Comprehensive Plans: Maxima Plus, Exec, Standard, StandardNet and Basis

These are 2013 rates for Fedhealth Comprehensive Plans: Maxima Plus, Exec, Standard, StandardNet and Basis

major medical benefit

All costs for hospitalisation are covered from this benefit
   maxima plus  maxima exec  maxima standard  maxima standard net  maxima basis
BENEFIT  ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED    
 Overall annual limit (OAL)  Unlimited  

Unlimited at network
hospitals only.
R4 500 co-payment on
voluntary use of nonnetwork
hospitals

  Unlimited

Healthcare Professional Tariff in hospital
(HPT)
Specialists tariff
- Fedhealth Specialist Partners
- Non-Fedhealth Specialist Partners
Other Healthcare Professionals including GPs

  

 

Covered at cost
Covered at 200% of FR
Covered at 300% of FR

 

Covered at cost
Covered at 200% of FR
Covered at 200% of FR

  

 

Covered at cost
Covered at 100% of FR
Covered at 200% of FR

  
 Prescribed Minimum Benefits (PMB) Unlimited in state hospitals    
 Hospitalisation costs Unlimited at negotiated tariff  

Unlimited at negotiated
tariff at network hospitals
only.
R4 500 co-payment on
voluntary use of nonnetwork
hospitals

Unlimited at negotiated
tariff
 Co-payments  See details on page 11    

Alternatives to hospitalisation
Sub-acute facilities, physical 
rehabilitation facilities, nursing 
services, private nurse practitioners & nursing agencies

  Unlimited at negotiated tariff   

 

Unlimited at negotiated tariff.
PMB level of care only

  
 Ambulance services  Unlimited with Europ Assistance    

Appliances, external accessories, orthotics,
blood, blood equivalents and blood products

  Unlimited at cost    

Additional medical services (occupational
therapy and speech therapy) and physical
therapy (physiotherapy and biokinetics)

  Unlimited (See Healthcare Professional Tariff)    
 Dentistry: Maxillo-facial surgery  Unlimited, subject to approval (See Healthcare Professional Tariff)    
 Emergency treatment in a casualty ward  Unlimited at Fedhealth Rate    
 Female health benefit: contraceptives  Unlimited at MPL*    
 Hospice care  R14 500 at Fedhealth Rate    
 Immune deficiency related to HIV infection  Unlimited (See Healthcare Professional Tariff)    

Oncology
- Specialised medication 

Unlimited. Subject to
Enhanced Protocols
(See HPT)
R265 000 at cost

Unlimited. Subject to
Enhanced Protocols (See
HPT)
R132 500 at cost

  

 

R424 000. Subject to Standard Protocols. DSPICON*
above limit (See HPT)
No benefit

 

R243 000 at ICON*.
Subject to Standard
Protocols (See HPT)
No benefit

Organ transplant including immunosuppression
medication
- Corneal graft

Unlimited (See HPT)
R15 900 per beneficiary

R333 000 (See HPT)
R15 900 per beneficiary

R312 000 (See HPT)
R15 900 per beneficiary

 

R243 000 (See HPT)
No benefit
 Pathology  Unlimited at Fedhealth Rate    
 Post-hospitalisation benefit  Up to 30 days after discharge at Fedhealth Rate    
 Post-natal midwifery benefit  4 days at Fedhealth Rate    

Prostheses
- Internal
- External

Various sub-limits apply
(See page 13)
R16 700 at cost

Various sub-limits apply
(See page 13)
R13 300 at cost

Various sub-limits apply
(See page 13)
R8 900 at cost

  
 Psychiatric services  R30 800 (See HPT)  R24 500 (See HPT)  R19 200 (see HPT)  

Renal Dialysis (chronic)
- Haemodialysis and peritoneal dialysis

 Unlimited at FR R333 000 at FR R312 000 at FR   R243 000 at FR

Specialised medication (eg. biologicals) benefit
(oncology & non-oncology)

  R265 000 at cost  R132 500 at cost  No benefit  
 Specialised radiology  Unlimited at Fedhealth Rate    
 Take-out medicines  7 days medication per hospital event at MPL*    

co-payments
   maxima plus  maxima exec  maxima standard  maxima standard net  maxima basis
CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY      
Colonoscopy, Upper GI endoscopy  R1 800    
 Extraction of wisdom teeth  R3 000    
 Hiatus hernia surgery No co-payment 

R3 000

Rhizotomies and facet pain block (limited to 1
of either procedures per beneficiary per year)

  R3 200     No benefit
 Balloon Sinuplasty  R5 300      No benefit
 Back surgery  No co-payment     R6 000
 Joint replacements  No co-payment   R6 000  

