We let you be YOU - Fedhealth
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flexiFED 3 member guide
2020
We let you be YOU.
Medical aid control, flexibility
Contents and choice like never before.
Medical aid control, flexibility and 2 Cover for day-to-day expenses 19
choice like never before Day-to-day benefits paid by Fedhealth
Consultations with a network GP
Customised interaction with members 3
Treatment for 30 days after discharge from hospital
Fedhealth website
Take-home medicine
Fedhealth Family Room
Specialised radiology
LiveChat and chatbot
Trauma treatment at a casualty ward
FedChat instant messaging app
Female contraception
Network GP, specialist and hospital locator
In-hospital dentistry for children under 7
flexiFED 3 – flexible healthcare 5 Medical Savings Account
In-hospital benefit MediVault & Wallet Plans that fit to You select your Choice to reduce Don’t pay for We pay more
Chronic disease benefit Threshold benefit every life stage level of your monthly certain benefits till from risk
Day-to-day benefits Maternity benefit
day-to-day funds contribution by you need them
Threshold benefit Doula benefit for labour support during
Day-to-day benefits paid by the Scheme natural childbirth either 11% or 25% with our 30 day
Screening benefit Postnatal midwifery benefit on certain plans upgrade policy
Savings Early childhood benefits
Consultations with a paediatrician
More about Fedhealth’s hospital cover 7
Infant hearing screening benefit
Cover for hospital admissions
Childhood illness specialised drug benefit
Prescribed Minimum Benefits and how Boasting an 83-year track record, Fedhealth has a
Optometry benefits
Fedhealth covers them
Co-payments on certain procedures
Dentistry benefits solvency rate of 31.42% (as at 31 December 2018),
Treatment for emergencies These benefits show we really care 21 and a Global Credit Rating of AA-, retained for
24-hour Fedhealth Nurse Line AA-
Treatment for selected procedures 9 13 consecutive years.
Paed-IQ
in a day ward, day clinic or doctors’ rooms
Fedhealth Baby Programme
Chronic medicine benefit 11 Emotional wellbeing programme
Prescribed minimum benefit conditions Emergency transport/ response For us, it’s about making a tangible impact on our members’
Chronic disease benefit MediTaxi
Chronic disease list SOS Call Me healthcare by moving away from a one-size-fits-all
Medication for additional chronic conditions Upgrades within 30 days of a life-changing event approach, and embracing customisation.
The Medicine Price List Child rates for financially dependent children
Chronic conditions on the Chronic Disease List (CDL) up to the age of 27
Obtaining chronic medicine Only pay for three children
Fedhealth pays more benefits from Risk than other
Programmes and wellness initiatives 13 flexiFED 3 benefits 23
by Fedhealth The MediVault & Wallet schemes, with options to suit every life stage. Our
Corporate wellness days flexiFED option range myFED option caters for first time members, whilst the
Health Risk Assessments Day-to-day benefits paid from Risk
Sisters-on-Site Additional benefits maxiFED range gives comprehensive cover for total
Fedhealth Conservative Back and Neck Rehabilitation Maternity benefit
In-hospital benefit
peace of mind.
programme
Weight Management Programme Chronic disease benefit
GoSmokeFree smoking cessation programme Threshold benefit
Aid for AIDS (HIV management) Day-to-day benefit But the real magic happens on our revolutionary option
Paed IQ Contributions range, flexiFED. Here, members experience more
Diabetes Care Rate calculations SAVE
A proactive stance on health: 16 Contact details 37 11% / choice, flexibility and control. On these options
screening benefits 25% members can also select a discount. Either by paying
What about cancer? 17 11% less every month by choosing from over 100
Oncology Disease Management
Independent Clinical Oncology Network (ICON) network hospitals; or by paying 25% less every month
Chemotherapy and associated medicine by choosing to pay a R12 000 co-payment for every
Radiotherapy
Specialised medication planned hospital event.
Consultations and visits
Pathology
Radiology
General radiology Our members are individuals… with unique needs and wellness
Specialised radiology
PET scans journeys. For us it makes sense that their medical aid should be a
Surgery and hospitalisation
Stoma therapy little unique too.
