Town Life West Coast Private Hospital Western Cape Vredenburg Please note: this list may be updated during the year, so please contact the Fedhealth Customer Contact Centre on or refer to for the latest Maxima EntrySaver Network Hospital list. Procedures with a co-payment on the hospital/facility bill: All open hernia surgery R5 000 Back & neck pain procedures R5 000 Spinal surgery R5 000 Bunion procedures R5 000 Cataract surgery R5 000 Elective caesarean sections R5 000 Gastritis/ dyspepsia/ heartburn R5 000 Hysterectomy (unless for cancer) R5 000 Nasal procedures R5 000 Colonoscopy, Upper GI endoscopy & cystoscopy R5 000 Skin biopsy/ excision R5 000 Tonsil/ adenoid procedures R5 000 Varicose vein procedures R5 000 Other arthroscopic procedures R5 000 Laparoscopic procedures R

44 03 Maxima EntrySaver Chronic Disease Maxima EntrySaver offers unlimited cover for medication for all 25 PMB chronic conditions as well as HIV/Aids. Cover is subject to a basic formulary of approved medications which must be obtained from a Medi-Rite Pharmacy or Pharmacy Direct, our Designated Service Providers (DSP). A 40% co-payment will apply when using medication not on the list or for using any other pharmacy except Medi-Rite or Pharmacy Direct for the dispensing of your medication. The following 25 chronic conditions are covered: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy COPD/Emphysema/Chronic Bronchitis Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis Screening We believe prevention is better than cure, and as such, Maxima EntrySaver gives you access to screening and preventative programmes aimed at improving your health. The following procedures are covered: Women s health 1 mammogram every 3 years for females aged Pap smear every 3 years for females aged (liquid based cytology will be reimbursed up to the rate for a standard Pap smear) Children s health Complete immunisation programme as per state EPI Cardiac health 1 cholesterol screening (full lipogram) every 5 years for all members aged 20 and older General 1 flu vaccination once a year for all members Health risk assessments 1 wellness screening (blood pressure, finger prick cholesterol and glucose tests) once a year for all members 1 preventative screening (waist-to-hip ratio, body fat %, flexibility, posture and fitness) once a year for all members Certain wearable devices (such as activity trackers) payable from Savings up to R750 per device for all members, as per approved list Day-to-Day s Your day-to-day expenses like visits to doctors and specialists, short-term courses of medicine, optometry and dentistry will be paid directly out of your Savings. You have the following funds available for the year: Member: R2 820 Adult dependant: R2 028 Child dependant: R900 Once your Savings has been depleted you will have to pay for your day-to-day expenses from your own pocket. Call the doctor Even if your Savings has run out, you will enjoy unlimited cover for FP consultations, as long as you use a nominated FP who is on the Fedhealth Network. Let s talk about contraception If you re not ready for the pajama drill quite just yet, there s no need to worry. The Scheme will pay for certain female contraceptives such as the Pill, contraceptive rings, IUD (including the Mirena) and certain injectables, from Risk, giving you the freedom to plan your family. Oh baby! Welcoming a teeny tiny baby into your family must be one of life s happiest moments! We like to make this special event even more joyful by not only ensuring that your day-to-day benefits cover all your pregnancy costs, but also offering you the value-adding Fedhealth Baby Programme. We pay pregnancy costs from Savings if you have funds available. Consultations with a gynaecologist will be covered at cost from your Savings, and if you use a Fedhealth Network gynaecologist, the costs will covered in full at the agreed rate. Just remember, non-network gynaecologists may charge more for consultations, which will result in your day-to-day funds being depleted sooner. We ll be with you every step of the way nine months and beyond! UNIQUE BENEFITS Plus, for more value-added support benefits paid from Risk to make your day-to-day medical spending go further, like specialised radiology, please go to page 5 of this brochure. 43

45 saver plans Quick Comparison maxima basis maxima saver maxima entrysaver Major Medical Hospitalisation Network FPs and Specialists Non-network FPs and Specialists Other healthcare professionals Oncology From R2 223pm No overall annual limit cover at cost with Fedhealth Network FPs and Specialists Up to 200% of R From R1 848pm Up to 100% of From R1 459pm No overall annual limit Network hospitals only Up to 150% of Up to 100% of R PMBs only Organ transplant R R PMBs only (state facility only) Renal dialysis R R PMBs only (state facility only) Specialised medication No benefit No benefit No benefit Chronic Disease PMB chronic conditions only from Medi-Rite pharmacies or Pharmacy Direct and subject to a restrictive formulary. Covers up to 100% of the Medicine Price List PMB chronic conditions only from Medi-Rite pharmacies or Pharmacy Direct and subject to a basic formulary. Covers up to 100% of the Medicine Price List R4 008 per member p.a. Day-to-Day Optometry - One consultation, one pair single vision or bifocal lenses per beneficiary and a frame valued at R182 per beneficiary every two years (Savings doesn t have to be depleted to use this Scheme benefit). Maternity - Two 2D antenatal scans, antenatal classes, six antenatal or postnatal consultations and one amniocentesis per year once Savings has been depleted R3 324 per member p.a. R2 820 per member p.a. Basic dentistry - Two annual dentist consultations per beneficiary (incl. scaling and polishing) at a Fedhealth Network dentist once Savings has been depleted Basic dentistry - Two annual dentist consultations per beneficiary (incl. scaling and polishing) at a Fedhealth Network dentist once Savings has been depleted FP visits at a Fedhealth Network FP once Savings has been depleted FP visits at a nominated FP on the Fedhealth FP Network specialised radiology paid from the Major Medical if pre-authorised 44

