Maxima Range Maxima Saver RISK BENEFITS Major Medical Benefit Chronic Disease Benefit Scheme Funded Day-to-Day Savings How the scheme works Major Medical Benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised. Chronic Disease Benefit Medication for approved chronic diseases is covered from this benefit. Day-to-Day Benefit Day-to-day expenses are covered from Savings. Once Savings is depleted, some Scheme Funded Benefits still apply. DAY-TO-DAY BENEFITS FEDHEALTH membership means REAL Medical Aid, REAL Service and REAL Benefits. Introducing Maxima Saver, a Saver Option. Maxima Saver provides young professionals with unlimited private hospitalisation, together with the freedom of a Savings Account that enables daily healthcare spending. The option even includes unlimited consultations at a nominated Network GP, paid from Risk once your Savings Account is depleted. Treatment by Fedhealth Network specialists is covered in full for in-hospital procedures. And the option still goes the extra mile to provide extensive cover for 25 chronic conditions at 100% of the Medicine Price List. contributions Risk Savings TOTAL Annual Savings Member 1 571 180 1 751 M 2 160 Adult Dependant 1 279 147 1 426 M + AD 3 924 Child Dependant 452 52 504 M + AD + CD 4 548
BENEFIT Overall annual limit (OAL) Healthcare Professional Tariff (HPT) - Fedhealth Network GPs and Specialists - Non-Fedhealth Network GPs and Specialists major medical benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Covered at cost Covered at 100% of FR - Other Healthcare Professionals Covered at 150% of FR Prescribed Minimum Benefits (PMBs) in state hospitals Hospitalisation costs at negotiated tariff Co-payments See details on page 2 Alternatives to hospitalisation BENEFIT Oncology - Specialised medication Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Post-hospitalisation benefit Post-natal midwifery benefit Prostheses major medical benefit (continued) [ 1 ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED R213 000 at ICON. Subject to Standard Protocols (See HPT above) R213 000 (See HPT above) at FR Up to 30 days after discharge at FR 4 consultations per pregnancy at FR - Sub-acute facilities and physical rehabilitation facilities PMB level of care only - Internal PMBs only - Nursing services, private nurse practitioners & nursing agencies Ambulance services Appliances, external accessories, orthotics Blood, blood equivalents and blood products Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Maxillo-facial surgery - Surgical extraction of impacted wisdom teeth Emergency treatment in a casualty ward Female health benefit: contraceptives Immune deficiency related to HIV infection at negotiated tariff with Europ Assistance (See HPT above), subject to approval (See HPT above) Co-payment applies to surgical extraction of impacted wisdom teeth at FR at MPL (See HPT above) - External Psychiatric services Renal Dialysis (chronic) R9 430 at cost R20 300 (See HPT above) - Haemodialysis and peritoneal dialysis R213 000 at FR Specialised medication benefit (eg. biologicals) - oncology & non-oncology Specialised radiology at FR Take-out medicines 7 days medication per hospital event at MPL Terminal care benefit R26 500 at FR FR - Fedhealth Rate ICON - Independent Clinical Oncology Network HPT - Healthcare Professional Tariff DSP - Designated Service Provider MPL - Medicine Price List
PROCEDURE co-payments CO-PAYMENTS (PER EVENT) APPLICA- BLE ON THE HOSPITAL/ FACILITY BILL ONLY All open hernia procedures, Back & neck pain, Spinal surgery, Bunion procedures, Cataract surgery, Elective caesarean sections, Gastritis/ dyspepsia/ heartburn, Hysterectomy (unless for cancer), Nasal procedures, Scopes (upper GI endoscopy, colonoscopy, cystoscopy), Skin R5 000 biopsy/ excision, Tonsil/ adenoid procedures, Varicose vein procedures Dental admissions R5 000 Surgical extraction of impacted wisdom teeth R5 000 Arthroscopic procedures Ankle, Knee, Shoulder R5 000 Laparoscopic procedures Diagnostic, Nissen/ Toupey R5 000 Only the costs for hospital/ facility, All arthroscopic and laparoscopic procedures not listed above theatre fees, anaesthetist & surgeon will be covered screening benefit This benefit provides access to a number of screening and preventative programmes aimed at improving members health BENEFIT CRITERIA ALL LIMITS ARE PER BENEFICIARY Women s Health Breast cancer screening with mammography Cervical cancer screening (PAP smear - test only) Liquid based Cytology will be reimbursed up to the rate for a standard PAP smear Women; ages 50 to 74 Women; ages 21 to 65 1 every 3 years 1 every 3 years Children s Health Immunisation Programme As per State EPI As per State EPI Cardiac Health Cholesterol screening (full lipogram) All lives; aged 20 and older 1 every 5 years General Flu vaccination All lives 1 every year [ 2 EPI - Expanded Programme on Immunisation