Terminal care and private nursing
Post-active treatment
flexiFED 3 / PAGE 2
Customised interaction Fedhealth website
Recently redesigned, the sleek new Fedhealth website,
fedhealth.co.za, is a one-stop shop for all things
with members Fedhealth. From easy-to-navigate information on the
various Fedhealth options and events sponsored by the
Scheme like the Fedhealth MTB Challenge, to quick,
step-by-step instructions on how to submit claims,
Using the latest technology to our advantage, members can find it all here.
we employ the following platforms to enable
members to manage their Fedhealth
Fedhealth Family Room
membership and interact with us... Fedhealth’s online member portal has been designed to make
members’ interaction with the Scheme more hassle-free,
informative and rewarding. Here, members can:
• Manage their membership by updating contact details,
viewing and submitting claims, seeing how much Savings
they’ve got left, activating their MediVault and making
transfers to their Wallet, registering for chronic
medication and obtaining hospital authorisations.
• Join cool communities based on their interests
and/or life stage for great reads, valuable tips and
credible information on topics like parenting, nutrition
and financial fitness.
• Get rewards like complimentary coffees, discounts on
meals or even clothing discounts.
LiveChat and chatbot
LiveChat is a functionality that’s available to members
via the Fedhealth website. They can type in their queries
and one of our LiveChat agents will assist them online.
The Fedhealth chatbot can be used for all members’
queries about the MediVault and Wallet, and is also
accessed via the Fedhealth website.
FedChat instant messaging app
A free Instant Messenger channel for Apple, Android,
Blackberry and Windows Phone users.
Network GP, specialist and hospital locator
Members may access the provider locator via the Fedhealth
website or the Fedhealth Family Room to find a general
practitioner, specialist or hospital on the Fedhealth network.
Go to www.fedhealth.co.za/provider-locator
PAGE 3 / flexiFED 3 flexiFED 3 / PAGE 4
flexiFED 3 BENEFIT STRUCTURE
On flexiFED, members enjoy the following benefits:
Cover for young, still growing families • In-hospital benefit –Members have no overall annual
limit for hospitalisation.
• Chronic disease benefit – This benefit covers chronic
conditions on the CDL. It’s covered in full up to the
Medicine Price List if members use medicine on the
flexiFED 3 is the perfect plan for families with children and formulary and obtain it from either one of our Preferred
perhaps another baby on the way. Providers: Clicks, Dis-Chem, MediRite and Pharmacy
Direct or designated service providers: MediRite and
It provides sound in-hospital benefits, chronic benefits, Pharmacy Direct (and Clicks on flexiFED 1). Additional
conditions are covered on flexiFED 3 and flexiFED 4.
screening benefits, and day-to-day benefits, that include
a Threshold benefit, which kicks in once day-to-day • Day-to-day benefits – Day-to-day expenses on the
claims have accumulated to the Threshold level, flexiFED option range are first funded from any
provided all day-to-day claims have been submitted. available Savings the member might have. Once their
This means that certain claims like unlimited nominated Savings is depleted, day-to-day expenses can be paid
network GP visits will be paid from the Threshold benefit. from the Wallet once the member has activated their
MediVault and transferred funds to their Wallet.
flexiFED 3 offers rich maternity and childhood benefits paid Each of the flexiFED options has a Nominal Savings
from Risk to see your growing family through these exciting contribution. This allows members to transfer/retain
years. These include two antenatal scans and 12 ante- and any accumulated Savings from a previous option/
postnatal consults with a midwife, network GP and gynae, scheme when joining a flexiFED option. Any member on
paediatric consultations without referral up to 24 months a flexiFED option can also top up this Savings Account
at any time up to a maximum annual amount of 25% of
old, and childhood illness specialised drug benefit up to
their gross contribution. Any claim submitted which is
18 years old. not payable from Risk will be funded from the member’s
Savings Account first.
On flexiFED 3, you can also choose flexiFED 3GRID
and save 11% on your monthly contributions by •Threshold benefit
using network hospitals only, or choose flexiFED On flexiFED 1, 2 and 3, the Threshold benefit pays for limited
day-to-day expenses once claims have accumulated to the
3Elect and save 25% on your monthly contribution
Threshold level.
by choosing to pay a R12 000 co-payment for On flexiFED 4 the Threshold benefit pays for comprehensive
planned procedures at any private hospital. day-to-day expenses once claims have accumulated to the
Threshold level.
