major medical benefit
All costs for hospitalisation are covered from this benefit

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 300% of FR
Covered at 300% of FR

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

Covered at cost
Covered at 100% of FR
Covered at 300% of FR

Hospitalisation costs

Alternatives to hospitalisation

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

Oncology

- Specialised medication (also see opposite)

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

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

R333 000. Subject to 
Enhanced Protocols. DSP-ICON* above limit 
(See HPT)
R132 500 at cost

Organ transplant including immunosuppression medication
- Corneal graft

Unlimited (See HPT)
R15 900 per beneficiary

R333 000 (See HPT)
R15 900 per beneficiary

Prostheses
- Internal
- External

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

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

Renal Dialysis (chronic)
- Haemodialysis and peritoneal dialysis

co-payments

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

Arthroscopic procedures
Ankle, Hip, Knee, Shoulder, Wrist

Laparoscopic procedures
Appendectomy, Diagnostic, Hernia repairs (other than inguinal hernia repair), Nissen/ Toupey

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

ALL LIMITS ARE PER FAMILY PER YEAR UNLESS
OTHERWISE SPECIFIED

screening benefit

This benefit provides access to a number of screening and preventative programmes aimed at improving members’ health

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

Women; 50 to 70
Women; 21 to 65

1 every 3 years
1 every 3 years

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

Cardiac Health
Cholesterol screening (full lipogram)

All lives; older than 20

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

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

1 per lifetime
1 per lifetime
1 every 2 years

General
Flu vaccination

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

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

 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, etc

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

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

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

R5 580 per beneficiary per year, R11 200 per family per year before and after Safety Net (R1 230 sublimit per frame).
Subject to OHEB, Savings and Safety Net

General Practitioners

- Fedhealth GP Partners

- Non-Fedhealth GP Partners

Subject to OHEB* then unlimited from Risk

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

Subject to Savings

Subject to Savings

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

Subject to Savings only. Does not accumulate to or pay from Safety Net

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

Paid from the Major Medical Benefit if pre-authorised 

Specialists excluding psychiatrists

- Fedhealth Specialist Partners

- Non-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*, Savings and Safety Net. Accumulation to

Safety Net at Fedhealth Rate only. Unlimited at 
Fedhealth Rate once
Safety Net is reached

Subject to Savings

Subject to Savings

Specialists: Psychiatrists

- Fedhealth Psychiatrist Partners

- 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 accumulation at cost to Safety Net

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 Savings

Subject to Savings

SAFETY NET BENEFIT 

chronic disease benefit

Your medication for approved chronic diseases is covered from this benefit

R3 600 per beneficiary,
subject to an overall limit of R6 460 per family per year

In-benefit means that you have not exhausted your Chronic Disease Benefit. 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.

LIST 1. 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. Alzheimer’s Disease, Angina, Ankylosing Spondylitis, Anorexia Nervosa, Attention Deficit Disorder (in children only), Barrett’s Oesophagus, Benign Prostatic Hyperplasia, Bulimia Nervosa, Conn’s Syndrome, Cushing’s Syndrome, Cystic Fibrosis, Deep Vein Thrombosis, Depression, Dermatomyositis, Gastro-Oesophageal Reflux Disease, Generalised Anxiety Disorder, Gout, Hypoparathyroidism, Menopause, Motor Neuron Disease, Muscular Dystrophy, Myaesthenia Gravis, Narcolepsy, Obsessive Compulsive Disorder, Osteoporosis, Paget’s Disease, Pancreatic Disease, Panic Disorder, Paraplegia/Quadriplegia (associated medicine), Pemphigus, Polyarteritis Nodosa, Post-Traumatic Stress Syndrome, Pulmonary Interstitial Fibrosis, Scleroderma, Stroke, Thromboangitis Obliterans, Thrombocytopaenic Purpura, Tourette’s Syndrome, Valvular Heart Disease, Zollinger Ellison Syndrome

ultimax (including OHEB and Savings)

Annual Self
Payment Gap

ultima 300 (including OHEB and Savings)

Annual Self
Payment Gap

ultima 200 (including OHEB and Savings)