46 04 hospital plans Our hospital plans at a glance In-hospital cover Chronic medication cover Maxima Core and Maxima EntryZone Hospital plans a safety net when you need it most Accidents, illness and other serious incidents are an unfortunate part of life, and can suddenly change life as we know it. Having a hospital plan gives you the peace of mind that you ll receive quality medical care should you end up in hospital. Our hospital plans provide the ideal solution for anyone who s just starting out from the student to the young, single professional with unlimited hospitalisation AND chronic medication cover. hospitalisation is available at all private hospitals through Maxima Core, and members on Maxima EntryZone will enjoy unlimited hospitalisation at all Network Hospitals. In addition, both options also care for members with chronic conditions with a Chronic Disease that covers 25 chronic conditions at 100% of the Medicine Price List. Our hospital plans offer you the reassurance that you ll be in expert hands even when you re not feeling your best just one of the perks of belonging to the Fedhealth family! 45

47 Maxima Core Ideal for: - Students - Young, single professionals What s in it for you? hospitalisation at all private hospitals Chronic Disease that covers 25 chronic conditions at 100% of the Medicine Price List Value-adds like a free annual flu vaccine and contracted fixed rates at Fedhealth Network Specialists RISK BENEFITS Major Medical Chronic Disease RISK BENEFITS Cost Member Adult dependant Child dependant R1 695 R1 436 R593 Major Medical Please note: All reimbursements for treatment by healthcare professionals depend on the type of healthcare professional and the reimbursement rates agreed to by the Scheme. No overall annual limit Use any hospital of your choice If you use Fedhealth Network FPs and Specialists, you will be covered unlimited at cost If you use out-of-network specialists and FPs, we will cover you up to 100% of the and any differences will have to be paid by you directly to the healthcare provider. Prescribed Minimum s (PMB) Treatment for PMB conditions can be funded in two ways: 1) To have the treatment for your PMB conditions covered in full you will have to use any of the Fedhealth Network FPs and Specialists. 2) Should you choose not to use network providers, the Scheme will only refund the treatment at 100% of the and you will have a co-payment. Also included in the Major Medical are: Healthcare Professionals in hospital - Fedhealth Network FPs and Specialists - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Alternatives to hospitalisation - Nursing services, private nurse practitioners & nursing agencies - Sub-acute facilities, physical rehabilitation facilities Ambulance Services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Balloon sinuplasty Immune deficiency related to HIV infection ALL LIMITS PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED cost 100% of 100% of 200% of Covered up to PMB level of care with Europ Assistance No benefit We refer to General Practitioners (GP) as Family Practitioners (FP). 46

48 04 Maxima Core Maternity - Fedhealth Network FPs and Specialists (eg. gynaecologists and paediatricians) - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Postnatal midwifery benefit Maxillo-facial surgery - Surgical extraction of impacted wisdom teeth Oncology: Oncologist consultations, visits, treatment and materials for chemotherapy and radiotherapy, approved medication, radiology and pathology at designated service provider* and subject to standard treatment protocols cost 100% of 100% of 200% of 4 consultations per pregnancy You pay a co-payment of R3 500 on the hospital bill R at an ICON specialist Specialised Medication for oncology (also see below) Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Prostheses - Internal - External Psychiatric services: Accommodation in a general ward, procedures, ECT, materials and hospital equipment, consultations and visits, medicines and injection material Renal dialysis (chronic): Consultations, visits, all services, materials and medicines associated with the cost of renal dialysis Rhizotomies & facet pain block Specialised Medication (eg. biologicals) (oncology & non-oncology) Take-out medicines Terminal care benefit *Designated service provider is ICON - Independent Clinical Oncology Network No benefit on this option R No benefit at 100% of the Various sub-limits apply, please see below R R R at 100% of the No benefit No benefit 7 days medication for each hospital event R at 100% of the Internal Prosthesis This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth. Hip and knee bilateral replacements will be allowed for up to double the amount for a single hip and knee replacement. Prostheses paid at cost subject to limits. Aorta stent grafts R Limits per family Detachable platinum coils R Cardiac stents Cardiac valves Cardiac pacemakers PMBs only PMBs only PMBs only Intraocular lenses (per lens) R2 958 Shoulder replacement Elbow replacement Hip replacement Knee replacement Bone lengthening devices Spinal plates and screws Carotid stents Peripheral arterial stent grafts Embolic protection devices Other approved spinal implantable devices *Combined benefit limit for all unlisted internal prosthesis R See combined benefit limit for all unlisted internal prosthesis* 47