On this option you have access to a
MediVault and Wallet facility, a • Day-to-day benefits paid by the Scheme –We pride
ourselves on paying more from Risk so the members’
predetermined amount available for your
day-to-day benefit lasts longer.
day-to-day medical expenses, which
you only start paying back over a • Screening benefit – Preventative screenings and as-
12-month or shorter period once you sessments like lifestyle screenings, wellness screenings
start using it. (includes finger prick glucose and total cholesterol,
blood pressure, waist circumference and body mass
index (BMI) and physical screenings are covered from
this benefit.
• Savings –The funds in the member’s Medical Savings
Control, customisation and Account (MSA) will be used first when he or she has
day-to-day medical expenses.
choice like never before!
PAGE 5 / flexiFED 3 flexiFED 3 / PAGE 6
Fedhealth has appointed our network specialists,
network GPs, network hospitals and three Designated
Service Provider pharmacies, Clicks, MediRite group
of pharmacies located in Checkers and Shoprite
supermarkets and Pharmacy Direct, a courier
pharmacy for the provision of PMBs. If a DSP is a
requirement on your option, a 40% co-payment will
More about apply if a DSP is not used. Members must make use of a
Fedhealth network specialist and a nominated network
GP in order for the cost to be refunded in full.
Fedhealth’s hospital cover Should the member not use these DSPs for the treatment
of a PMB condition, the Scheme will reimburse treatment
at the non-network rate. Co-payments are applicable to
the voluntary use of non-DSPs. Referral must be obtained
from a Fedhealth Network GP for consultations with
Fedhealth Network Specialists. If referral is not obtained,
We pay for unlimited private there will be a co-payment on specialist claims paid from
the Risk benefit. The co-payment depends on your option.
hospitalisation!
Please note: Qualification for reimbursement as a PMB is
not based solely on the diagnosis (condition), but also on
All our options have an unlimited in-hospital benefit. Prescribed Minimum Benefits and how Fedhealth the treatment provided (level of care). This means that
Members must obtain pre-authorisation for all planned covers them although a member’s condition may be a PMB condition,
hospital admissions and in the case of an emergency Prescribed Minimum Benefits or PMBs refer to a basic the Scheme would only be obliged to fund it in full if the
admission, they must obtain authorisation within two level of cover for a defined set of conditions. treatment provided was deemed to be PMB level of care.
working days after going to hospital.
By law, all medical schemes are required to cover Co-payments on certain procedures
The in-hospital benefit covers hospital costs as well the treatment of 270 hospital-based conditions and For some treatments and procedures, members must
as the accounts from doctors, specialists e.g. the anaes- 27 chronic conditions, i.e the Chronic Disease List (CDL), pay an amount out of their own pocket. This is called a
thetist and other healthcare providers like the x-ray de- in full without co-payment or deductibles, as well as co-payment. Co-payments apply to the hospital account
partment. any emergency treatment and certain out-of-hospital and/or certain procedures, depending on the option.
treatment.
This benefit also covers selected procedures performed Treatment for emergencies
in day wards, day clinics and doctors’ rooms. On certain This means that all schemes must provide PMB level To qualify as an emergency, the condition must be
options, members must use day clinics on the Fedhealth of care at cost for these conditions. The Medical Schemes unexpected and require immediate treatment. (This
Day Clinic Network. Act 131 of 1998 allows schemes to require members means that if there is no immediate treatment, the
to make use of Designated Service Providers (DSPs) condition might result in lasting damage to organs, limbs
Cover for hospital admissions in order for a member to be entitled to funding in or other body parts, or even in death). If the member
We cover the hospital account from the in-hospital full. Schemes may also apply formularies – a list of is on a network hospital option, treatment of an
benefit. Specialists and GPs who are on the Fedhealth medicines which should be used to treat PMBs, and emergency medical condition may take place at any
network are covered in full. Specialists and GPs who are managed care protocols – based on evidence-based hospital, but once their condition has stabilised and they
not on the Fedhealth network, are covered up to the medicine and cost-effectiveness principles to manage this can be safely transferred to a network hospital, the
Fedhealth Rate. benefit. co-payment will apply if they opt not to be transferred.
Referral by a medical practitioner and pre-authorisation
is required for physical therapy (physiotherapists),
which is covered up to the Fedhealth Rate.