Arthroscopic procedures
Ankle, Knee, Shoulder

  No co-payment  R1 800   
 Hip, Wrist  No co-payment  R1 800  Included in additional list below  

Laparoscopic procedures
Appendectomy, Hernia repairs (other than
inguinal hernia repair)

  No co-payment  R1 800  Included in additional list below  
 Diagnostic, Nissen/ Toupey  No co-payment  R1 800   
 Nephrectomy  No co-payment   Included in additional list below  
 ADDITIONAL ARTHROSCOPIC AND LAPAROSCOPIC PROCEDURES WHERE THE SCHEME WILL NOT FUND LAPAROSCOPIC EQUIPMENT AND DISPOSABLES     

Hysterectomy, Pyeloplasty, Radical Prostatec-
tomy, Splenectomy, Unilateral Inguinal Hernias

  Only the costs for hospital/ facility, 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
     maxima plus  maxima exec  maxima standard  maxima standard net maxima basis
BENEFIT  CRITERIA   ALL LIMITS ARE PER BENEFICIARY   

Women’s Health
Breast cancer screening with mammography
Cervical cancer screening

Women; 
ages 50 to 70
Women; 
ages 21 to 65

  

 

1 every 3 years
1 every 3 years

    

Children’s Health
Immunisation Programme (as per State EPI)

  Various  Various    

Cardiac Health
Cholesterol screening (full lipogram)

 All lives; older than 20  1 every 5 years    

Geriatric Health
Pneumococcal vaccination
Bone densitometry
Colorectal cancer screening (faecal occult blood test)

All lives; 
older than 65
Women; 
older than 65
All lives; 
ages 50 to 75

1 per lifetime
1 per lifetime

1 every 2 years

 

  N/A  

General
Flu vaccination

  All lives  1 every year    

maxima StandardNet hospitals
 HOSPITAL  PROVINCE  SUBURB
 Life Beacon Bay Hospital  Eastern Cape  East London
 Mercantile Private Hospital  Eastern Cape  Korsten
 St Georges Hospital  Eastern Cape  Centrahill
 St James Hospital  Eastern Cape  Southernwood
 Bloemfontein Eye Centre  Free State  Bloemfontein
 Pasteur Hospital  Free State  Bloemfontein
 Rosepark Hospital  Free State  Bloemfontein
 Bougainville Private Hospital  Gauteng  Hercules
 Brenthurst Clinic  Gauteng  Johannesburg
 Cormed Clinic  Gauteng  Vanderbijlpark
 Dalview Clinic  Gauteng  Brakpan
 Flora Clinic  Gauteng  Roodepoort
 Fourways Hospital  Gauteng  Fourways Gardens
 Glynnwood Hospital  Gauteng  Benoni
 Louis Pasteur Hospital  Gauteng  Pretoria Central
 Midvaal Private Hospital (Pty) Ltd  Gauteng  Three Rivers
 Robinson Hospital  Gauteng  Randfontein
 Roseacres Clinic  Gauteng  Primrose
 Chatsmed Garden Hospital  Kwa-Zulu Natal  Chatsworth
 Durdoc Clinic  Kwa-Zulu Natal  Durban Central
 Entabeni Private Hospital  Kwa-Zulu Natal  Durban
 Maxwell Clinic  Kwa-Zulu Natal  Qualbert
Mount Edgecombe (Phoenix) Hospital Kwa-Zulu Natal Mount Edgecombe
Westville Hospital Kwa-Zulu Natal Westville
 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
 Claremont Hospital  Western Cape  Claremont
 Kingsbury Hospital  Western Cape  Claremont
 West Coast Private Hospital  Western Cape  Vredenburg

internal prosthesis benefit table

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, whichever is the lower
     maxima plus  maxima exec  maxima standard  maxima standard net  maxima basis
BENEFIT  COVER   ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED    
 Detachable platinum coils  100% of cost                  R38 600    
 Cardiac stents  R38 100   R21 200   PMBs only  
 Cardiac valves  R33 900   R21 200 
 Cardiac pacemakers  R44 500  R37 100  R21 200 
 Carotid stents  See combined benefit limit for all unlisted internal prosthesis*    
 Aorta stent grafts  R44 500    
 Peripheral arterial stent grafts  See combined benefit limit for all unlisted internal prosthesis*    
 Embolic protection devices  See combined benefit limit for all unlisted internal prosthesis*    
 Shoulder replacement  R33 900  R26 500  R21 200  R21 200

See combined benefit
limit for all unlisted
internal prosthesis*
 Elbow replacement  R33 900  R26 500  R21 200  R21 200