49 Procedures with a co-payment on the hospital/facility bill: Colonoscopy, Upper GI endoscopy R3 500 Surgical extraction of impacted wisdom teeth R3 500 Open hiatus hernia surgery R3 500 Spinal surgery R5 000 Joint replacements R5 000 Arthroscopic procedures: hip, wrist R6 500 Other arthroscopic procedures R3 500 All laparoscopic procedures R5 500 Hysterectomy (unless for cancer) R3 500 Inguinal hernia surgery R3 500 Varicose vein procedures R3 500 Chronic Disease Maxima Core offers unlimited cover for medication for all 25 PMB chronic conditions as well as HIV/Aids. Cover is subject to a restrictive formulary of approved medications which must be obtained from a Medi-Rite Pharmacy or Pharmacy Direct, our Designated Service Providers (DSP). A 40% co-payment will apply when using medication not on the list or for using any other pharmacy except Medi-Rite or Pharmacy Direct for the dispensing of your medication. The following 25 chronic conditions are covered: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy COPD/Emphysema/Chronic Bronchitis Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis Screening We believe prevention is better than cure, and as such, Maxima Core gives you access to screening and preventative programmes aimed at improving your health. The following procedures are covered: Women s health 1 mammogram every 3 years for females aged Pap smear every 3 years for females aged (liquid based cytology will be reimbursed up to the rate for a standard Pap smear) Children s health Complete immunisation programme as per state EPI Cardiac health 1 cholesterol screening (full lipogram) every 5 years for all members aged 20 and older General 1 family practitioner consultation (in network only) for all members 1 flu vaccination once a year for all members Health assessments: 1 wellness screening (blood pressure, finger prick cholesterol and glucose tests) once a year for all members 1 preventative screening (waist-to-hip ratio, body fat %, flexibility, posture and fitness) once a year for all members Day-to-Day s Under Maxima Core, you will receive PMB level of care at our Specialist Network, FP Network and designated pharmacy providers (Medi-Rite Pharmacies and Pharmacy Direct) only. Let s talk about contraception If you re not ready for the pajama drill quite just yet, there s no need to worry. The Scheme will pay for certain oral contraceptives from Risk, giving you the freedom to plan your family. Subject to an approved list. UNIQUE BENEFITS Plus, for more value-added support benefits paid from Risk to make your day-to-day medical spending go further, like specialised radiology, please go to page 5 of this brochure. 48

50 04 Maxima EntryZone Maxima EntryZone Ideal for: - Young single professionals What s in it for you? hospitalisation at Fedhealth Network Hospitals Chronic Disease that covers 25 chronic conditions at 100% of the Medicine Price List Value-adds like a free annual flu vaccine and contracted fixed rates at Fedhealth Network Specialists RISK BENEFITS Major Medical Chronic Disease RISK BENEFITS Cost Member Adult dependant Child dependant R1 179 R881 R396 Major Medical No overall annual limit Use one of the Maxima EntryZone network hospitals for full cover at the negotiated tariff. A R5 270 co-payment applies should you choose to use a non-network hospital If you use Fedhealth Network FPs and Specialists you will be covered unlimited at cost If you use out-of-network specialists and FPs, we will cover you up to 100% of the and any differences will have to be paid by you directly to the healthcare provider. Prescribed Minimum s (PMB) Treatment for PMB conditions can be funded in two ways: 1) To have the treatment for your PMB conditions covered in full, you will have to use Fedhealth Network Hospitals, FPs and Specialists. 2) Should you choose not to use network providers, the Scheme will only refund the treatment at 100% of the and you will have a co-payment. Should you not make use of a network hospital, a R5 270 co-payment will apply. Also included in the Major Medical are: Healthcare Professionals in hospital - Fedhealth Network FPs and Specialists - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Alternatives to hospitalisation - Nursing services, private nurse practitioners & nursing agencies - Sub-acute facilities, physical rehabilitation facilities Ambulance Services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Arthroscopic procedures: hip & wrist Balloon sinuplasty Dental admissions Immune deficiency related to HIV infection Joint replacements ALL LIMITS PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED cost 100% of 100% of 100% of Covered up to PMB level of care with Europ Assistance No benefit No benefit No benefit Covered up to PMB level of care 49 We refer to General Practitioners (GP) as Family Practitioners (FP).

