Saver options Choose from: Maxima Saver Maxima EntrySaver Unlimited hospitalisation, plus the benefit of Day-to-Day and Chronic cover. Those who want all the perks associated with top-notch hospital cover, but also require a medical aid option that covers their day-to-day healthcare spending, should consider our saver options. Single, young professionals can benefit from both saver options, as they provide quality hospital cover complemented by a Medical Savings Account that handles day-to-day healthcare expenses. Maxima Range Unlimited hospitalisation at all private hospitals is available on Maxima Saver, whilst members can enjoy unlimited hospitalisation at Network Hospitals only on Maxima EntrySaver. As an added benefit, both options allow all beneficiaries to visit a nominated Network GP for unlimited consultations covered from Risk and on Maxima Saver, there s a Basic Dentistry benefit that is also covered from Risk. These Risk benefits apply once Savings is depleted. Both options also provide a Chronic Disease Benefit that covers 25 chronic conditions at 100% of the Medicine Price List. Saver Options
RISK BENEFITS Major Medical Benefit Chronic Disease Benefit Scheme Funded Day-to-Day Savings DAY-TO-DAY BENEFITS Major Medical Benefit Hospitalisation Network GPs and Specialists Non-network GPs and Specialists Other healthcare professionals From R1 751pm No overall annual limit Up to 150% of Fedhealth Rate Up to 100% of Fedhealth Rate From R1 327pm No overall annual limit Network hospitals only Unlimited cover at cost with Fedhealth Network GPs and Specialists Up to 100% of Fedhealth Rate How the scheme works Major Medical Benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised - Network Hospitals apply to Maxima EntrySaver. Chronic Disease Benefit PMB chronic conditions only from Medi-Rite pharmacies and subject to a restrictive formulary. Covers up to 100% of the Medicine Price List Chronic Disease Benefit Medication for approved chronic diseases is covered from this benefit. R2 160 per member p.a. R2 568 per member p.a. 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 Benefit Basic dentistry Unlimited GP visits at a nominated GP on the Fedhealth GP Network Unlimited specialised radiology paid from the Major Medical Benefit if pre-authorised
[ 1 BENEFIT major medical benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised - Network Hospitals apply to Maxima EntrySaver ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Overall annual limit (OAL) Unlimited Unlimited at network hospitals only Healthcare Professional Tariff (HPT) - Fedhealth Network GPs and Specialists - Non-Fedhealth Network GPs and Specialists Covered at cost Covered at 100% of FR Covered at cost Covered at 100% of FR - Other Healthcare Professionals Covered at 150% of FR Covered at 100% of FR Prescribed Minimum Benefits (PMBs) Unlimited in state hospitals Hospitalisation costs Unlimited at negotiated tariff Unlimited at negotiated tariff at network hospitals only. R5 000 co-payment on voluntary use of a non-network hospital Co-payments See details on page 2 Alternatives to hospitalisation - Sub-acute facilities and physical rehabilitation facilities - 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 PMB level of care only Unlimited at negotiated tariff Unlimited with Europ Assistance Unlimited Unlimited (See HPT above) Unlimited, subject to approval (See HPT above) Unlimited, subject to approval (See HPT above) - Surgical extraction of impacted wisdom teeth Emergency treatment in a casualty ward Female health benefit: contraceptives Immune deficiency related to HIV infection Co-payment applies to surgical extraction of impacted wisdom teeth Unlimited at FR Unlimited at MPL Unlimited (See HPT above) No benefit for surgical extraction of impacted wisdom teeth FR - Fedhealth Rate ICON - Independent Clinical Oncology Network HPT - Healthcare Professional Tariff DSP - Designated Service Provider MPL - Medicine Price List