See combined benefit
limit for all unlisted
internal prosthesis*
 Hip replacement  R33 900  R26 500  R21 200  R21 200

See combined benefit
limit for all unlisted
internal prosthesis*
 Knee replacement  R33 900  R26 500  R21 200  R21 200

See combined benefit
limit for all unlisted
internal prosthesis*
 Bone lengthening devices  See combined benefit limit for all unlisted internal prosthesis*    
 Spinal plates and screws  See combined benefit limit for all unlisted internal prosthesis*    

Other approved spinal implantable devices

  See combined benefit limit for all unlisted internal prosthesis*    
 Intraocular lenses (per lens)  R2 500    

*Combined benefit for all unlisted
internal prosthesis

  *R27 500  *R22 200  *R19 000  

chronic disease benefit

Medication for approved chronic diseases is covered from this benefit
   maxima plus  maxima exec  maxima standard maxima standard net   maxima basis
 COVER     
 Limit  R11 600 per
beneficiary, subject 
to an overall limit of 
R21 600 per family per year

R5 450 per
beneficiary, subject to an
overall limit of R10 200
per family per year

  

 

R4 340 per beneficiary, subject to an overall limit of
R8 630 per family per year

 

  

 

Prescribed Minimum
Benefits only
 IN-BENEFIT (Lists 1, 2 and 3 below)      IN-BENEFIT (List 1)
Conditions covered

51 conditions
See lists 1, 2 & 3 below

39 conditions
See lists 1 & 2 below

 See list 1 below
 Formulary  No formulary restrictions  Comprehensive formulary    Restrictive formulary
 Designated Service Provider  Service provider of choice     MEDI-Rite pharmacy
 OUT-OF-BENEFIT (List 1 below only)      Out-of-benefit does not apply  
 Formulary  Comprehensive formulary   Restrictive formulary 
 Designated Service Provider  Service provider of choice   MEDI-Rite pharmacy 
 HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS     
 Limit  Unlimited    

In-benefit means that you have not exhausted your Chronic Disease Benefit limit.
Out-of-benefit means that you have exhausted your Chronic Disease Benefit limit.
Non-compliance with DSP and/ or formulary requirements, as per the specific option will attract a co-payment of 40%. If this is in respect of a PMB condition, then the co-payment 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.
 CHRONIC CONDITIONS LISTS     

LIST 1. PMB Conditions (all options): 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. (Maxima Plus, Exec and 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

LIST 3. (Maxima Plus and Exec): Angina, Barrett’s Oesophagus, Conn’s Syndrome, Cushing’s Syndrome, Deep Vein Thrombosis, Gastro-Oesophageal Reflux Disease, Polyarteritis Nodosa, Pulmonary Interstitial Fibrosis, Thromboangitis Obliterans, Thrombocytopaenic Purpura, Valvular Heart Disease, Zollinger-Ellison Syndrome

day-to-day benefit

Day-to-day expenses are covered from available funds in the Out-of-Hospital Expenses Benefit (OHEB) and Savings Account. Limits may apply when calculating certain claims for accumulation to Safety Net. These limits will also apply for refunds from OHEB and Safety Net
   maxima plus  maxima exec  maxima standard  maxima standard net  maxima basis
BENEFIT  LIMIT PER FAMILY PER YEAR    
 Tariff  Up to 100% of Fedhealth Rate    
 Co-payments in Safety Net  No co-payment  10% co-payment  20% co-payment  

Appliances, external accessories and orthotics

R12 000 per family per year before and after Safety Net.
Subject to OHEB*, Savings and Safety Net

R8 940 per family per year before and after Safety Net.
Subject to OHEB*, Savings and Safety Net

 

R8 940 per family per
year before and after
Safety Net.
Subject to OHEB* and
Safety Net

Alternative healthcare
Accupuncture, homeopathy,
naturopathy, osteopathy and
phytotherapy (including prescribed
medication)

  Subject to OHEB* and Savings. Does not accumulate to or pay from Safety Net   

Subject to OHEB*. 
Does not accumulate to or pay 
from Safety Net

Additional medical services
Audiology, dietetics, occupational
therapy, orthoptics, podiatry, psychologists, social workers and
speech therapy, etc

R13 400 per family per year before and after Safety
Net.
Subject to OHEB*, Savings and Safety Net

R8 940 per family per year before and after Safety Net.
Subject to OHEB*, Savings and Safety Net

R8 940 per family per year before and after Safety Net
Subject to OHEB* and
Safety Net

Dentistry (Advanced)
including oral surgery, osseo-
integrated implants, orthognathic
surgery and orthodontic treatment