51 Maternity - Fedhealth Network FPs and Specialists (eg. gynaecologists and paediatricians) - Non-Fedhealth Network FPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Postnatal midwifery benefit Maxillo-facial surgery Oncology: Oncologist consultations, visits, treatment and materials for chemotherapy and radiotherapy, approved medication, radiology and pathology at designated service provider* and subject to standard treatment protocols cost 100% of 100% of 100% of 4 consultations per pregnancy No benefit for surgical extraction of impacted wisdom teeth Covered up to PMB level of care at an ICON specialist Specialised Medication for oncology (also see below) Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Prostheses - Internal - External Psychiatric services: Accommodation in a general ward, procedures, ECT, materials and hospital equipment, consultations and visits, medicines and injection material Renal dialysis (chronic): Consultations, visits, all services, materials and medicines associated with the cost of renal dialysis Rhizotomies & facet pain block Specialised Medication (eg. biologicals) (oncology & non-oncology) Take-out medicines Terminal care benefit No benefit on this option Covered up to PMB level of care in state facilities No benefit at 100% of the Covered up to PMB level of care Covered up to PMB level of care Covered up to PMB level of care Covered up to PMB level of care in state facilities No benefit No benefit 7 days medication for each hospital event R at 100% of the *Designated service provider is ICON - Independent Clinical Oncology Network Fedhealth has an agreement with a list of facilities for this option. It s always best to use a facility in the network, as it means your hospital account is covered in full. If you use any other hospital, you will need to pay R5 270 of the cost of the hospital account. MAXIMA ENTRYZONE NETWORK HOSPITALS PROVINCE SUBURB Life Beacon Bay Hospital Eastern Cape East London Life Mercantile Hospital Eastern Cape Korsten Life St George s Hospital Eastern Cape Centrahill Life St James Hospital Eastern Cape Southernwood Life St Mary's Private Hospital Eastern Cape Umtata Netcare Settlers Hospital Eastern Cape Grahamstown Netcare Cuyler Hospital Eastern Cape Uitenhage Horizon Eye Care Centre Free State Bloemfontein Life Pasteur Hospital Free State Bloemfontein Life Rosepark Hospital Free State Bloemfontein Mediclinic Hoogland Free State Bethlehem Netcare Kroon Hospital Free State Kroonstad Arwyp Medical Centre Gauteng Kempton Park Botshilu Private Hospital Gauteng Soshanguve Clinix Selby Park Hospital Gauteng Marshalltown Clinix Tshepo - Themba Private Hospital Gauteng Dobsonville Cormed Clinic Gauteng Vanderbijlpark Ahmed Kathrada Private Hospital Gauteng Lenasia Lenmed Health Randfontein Private Hospital Gauteng Randfontein Lesedi Private Hospital Gauteng Southdale Leslie Williams Memorial Private Hospital Gauteng Carletonville Life Bedford Gardens Hospital Gauteng Gardenview Life Brenthurst Clinic Gauteng Johannesburg Life Carstenhof Clinic Gauteng Midrand Life Dalview Clinic Gauteng Brakpan Life Faerie Glen Hospital Gauteng Faerie Glen 50

52 04 Maxima EntryZone 51 MAXIMA ENTRYZONE NETWORK HOSPITALS PROVINCE SUBURB Life Flora Clinic Gauteng Roodepoort Life Fourways Hospital Gauteng Fourways Gardens Life The Glynnwood Gauteng Benoni Life Robinson Private Hospital Gauteng Randfontein Life Roseacres Clinic Gauteng Primrose Life Wilgeheuwel Hospital Gauteng Honeydew Louis Pasteur Hospital Gauteng Pretoria Central Mediclinic Emfuleni Gauteng Vanderbijlpark Mediclinic Legae Gauteng Mabopane Mediclinic Midstream Gauteng Midstream Midvaal Private Hospital Gauteng Three Rivers Netcare Akasia Hospital Gauteng Akasia Netcare Bougainville Hospital Gauteng Hercules Netcare Clinton Hospital Gauteng Alberton Netcare Mulbarton Gauteng Mulbarton Vaalpark Hospital Gauteng Vaalpark Hibiscus Private Hospital KwaZulu-Natal Port Shepstone Hillcrest Private Hospital KwaZulu-Natal Pinetown Kokstad Private Hospital KwaZulu-Natal Kokstad La Verna Private Hospital KwaZulu-Natal Ladysmith Life Chatsmed Garden Hospital KwaZulu-Natal Chatsworth Life Empangeni Garden Clinic KwaZulu-Natal Richards Bay Life Entabeni Hospital KwaZulu-Natall Durban Life Mount Edgecombe Hospital KwaZulu-Natal Mount Edgecombe Life Westville Hospital KwaZulu-Natal Westville Midlands Medical Centre KwaZulu-Natal Pietermaritzburg Netcare Alberlito Hospital KwaZulu-Natal Ballito Netcare Kingsway Hospital KwaZulu-Natal Amanzimtoti Netcare The Bay Hospital KwaZulu-Natal Richards Bay Mediclinic Limpopo Limpopo Polokwane Zoutpansberg Private Hospital Limpopo Polokwane Life Cosmos Hospital Mpumalanga Witbank Life Anncron Clinic North West Klerksdorp Life Peglerae Hospital North West Rustenburg Mooimed Private Hospital North West Potchefstroom Netcare Ferncrest Hospital North West Rustenburg Mediclinic Gariep Northern Cape Kimberley Life Bay View Private Hospital Western Cape Mossel Bay Netcare N1 City Hospital Western Cape Goodwood Netcare Kuils River Western Cape Kuils River Mediclinic Vergelegen Western Cape Somerset West Netcare Blaauwberg Hospital Western Cape Bloubergrant Mediclinic Cape Gate Western Cape Cape Gate Mediclinic Cape Town Western Cape Mill Street Ceres Private Hospital Western Cape Ceres Life Claremont Hospital Western Cape Claremont Life Kingsbury Hospital Western Cape Claremont Mediclinic Geneva Western Cape George Mediclinic George Western Cape George Mediclinic Stellenbosch Western Cape Die Boord Melomed Bellville Medical Centre Western Cape Bellville Melomed Gatesville Medical Centre Western Cape Gatesville Melomed Mitchells Plain Medical Centre Western Cape Cape Town Life West Coast Private Hospital Western Cape Vredenburg