[ 2 BENEFIT Pathology, radiology (general) Post-hospitalisation benefit Post-natal midwifery benefit Prostheses major medical benefit (continued) ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Unlimited at FR Up to 30 days after discharge at FR 4 consultations per pregnancy at FR - Internal PMBs only PMBs only - External R9 430 at cost PMBs only Psychiatric services R20 300 (See HPT on page 1) PMBs only Renal Dialysis (chronic) - Haemodialysis and peritoneal dialysis R213 000 at FR PMBs only in state facilities Specialised medication benefit (eg. biologicals) - oncology & non-oncology No benefit Specialised radiology Unlimited at FR Take-out medicines 7 days medication per hospital event at MPL Terminal care benefit R26 500 at FR HPT - Healthcare Professional Tariff FR - Fedhealth Rate MPL - Medicine Price List co-payments PROCEDURE CO-PAYMENTS (PER EVENT) APPLICABLE 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 biopsy/ excision, Tonsil/ adenoid procedures, Varicose vein procedures R5 000 Dental admissions R5 000 No benefit Surgical extraction of impacted wisdom teeth R5 000 No benefit Arthroscopic procedures Ankle, Knee, Shoulder R5 000 Laparoscopic procedures Diagnostic, Nissen/ Toupey R5 000 All arthroscopic and laparoscopic procedures not listed above Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered
[ 3 network hospitals HOSPITAL 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 Horizon Eye Care Centre Free State Bloemfontein Mediclinic Hoogland Free State Bethlehem Life Pasteur Hospital Free State Bloemfontein Life Rosepark Hospital Free State Bloemfontein Netcare Bougainville Hospital Gauteng Hercules Life Brenthurst Clinic Gauteng Johannesburg Life Carstenhof Clinic Gauteng Midrand Cormed Clinic Gauteng Vanderbijlpark Life Dalview Clinic Gauteng Brakpan Life Flora Clinic Gauteng Roodepoort HOSPITAL PROVINCE SUBURB Life Fourways Hospital Gauteng Fourways Gardens Life The Glynnwood Gauteng Benoni Louis Pasteur Hospital Gauteng Pretoria Central Midvaal Private Hospital Gauteng Three Rivers Life Robinson Private Hospital Gauteng Randfontein Life Roseacres Clinic Gauteng Primrose Life Chatsmed Garden Hospital Kwa-Zulu Natal Chatsworth Durdoc Clinic Kwa-Zulu Natal Durban Central Life Entabeni Hospital Kwa-Zulu Natal Durban Maxwell Clinic Kwa-Zulu Natal Qualbert Life Mount Edgecombe Hospital Kwa-Zulu Natal Mount Edgecombe Life Westville Hospital Kwa-Zulu Natal Westville Zoutpansberg Private Hospital Limpopo Polokwane Life Cosmos Hospital Mpumalanga Witbank HOSPITAL PROVINCE SUBURB Life Peglerae Hospital North West Rustenburg Mediclinic Kimberley Northern Cape Kimberley Life Bay View Private Hospital Western Cape Mossel Bay 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 Melomed Mitchells Plain Medical Western Cape Cape Town Centre Life West Coast Private Hospital Western Cape Vredenburg Please note that this list may change/ expand during the year. Please contact the Fedhealth Customer Contact Centre on 0860 002 153 or refer to the website for the latest Maxima EntrySaver Network Hospital list
[ 4 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 chronic disease benefit Medication for approved chronic diseases is covered from this benefit Limit Conditions covered Formulary Designated Service Provider (DSP) Limit Unlimited 25 Chronic Conditions below Restrictive formulary Medi-Rite pharmacy HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS Unlimited Non-compliance with DSP and/ or formulary requirements will attract a co-payment of 40%. 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 EPI - Expanded Programme on Immunisation
[ 5 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 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. 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. Unlimited GP visits at nominated Fedhealth Network GP once Savings is depleted. Unlimited GP visits at nominated Fedhealth Network GP once Savings is depleted - Non-Fedhealth Network GPs Maternity Over-the-counter medication Prescribed medication Radiology (Specialised) Paid from the Major Medical Benefit if pre-authorised Paid from the Major Medical Benefit if pre-authorised Specialists - Fedhealth Network Specialists - Non-Fedhealth Network Specialists
[ 6 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: Unlimited visits to a nominated Network GP paid from Risk once Savings is depleted on both Saver options 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 follow-up 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. This benefit does not apply to Maxima EntrySaver 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.
[7 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 Risk Savings TOTAL 1 113 214 1 327 Adult Dependant 753 145 Child Dependant 338 65 Member Annual Savings M 2 568 898 M + AD 4 308 403 M + AD + CD 5 088