R5 700 per beneficiary per year, R17 100 per family per year before and after Safety Net.
Subject to OHEB*, Savings and Safety Net

R5 700 per beneficiary
per year, R17 100 per
family per year before
and after Safety Net.
Subject to OHEB* and
Safety Net

Biokinetics, Chiropractics, Dentistry
(Basic), Radiology (General), Pathology
and Physiotherapy

  Subject to OHEB*, Savings and Safety Net. Unlimited once Safety Net is reached   

Subject to OHEB* and
Safety Net.
Unlimited once Safety
Net is reached

General Practitioners
- Fedhealth GP Partners

 Subject to OHEB* then unlimited from Risk     Subject to OHEB* then unlimited from Risk
 - Non-Fedhealth GP Partners  Subject to OHEB*, Savings and Safety Net. Unlimited once Safety Net is reached   

Subject to OHEB* and
Safety Net. Unlimited
once Safety Net is
reached
 Antenatal Scans

2 x 2D antenatal scans per year before and after Safety Net
Subject to OHEB*, Savings and Safety Net

2 x 2D antenatal scans
per year before and after
Safety Net.
Subject to OHEB* and
Safety Net

Optometry
Frames, single vision, bifocal,
multifocal or special lenses, lens
add-ons, contact lenses, readers
and optometric examinations

  

 

R2 560 per beneficiary per year, R7 760 per family per year before and after Safety Net.
Subject to OHEB*, Savings and Safety Net

   

R2 560 per beneficiary
per year, R7 760 per
family per year before
and after Safety Net
Subject to OHEB* and
Safety Net
 Over-the-counter medication  Subject to Savings only. Does not accumulate to or pay from Safety Net   

R405 per beneficiary per
year, R815 per family
per year before and after
Safety Net. Included in
Prescribed Medication
limits. Subject to OHEB*
and refund from Safety
Net. Does not accumulate
to Safety Net
 Prescribed medication

R7 600 per beneficiary per year, R15 200 per family per year before and after Safety Net.
Subject to OHEB*, Savings and Safety Net.

R7 600 per beneficiary
per year, R15 200 per
family per year before
and after Safety Net.
Subject to OHEB* and
Safety Net
 Radiology (Specialised)  Paid from the Major Medical Benefit if pre-authorised    

Specialists excluding psychiatrists
- Fedhealth Specialist Partners

  Subject to OHEB*, Savings and accumulation at cost to Safety Net. Unlimited at cost once Safety Net is reached   

Subject to OHEB* and
accumulation at cost to
Safety Net. Unlimited at
cost once Safety Net is
reached
- Non-Fedhealth Specialist Partners

Subject to OHEB*, Savings and Safety Net. Accumulation to Safety Net at Fedhealth Rate only. Unlimited at
Fedhealth Rate once Safety Net is reached

Subject to OHEB* and
Safety Net. Accumulation
to Safety Net at FR only. Unlimited at FR once
Safety Net is reached

Specialists: Psychiatrists
- Fedhealth Psychiatrist Partners

Subject to Additional Medical Services limit of
R13 400 per family before and after Safety Net. Subject
to OHEB*, Savings and accumulation at cost
to Safety Net

  Subject to Additional Medical Services limit of 
R8 940 per family before and after Safety Net. Subject 
to OHEB*, Savings and accumulation at cost 
to Safety Net

Subject to Additional
Medical Services limit of
R8 940 per family before
and after Safety Net.
Subject to OHEB* and
accumulation at cost to
Safety Net

-Non-Fedhealth Psychiatrist
Partners

Subject to Additional Medical Services limit of
R13 400 per family before and after Safety Net. Subject to OHEB*, Savings and Safety Net. Accumulation to and
refund from Safety Net at Fedhealth Rate only

Subject to Additional Medical Services limit of
R8 940 per family before and after Safety Net. Subject to OHEB*, Savings and Safety Net. Accumulation to and
refund from Safety Net at Fedhealth Rate only

Subject to Additional
Medical Services limit of R8 940 per family before and after Safety Net. Subject
to OHEB* and Safety
Net. Accumulation to and 
refund from Safety Net at
FR only
 SAFETY NET BENEFIT     

The Safety Net Benefit pays for certain day-to-day expenses once OHEB and Savings have been depleted and claims have accumulated up to the required level. The Safety Net level is reached through the accumulation of claims paid from OHEB, Savings and the member’s own pocket through the year at the Fedhealth Rate. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from Safety Net. A 20% co-payment will apply to all claims paid from the Safety Net Benefit on Maxima Standard and Basis and a 10% co-payment will apply to all claims paid from the Safety Net Benefit on Maxima Exec. No co-payment will apply to GP or specialist consultations in-network.

benefits unique to fedhealth

Because life is not always predictable, we are there with benefits that are about our members. We are talking about benefits that are practical and usable, ensuring that our members always get value for their money.
These benefits form the core of our philosophy of being Real. If you want to measure us for living up to our promise, then our unique benefits are the place to look. It’s what makes us stand out from the rest because they are mostly designed around one simple premise: ALLOWING MEMBERS TO SAVE MONEY.