53 Procedures with a co-payment on the hospital/facility bill: All open hernia surgery R5 000 Back & neck pain procedures R5 000 Spinal surgery R5 000 Bunion procedures R5 000 Cataract surgery R5 000 Elective caesarean sections R5 000 Gastritis/ dyspepsia/ heartburn R5 000 Hysterectomy (unless for cancer) R5 000 Nasal procedures R5 000 Colonoscopy, Upper GI endoscopy & cystoscopy R5 000 Skin biopsy/ excision R5 000 Tonsil/ adenoid procedures R5 000 Varicose vein procedures R5 000 Other arthroscopic procedures R5 000 Laparoscopic procedures R5 500 Chronic Disease Maxima EntryZone offers unlimited cover for medication for all 25 PMB chronic conditions as well as HIV/Aids. Cover is subject to a basic formulary of approved medications which must be obtained from a Medi-Rite Pharmacy or Pharmacy Direct, our Designated Service Providers (DSP). A 40% co-payment will apply when using medication not on the list or for using any other pharmacy except Medi-Rite or Pharmacy Direct for the dispensing of your medication. The following 25 chronic conditions are covered: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy COPD/Emphysema/Chronic Bronchitis Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis Screening We believe prevention is better than cure, and as such, Maxima EntryZone gives you access to screening and preventative programmes aimed at improving your health. The following procedures are covered: Women s health 1 mammogram every 3 years for females aged Pap smear every 3 years for females aged (liquid based cytology will be reimbursed up to the rate for a standard Pap smear) Children s health Complete immunisation programme as per state EPI Cardiac health 1 cholesterol screening (full lipogram) every 5 years for all members aged 20 and older General 1 family practitioner consultation (in network only) for all members 1 flu vaccination once a year for all members Health assessments: 1 wellness screening (blood pressure, finger prick cholesterol and glucose tests) once a year for all members 1 preventative screening (waist-to-hip ratio, body fat %, flexibility, posture and fitness) once a year for all members Day-to-Day s Under Maxima EntryZone, you will receive PMB level of care at our Specialist Network, FP Network and designated pharmacy providers (Medi-Rite Pharmacies and Pharmacy Direct) only. Let s talk about contraception If you re not ready for the pajama drill quite just yet, there s no need to worry. The Scheme will pay for certain oral contraceptives from Risk, giving you the freedom to plan your family. Subject to an approved list. UNIQUE BENEFITS Plus, for more value-added support benefits paid from Risk to make your day-to-day medical spending go further, like specialised radiology, please go to page 5 of this brochure. 52

54 hospital plans Quick Comparison maxima core From R1 695pm maxima entryzone From R1 179pm Major Medical Hospitalisation Network FPs and Specialists Non-network FPs and Specialists Other healthcare professionals No overall annual limit cover at cost with Fedhealth Network FPs and Specialists Up to 200% of Up to 100% of No overall annual limit Network hospitals only Up to 100% of Chronic Disease PMB chronic conditions only from Medi-Rite pharmacies or Pharmacy Direct and subject to a restrictive formulary. Covers up to 100% of the Medicine Price List PMB chronic conditions only from Medi-Rite pharmacies or Pharmacy Direct and subject to a basic formulary. Covers up to 100% of the Medicine Price List Day-to-Day No Day-to-Day PMB level of care applies at the Designated Pharmacy providers, FP Network and Specialist Network only specialised radiology paid from the Major Medical if pre-authorised 53

55 05 blue door plus Blue Door Plus at a glance hospitalisation at Fedhealth Network Hospitals Day-to-day cover Chronic cover Our family always welcomes more members One of the best things about families is the unconditional love and support they offer, as well as the willingness to welcome more members to the fold. Take Blue Door Plus for example. Through this affordable, entry-level option we extend our quality healthcare to previously uncovered, lower-income employees to ensure that their health and wellness needs are met. It s an excellent option for companies to offer their staff who ve never had medical cover before and is competitively priced for superb value for money. Allow Blue Door Plus to welcome your employees into the Fedhealth family with care they can trust! 54