chronic disease benefit Medication for approved chronic diseases is covered from this benefit day-to-day benefit Day-to-day expenses are covered directly from available funds in Savings - with no Threshold benefit available. However, once Savings is depleted, various Scheme Funded Benefits still apply to each option. [ 3 Limit Conditions covered Formulary Designated Service Provider (DSP) Limit 25 Chronic Conditions below Restrictive formulary Medi-Rite pharmacy HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS Non-compliance with DSP and/ or formulary requirements will attract a co-payment of 40%, which is not 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. 25 CHRONIC 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 day-to-day benefit Day-to-day expenses are covered directly from available funds in Savings - with no Threshold benefit available. However, once Savings is depleted, various Scheme Funded Benefits still apply to each option. benefit Appliances, external accessories and orthotics Alternative healthcare Accupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including prescribed medication) Additional medical services Audiology, dietetics, occupational therapy, orthoptics, podiatry, psychologists, social workers and speech therapy Dentistry (Advanced) Including oral surgery, osseo-integrated implants, orthognathic surgery and orthodontic treatment benefit 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 fees for all such dentistry Optometry Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, readers and optometric examinations Biokinetics, Chiropractics, Radiology (General), Pathology and Physiotherapy General Practitioners - Fedhealth Network GPs - Non-Fedhealth Network GPs Maternity Over-the-counter medication Prescribed medication Radiology (Specialised) Specialists - Fedhealth Network Specialists - Non-Fedhealth Network Specialists. Once Savings is depleted the following benefits will be paid from Risk: 2 Annual consultations per beneficiary including scaling and polishing. 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. GP visits at nominated Fedhealth Network GP once Savings is depleted Paid from the Major Medical Benefit if pre-authorised
Benefits that set us apart What sets us apart is that together with our first-rate medical aid options, we offer unique value-added benefits. With some of these tangible benefits we pay more from Risk than other schemes to ensure that members day-to-day medical spending not only goes further, but also works harder when they really need it. Benefits unique to Fedhealth: visits to a nominated Network GP paid from Risk once Savings is depleted Child rates for financially dependent children up to 27 years of age so student dependants pay rates applicable to children, provided they re unmarried and not earning more than the maximum social pension Upgrades to higher options any time of the year within 30 days of diagnosis of a dread disease, or in the case of a life changing event which means the member s never locked into an option, and can upgrade should something dramatic happen that changes their circumstances during the year. *New contributions will apply Where we pay more from Risk than other schemes: Post-hospitalisation treatment for up to 30 days after discharge from hospital (physiotherapy, pathology, occupational therapy, speech therapy and general radiology) that means most followup treatment for a full 30-day period paid directly from Risk not to deplete the member s day-to-day benefit 7 days of take-home medication - after discharge from hospital paid for 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 the member s on, whether performed in or out-of-hospital Trauma treatment at a casualty ward - whether admitted to hospital or not, emergency treatment, like stitches, is always paid from Risk and never from the member s day-to-day benefit Cover for female contraception - including oral, patches, certain injectables as well as IUDs that include Mirena, contraceptive rings and implants on all comprehensive and saver options. *Must be prescribed by a GP or gynaecologist and not applicable to pills prescribed for acne The Screening Benefit - health screenings for women and children, cardiac screenings as well as an annual flu vaccine funded from Risk and not from the member s day-to-day benefit. How we add value: The Fedhealth Baby Programme 24-Hour Fedhealth Nurseline 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 still 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. And then members still get: 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 Major Medical Benefit while the dentist s account comes from day-to-day benefits. *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 are at an age and status to afford their own medical aid, meaning no underwriting required for child dependants moving from their parent s medical aid onto their own at Fedhealth. Disclaimer: This document is a summary for information purposes only and does not supersede the rules of the Scheme. In the event of any discrepancy between this summary and the Rules, the Rules will prevail. A copy of the Rules is available on request.