We pay more from risk:
• Unlimited private hospitalisation
• Post-hospitalisation treatment for up to 30 days after discharge from hospital
• 7 days of take-home medication
• All specialised radiology like MRI and CT Scans
• Trauma treatment at a casualty ward whether admitted to hospital or not
• Monthly prescription for female contraceptives:
oral, patch and IUDs including Mirena®
• Contracted fixed rates at partner providers.

We add more value to every day:
• Child rates for financially dependent children up to 27 years of age
• Upgrade to a higher option any time of the year on diagnosis of a dread disease or in the case of a life-changing event
• Emergency medical transport anywhere in SA through Europ Assistance
• A Fedhealth Baby Programme that offers education, support, great give-aways and the support of a Doula during labour
• 24-Hour Fedhealth Nurseline
• Free trauma counselling for practical and emotional support
• Comprehensive HIV/AIDS and other disease management programmes.

maxima plus

(including OHEB and Savings)
   Risk  Savings  TOTAL

Annual
Safety Net*

Annual
OHEB

  

Annual
Savings

 Annual OHEB

Annual Day-
to-Day

Annual Safety
Net Level

Annual Self
Payment Gap
Member  4073  268  4 341  10 500  6 650

 M 

 M + AD

 M + AD + CD 

  3 216  6 650  9 866  10 500 634 
Adult Dependant 3465  227  3 692  8 010  4 810  5 940 11 460   17 400  18 510 1 110 
Child Dependant 1222  79  1 301   2 780  1 480  6 888  12 940  19 828  21 290 1 462

maxima exec

(including OHEB and Savings)
   Risk  Savings  TOTAL

Annual
Safety Net*

Annual
OHEB

  

Annual
Savings

 Annual OHEB

Annual Day-
to-Day

Annual Safety
Net Level

Annual Self
Payment Gap
Member  2352 206 2 558 8 500 4 570

 M 

 M + AD

 M + AD + CD 

 2 472 4 570 7 042 8 500 1 458
Adult Dependant 2004 175 2 179 6 500 3 570 4 572 8 140 12 712 15 000 2 288
Child Dependant 702 61 763 2 200 593 5 304 8 733 14 037 17 200 3 163

maxima standard

(including OHEB and Savings)
   Risk  Savings  TOTAL

Annual
Safety Net*

Annual
OHEB

  

Annual
Savings

 Annual OHEB

Annual Day-
to-Day

Annual Safety
Net Level

Annual Self
Payment Gap
Member  1880 175 2 055 8 500 3 520

 M 

 M + AD

 M + AD + CD 

 2 100 3 520 5 620 8 500 2 880
Adult Dependant 1602 149 1 751 6 500 2 550 3 888 6 070 9 958 15 000 5 042
Child Dependant 563 53 616 2 200 349 4 524 6 419 10 943 17 200 6 257

maxima standard Net 

(including OHEB and Savings)
   Risk  Savings  TOTAL

Annual
Safety Net*

Annual
OHEB

  

Annual
Savings

 Annual OHEB

Annual Day-
to-Day

Annual Safety
Net Level

Annual Self
Payment Gap
Member  1692  175  1 867  8 500  3 520

 M 

 M + AD

 M + AD + CD 

  2 100  3 520  5 620  8 500  2 880
Adult Dependant 1442  149  1 591  6 500  2 550  3 888  6 070  9 958  15 000  5 042
Child Dependant 507  53  560  2 200  349  4 524  6 419  10 943  17 200  6 257

maxima basis

(including OHEB and Savings)
   Risk  Savings  TOTAL

Annual
Safety Net*

Annual
OHEB

  

Annual
Savings

 Annual OHEB

Annual Day-
to-Day

Annual Safety
Net Level

Annual Self
Payment Gap
Member  1668  0  1 668  8 500  2 600

 M 

 M + AD

 M + AD + CD 

  0  2 600  2 600  8 500  5 900
Adult Dependant 1420  0   1 420  6 500  1 950  0  4 550  4 550  15 000  10 450
Child Dependant  503  0   503  2 200  265  0   4 815  4 815  17 200  12 385