56 05 Blue Door Plus Blue Door Plus Ideal for: - Previously uncovered employees What s in it for you? Affordable medical aid with no Overall Annual Limit FP visits at a nominated contracted FP prescribed medication at contracted Blue Door Plus FPs Generous cover for specialised radiology (up to 100% of the ) in-hospital Emergency transport in the case of an accident Basic cover for dentistry and optometry RISK BENEFITS Major Medical Chronic Disease Day-to-Day RISK BENEFITS Cost Household income per month Member Adult dependant Child dependant < R5 000 R5 001 R8 200 R8 201 R R R R R690 R875 R1 227 R1 559 R2 114 R572 R723 R1 018 R1 222 R1 832 R328 R422 R464 R602 R796 Major Medical No overall annual limit at Fedhealth Network Hospitals only. A 40% co-payment will apply if you choose to use a non-network hospital If you use Fedhealth Network FPs and Specialists, you will be covered unlimited at cost If you use out-of-network specialists and FPs, the Scheme will cover you up to 100% of the and any differences will have to be paid by you directly to the healthcare provider. Prescribed Minimum s (PMB) Treatment for PMB conditions can be funded in two ways: 1) To have the treatment for your PMB conditions covered in full, you will have to use Fedhealth Network FPs and Specialists. 2) Should you choose not to use network providers, the Scheme will only refund the treatment at 100% of the and you will have a co-payment. Should you not make use of a network hospital, a 40% co-payment will apply. Also included in the Major Medical are: BENEFIT ALL LIMITS PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Overall annual limit (OAL) at Fedhealth Network Hospitals only. A 40% co-payment on voluntary use of non-network hospitals will apply. Healthcare Professionals in hospital - Fedhealth Network FPs and Specialists - Non-Fedhealth Network FPs and Specialists - Other Healthcare Professionals Alternatives to hospitalisation - Acute facilities and rehabilitation facilities (does not include Hospice) Ambulance services Appliances, external accessories, orthotics Blood, blood equivalents and blood products Physical therapy (physiotherapy and biokinetics) Immune deficiency related to HIV infection Hospitalisation Anti-retroviral & related medication Related pathology cost 100% of 100% of Covered up to PMB level of care with Europ Assistance Covered up to PMB level of care at PMB level of care 55

57 Maternity R per maternity event with a limit of R per family per year. Elective Caesarean sections subject to a 40% co-payment. Oncology Oncologists, haematologists and credentialed medical practitioners, consultations, visits, treatment and materials used in radiotherapy and chemotherapy at designated service provider* and subject to standard treatment protocols Organ, tissue and haemopoietic stem cell transplant and immunosuppression medication Pathology and medical technology Prostheses and devices - Internal - External PMBs only at ICON* PMBs only in state facilities Psychiatric services R8 010 Radiology - General - Specialised radiology Renal dialysis (chronic) Haemodialysis and peritoneal dialysis, radiology and pathology. Consultations, visits, all services, materials and medicines associated with the cost of renal dialysis Take-out medicines *Designated service provider is ICON - Independent Clinical Oncology Network PMBs only in state facilities PMBs only in state facilities R per beneficiary, subject to an overall limit of R per family per year PMBs only in state facilities Up to 100% of MPL Limited to 7 days medication per hospital event Fedhealth has an agreement with a list of facilities for this option. It s always best to use a facility in the network, as it means your hospital account is covered in full. If you use any other hospital, you will need to pay a 40% co-payment on the cost of the hospital account. BLUE DOOR PLUS NETWORK HOSPITALS PROVINCE SUBURB Life Beacon Bay Hospital Eastern Cape East London Netcare Cuyler Hospital Eastern Cape Uitenhage Life Mercantile Hospital Eastern Cape Port Elizabeth Port Elizabeth Provincial Hospital Eastern Cape Port Elizabeth Life St James Hospital Eastern Cape East London Uitenhage Hospital Eastern Cape Uitenhage Horizon Eye Care Centre Free State Bloemfontein Life Pasteur Hospital Free State Bloemfontein Life Rosepark Hospital Free State Bloemfontein Universitas Academic Hospital Free State Bloemfontein Netcare Vaalpark Hospital Free State Sasolburg Welkom (Bongani) Provincial Hospital Free State Welkom Netcare Kroon Free State Kroonstad Mediclinic Welkom Free State Welkom Clinix Botshelong-Empilweni Private Hospital Gauteng Vosloorus Netcare Bougainville Hospital Gauteng Pretoria West Life Brenthurst Clinic Gauteng Parktown Life Carstenhof Clinic Gauteng Midrand Charlotte Maxeke Hospital Gauteng Parktown Chris Hani Baragwanath Hospital Gauteng Soweto Netcare Clinton Hospital Gauteng Alberton Cormed Clinic Gauteng Vanderbijlpark Life Dalview Clinic Gauteng Brakpan Lenmed Daxina Private Hospital Gauteng Lenasia Clinix Ahmed Kathrada Private Hospital Gauteng Lenasia Lesedi Private Hospital Gauteng Soweto Leslie Williams Memorial Hospital Gauteng Carletonville Netcare Linmed Hospital Gauteng Benoni Louis Pasteur Hospital Gauteng Pretoria Midvaal Private Hospital Gauteng Vereeniging We refer to General Practitioners (GP) as Family Practitioners (FP). 56

