These are 2013 rates for Fedhealth Comprehensive Plans: Maxima Plus, Exec, Standard, StandardNet and Basis
major medical benefitAll costs for hospitalisation are covered from this benefit |
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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 |
Unlimited | ||
Healthcare Professional Tariff in hospital |
Covered at cost |
Covered at cost |
Covered at cost
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Prescribed Minimum Benefits (PMB) | Unlimited in state hospitals | ||||
Hospitalisation costs | Unlimited at negotiated tariff |
Unlimited at negotiated |
Unlimited at negotiated |
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Co-payments | See details on page 11 | ||||
Alternatives to hospitalisation |
Unlimited at negotiated tariff |
Unlimited at negotiated tariff.
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Ambulance services | Unlimited with Europ Assistance | ||||
Appliances, external accessories, orthotics, |
Unlimited at cost | ||||
Additional medical services (occupational |
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 |
Unlimited. Subject to |
Unlimited. Subject to |
R424 000. Subject to Standard Protocols. DSPICON*
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R243 000 at ICON*. |
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Organ transplant including immunosuppression |
Unlimited (See HPT) |
R333 000 (See HPT) |
R312 000 (See HPT)
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R243 000 (See HPT) |
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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 |
Various sub-limits apply |
Various sub-limits apply |
Various sub-limits apply
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Psychiatric services | R30 800 (See HPT) | R24 500 (See HPT) | R19 200 (see HPT) | ||
Renal Dialysis (chronic) |
Unlimited at FR | R333 000 at FR | R312 000 at FR | R243 000 at FR | |
Specialised medication (eg. biologicals) benefit |
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 |
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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 |
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Rhizotomies and facet pain block (limited to 1 |
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 |
No co-payment | R1 800 | |||
Hip, Wrist | No co-payment | R1 800 | Included in additional list below | ||
Laparoscopic procedures |
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- |
Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered |
screening benefitThis benefit provides access to a number of screening and preventative programmes aimed at improving members’ health |
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maxima plus | maxima exec | maxima standard | maxima standard net | maxima basis | ||
BENEFIT | CRITERIA | ALL LIMITS ARE PER BENEFICIARY | ||||
Women’s Health |
Women; |
1 every 3 years
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Children’s Health |
Various | Various | ||||
Cardiac Health |
All lives; older than 20 | 1 every 5 years | ||||
Geriatric Health |
All lives; |
1 per lifetime 1 every 2 years
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N/A | |||
General |
All lives | 1 every year |
maxima StandardNet hospitals |
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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 tableThis 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 |
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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 |
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Elbow replacement | R33 900 | R26 500 | R21 200 | R21 200 |
See combined benefit |
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Hip replacement | R33 900 | R26 500 | R21 200 | R21 200 |
See combined benefit |
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Knee replacement | R33 900 | R26 500 | R21 200 | R21 200 |
See combined benefit |
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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 |
*R27 500 | *R22 200 | *R19 000 |
chronic disease benefitMedication for approved chronic diseases is covered from this benefit |
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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 |
R4 340 per beneficiary, subject to an overall limit of
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Prescribed Minimum |
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IN-BENEFIT (Lists 1, 2 and 3 below) | IN-BENEFIT (List 1) | ||||
Conditions covered |
51 conditions |
39 conditions |
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. |
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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 LIST 2. (Maxima Plus, Exec and Standard): Ankylosing Spondylitis, Anorexia Nervosa, Attention Deficit Disorder (in children only), Bulimia Nervosa, Depression, Dermatomyositis, Generalised Anxiety 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 benefitDay-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 |
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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. |
R8 940 per family per year before and after Safety Net.
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R8 940 per family per |
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Alternative healthcare |
Subject to OHEB* and Savings. Does not accumulate to or pay from Safety Net |
Subject to OHEB*. |
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Additional medical services |
R13 400 per family per year before and after Safety |
R8 940 per family per year before and after Safety Net. |
R8 940 per family per year before and after Safety Net |
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Dentistry (Advanced) |
R5 700 per beneficiary per year, R17 100 per family per year before and after Safety Net. |
R5 700 per beneficiary |
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Biokinetics, Chiropractics, Dentistry |
Subject to OHEB*, Savings and Safety Net. Unlimited once Safety Net is reached |
Subject to OHEB* and |
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General Practitioners |
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 |
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Antenatal Scans |
2 x 2D antenatal scans per year before and after Safety Net |
2 x 2D antenatal scans |
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Optometry |
R2 560 per beneficiary per year, R7 760 per family per year before and after Safety Net.
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R2 560 per beneficiary |
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Over-the-counter medication | Subject to Savings only. Does not accumulate to or pay from Safety Net |
R405 per beneficiary per |
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Prescribed medication |
R7 600 per beneficiary per year, R15 200 per family per year before and after Safety Net. |
R7 600 per beneficiary |
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Radiology (Specialised) | Paid from the Major Medical Benefit if pre-authorised | ||||
Specialists excluding psychiatrists |
Subject to OHEB*, Savings and accumulation at cost to Safety Net. Unlimited at cost once Safety Net is reached |
Subject to OHEB* and |
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- Non-Fedhealth Specialist Partners |
Subject to OHEB*, Savings and Safety Net. Accumulation to Safety Net at Fedhealth Rate only. Unlimited at |
Subject to OHEB* and |
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Specialists: Psychiatrists |
Subject to Additional Medical Services limit of |
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 |
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-Non-Fedhealth Psychiatrist |
Subject to Additional Medical Services limit of |
Subject to Additional Medical Services limit of |
Subject to Additional |
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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) |
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Risk | Savings | TOTAL |
Annual |
Annual |
Annual |
Annual OHEB |
Annual Day- |
Annual Safety |
Annual Self |
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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) |
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Risk | Savings | TOTAL |
Annual |
Annual |
Annual |
Annual OHEB |
Annual Day- |
Annual Safety |
Annual Self |
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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) |
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Risk | Savings | TOTAL |
Annual |
Annual |
Annual |
Annual OHEB |
Annual Day- |
Annual Safety |
Annual Self |
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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) |
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Risk | Savings | TOTAL |
Annual |
Annual |
Annual |
Annual OHEB |
Annual Day- |
Annual Safety |
Annual Self |
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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) |
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Risk | Savings | TOTAL |
Annual |
Annual |
Annual |
Annual OHEB |
Annual Day- |
Annual Safety |
Annual Self |
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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 |