58 05 Blue Door Plus BLUE DOOR PLUS NETWORK HOSPITALS PROVINCE SUBURB Clinix Naledi-Nkanyezi Private Hospital Gauteng Sebokeng Life Robinson Private Hospital Gauteng Randfontein Life Roseacres Clinic Gauteng Primrose Clinix Selby Park Hospital Gauteng Selby Steve Biko Academic Hospital (Pretoria Academic) Gauteng Pretoria TK Maternity Services Hospital Gauteng Katlehong Clinix Tshepo-Themba Private Hospital Gauteng Soweto Zamokhule Private Hospital Gauteng Tembisa Botshilu Private Hospital Gauteng Soshanguve Addington Hospital KwaZulu-Natal Durban Life Chatsmed Garden Hospital KwaZulu-Natal Chatsworth City Hospital KwaZulu-Natal Durban Life Empangeni Garden Clinic KwaZulu-Natal Empangeni Isipingo Hospital KwaZulu-Natal Isipingo Netcare Kokstad Private Hospital KwaZulu-Natal Kokstad La Verna Hospital KwaZulu-Natal Ladysmith Life Mount Edgecombe Hospital KwaZulu-Natal Phoenix Mediclinic Newcastle Hospital KwaZulu-Natal Newcastle Newcastle Provincial Hospital KwaZulu-Natal Newcastle Mediclinic Victoria Private Hospital KwaZulu-Natal Tongaat Mediclinic Lephalale Limpopo Lephalale Mediclinic Limpopo Limpopo Polokwane Mediclinic Tzaneen Limpopo Tzaneen Mediclinic Thabazimbi Limpopo Thabazimbi Life Cosmos Hospital Mpumalanga Witbank Life Midmed Hospital Mpumalanga Middleburg Mediclinic Barberton Mpumalanga Barberton Mediclinic Nelspruit Mpumalanga Nelspruit Clinix Phalaborwa Private Hospital Mpumalanga Phalaborwa Mediclinic Brits North West Brits Mediclinic Legae North West Rosslyn Life Anncron Clinic North West Klerksdorp Mooimed Private Hospital North West Potchefstroom Life Peglerae Hospital North West Rustenburg Clinix Itokolle-Victoria Private Hospital North West Mafikeng Netcare Ferncrest Hospital North West Rustenburg Lenmed Health Kathu Private Northern Cape Kathu Mediclinic Gariep Northern Cape Kimberley Mediclinic Upington Northern Cape Uitenhage Life Bay View Private Hospital Western Cape Mossel Bay Melomed Bellville Medical Centre Western Cape Bellville Netcare Blaauwberg Hospital Western Cape Blaauwberg Mediclinic Cape Gate Western Cape Brackenfell Ceres Private Hospital Western Cape Ceres Melomed Gatesville Medical Centre Western Cape Athlone Groote Schuur Hospital Western Cape Cape Town Mediclinic Hermanus Western Cape Hermanus Karl Bremmer Hospital Western Cape Bellville Netcare Kuils River Hospital Western Cape Kuils River Melomed Mitchells Plain Medical Centre Western Cape Mitchells Plain Paarl Hospital Western Cape Paarl Mediclinic Paarl Western Cape Paarl Red Cross War Memorial Children's Hospital Western Cape Rondebosch Mediclinic Stellenbosch Western Cape Stellenbosch Stellenbosch Provincial Hospital Western Cape Stellenbosch Swartland Hospital Western Cape Malmesbury Tygerberg Hospital Western Cape Bellville Victoria Hospital Western Cape Wynberg 57

59 BLUE DOOR PLUS NETWORK HOSPITALS PROVINCE SUBURB Vredenburg Hospital Western Cape Vredenburg Vredendal Hospital Western Cape Vredendal Life West Coast Private Hospital Western Cape Vredenburg Worcester Hospital Western Cape Worcester Mediclinic Worcester Western Cape Worcester Netcare Christiaan Barnard Memorial Hospital Western Cape Cape Town Chronic Disease Blue Door Plus offers unlimited cover for medication for all 25 PMB chronic conditions as well as HIV/Aids. Cover is subject to a basic formulary of approved medications which must be obtained from a Medi-Rite Pharmacy or Pharmacy Direct, our Designated Service Providers (DSP). A 40% co-payment will apply when using medication not on the list or for using any other pharmacy except Medi-Rite or Pharmacy Direct for the dispensing of your medication. The following 25 chronic conditions are covered: Addison s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy COPD/Emphysema/Chronic Bronchitis Chronic Renal Disease Coronary Artery Disease Crohn s Disease Diabetes Insipidus Diabetes Mellitus type 1 & 2 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosus Ulcerative Colitis We believe that prevention is better than cure, and as such, Blue Door Plus gives you access to the following health risk assessments: 1 wellness screening (blood pressure, finger prick cholesterol and glucose tests) once a year for all members 1 preventative screening (waist-to-hip ratio, body fat %, flexibility, posture and fitness) once a year for all members 58

60 05 Day-to-Day s Blue Door Plus BENEFIT Family Practitioners Contracted Not contracted Specialists Fedhealth Network Specialists Non-Fedhealth Network Specialists Dentistry (basic) Removal of teeth and roots and suturing of traumatic wounds. Oral medical procedures: diagnosis and treatment of oral and associated conditions, plastic dentures and dental technician s fees for all such dentistry Female contraception Mental health Optometry Over-the-counter medication Maternity Pathology Prescribed medication Dispensing FP Non-dispensing medical practitioner (eg. Fedhealth Network Specialists, FPs and dentists) Physiotherapy Radiology General Specialised ALL LIMITS PER FAMILY PER YEAR at contracted nominated FP subject to protocols and utilisation monitoring after 6 visits per beneficiary Limited to 2 consultations per family 2 specialist consultations per family per year. Must be referred by contracted FP No benefit Subject to a contracted list of dentists and limited to a list of approved procedures, dental tariff codes and protocols. Plastic dentures limited to one set per beneficiary every two years Oral contraceptives subject to the acute formulary See FP benefit. Limited to 2 psychiatric consultations per family Subject to ISO Leso network optometrists. Frame to the value of R182 or R182 off any other frame. 1 pair of single vision clear CR39 lenses or 1 pair of bifocal clear CR39 lenses. 1 comprehensive consultation. This benefit is available in a two-year benefit cycle No benefit 2 x 2D scans per beneficiary per maternity event subject to basic protocols and limited list of tests and procedures. Must be referred by contracted medical practitioner at Network FP subject to acute formulary for all medical practitioners No benefit subject to basic protocols and a limited list of tests and procedures. Must be referred by contracted medical practitioner No benefit UNIQUE BENEFITS Unique s There s nothing we won t do for our family! Our benefits are practical and tangible, to ensure that our Blue Door Plus family members get absolute value for money. Taking care of our younger family members: Child rates for financially dependent children up to the age of 27. Where we pay more from Risk than other schemes: hospitalisation at Blue Door Plus Network Hospitals and State Hospitals 7 days of take-home medication Specialised radiology up to R per family in hospital only. Female health benefit we pay for oral contraceptives, i.e. the Pill, subject to the acute formulary. From our family, with love to you: The Fedhealth Blue Door Plus Baby Programme with great giveaways 24-Hour Fedhealth Nurseline FREE trauma counselling for practical and emotional support Emergency transport/response through Europ Assistance Comprehensive HIV/AIDS and other disease management programmes. 59

61 60

62 06 05 Contributions Overview comprehensive contributions maxima plus (including Savings and OHEB) + = Risk Savings TOTAL Annual Threshold* contributions Rand amounts paid monthly to the Scheme for cover received as well as annual benefit values Annual OHEB Member Adult Dependant Child Dependant maxima exec (including Savings and OHEB) saver contributions maxima basis + = Risk Savings TOTAL Member Adult Dependant Child Dependant maxima saver + = Risk Savings TOTAL Annual Threshold* Annual OHEB Member Adult Dependant Child Dependant = Risk Savings TOTAL Member Adult Dependant Child Dependant maxima standard (including Savings and OHEB) + = Risk Savings TOTAL Annual Threshold* Annual OHEB Member Adult Dependant Child Dependant maxima entrysaver + = Risk Savings TOTAL Member Adult Dependant Child Dependant M - member AD - adult dependant CD - child dependant maxima standard Elect (including Savings and OHEB) + = Risk Savings TOTAL Annual Threshold* Annual OHEB Member Adult Dependant Child Dependant *Up to a maximum of three children hospital plans contributions maxima core Member Adult Dependant Child Dependant 593 maxima entryzone Member Adult Dependant 881 Child Dependant

63 Great savings with Sanlam Reality! Fedhealth members can join Sanlam Reality a lifestyle, wellness and rewards programme that helps members save money on travel and entertainment, improve their health and day-to-day expenses, and learn more about financial fitness. s include: Save up to 80% on gym fees Save up to 30% on hotel accommodation Buy one, get one free for theatre shows, sports events and festivals Pay only R15 a movie ticket Save up to 50% on car hire Great discounts on flights: save up to 30% on local flights and up to 25% on international flights And much, much more Talk to your broker about joining Sanlam Reality.