PAGE 7 / flexiFED 3 flexiFED 3 / PAGE 8
Treatment for ENT Urological Gastroscopy (no general
Nasal polypectomy Circumcision anaesthetic will be paid for)
Antrostomy Vasectomy Colonoscopy (no general
selected procedures Nasal cautery
Deep proof puncture
Ethmoidectomy
Cystoscopy diagnostic or with
urethral dilation
Orchidopexy
anaesthetic will be paid for)
Flexible sigmoidoscopy
Indirect laryngoscopy
in a day ward, Nasal and sinus endoscopy
Drainage of sinuses
Turbinectomy
Other
Removal of impacted wisdom
teeth
Excision of superficial benign
day clinic or
Intravenous administration of
Tonsillectomy with adenoidectomy tumours
bolus injections for medicines
younger than 12 years of age Gastroscopy
Myringotomy and grommets that include antimicrobials and
doctors’ rooms
Colonoscopy
Drainage of ear abscess Immunoglobulins (payment of
Fibreoptic sigmoidoscopy
Removal of foreign bodies Paediatric rigid sigmoidoscopy immunoglobulins is subject to the
Nasal plugging for epistaxis Breast biopsy Specialised Medication Benefit)
Endoscopic retrograde Fine needle aspiration biopsy
Gynaecological cholangiopancreatography (ERCP) Excision of nailbed
The following procedures will be paid from the in-hospital Bartholin cyst excision Bronchoscopy Drainage of abscess or cyst
benefit if done in a day clinic, day ward or an outpatient section Dilation and curettage (D & C) Hernia repair (unilateral inguinal Injection of varicose veins
of a hospital. Please note that some may incur a procedure Polypectomy and femoral) Excision of superficial benign
co-payment. Overnight admissions will not be covered except Hysteroscopy Drainage of superficial abscesses tumours
Diagnostic laparoscopy Surgical extraction of impacted
for Prescribed Minimum Benefits. Superficial foreign body removal
Laparoscopic sterilisation wisdom teeth and multiple dental
Nasal plugging for epistaxis
Cone biopsy extractions
These procedures must be pre-authorised. If the procedure is Cauterisation of warts
Cauterisation of cervix Apicectomy
performed without pre-authorisation, the full amount will be Bartholin cyst excision
Cauterisation of warts Superficial wound debridement
paid from the Savings account or self-funded by the member Colposcopy Minor perianal surgery
and will not accumulate towards the Threshold level.
Stripping of varicose veins
Orthopaedic Hickman line insertion or a-port
If authorisation is requested after the procedure has taken Arthroscopy diagnostic with line insertion
place, there will be a R1 000 penalty that will be paid from the meniscectomy, with debridement Superficial foreign body removal
Savings account or self-funded by the member, and will not Carpal tunnel release Excision of ingrown toenail
accumulate to the Threshold level. Ganglion excision
Removal of small hardware (plates,
k-wires, screws) Procedures performed in a
Bunionectomy (unilateral) doctor’s rooms or suitably
Epidural block equipped procedure room
Intra-articular hydrocortisone
injection The following procedures will be
We cover certain procedures Tennis elbow release paid from the in-hospital benefit
if performed in a doctor’s room or
unlimited from the hospital Ophthalmic suitably equipped procedure room,
benefit if done in a day ward, Cataract extraction
Lens implant
up to 100% of the Fedhealth Rate.
Pre-authorisation must be obtained
day clinic or doctors’ rooms! Meibomian cyst excision and should no pre-authorisation
Pterygium excision take place, reimbursement will be
Dacryocystorhinostomy restricted to the member’s availa-
ble Savings account or self-funded
by the member. This will not accu-
mulate to the Threshold Level:
flexiFED 3 / PAGE 10
Additional chronic conditions covered on this option Obtaining chronic medicine
Acne (up to the age of 21) Members can obtain their chronic
medicine from any of our preferred
Chronic medicine
Allergic rhinitis (up to the age of 18)
provider pharmacies. These
Attention Deficit Hyperactivity Disorder (from 6 to the age of 18) preferred provider pharmacies
Depression ensure price certainty for members
benefit Eczema (up to the age of 18)
Generalised Anxiety Disorder
when obtaining medication.
Fedhealth’s preferred providers are
the MediRite group
Post-Traumatic Stress Disorder
of pharmacies located in Checkers
and Shoprite supermarkets,
Dis-Chem, Clicks and Pharmacy
Prescribed Minimum Benefit conditions Direct, a courier pharmacy.
You have a benefit for the 27 chronic conditions on We provide unlimited Members may use any pharmacy,
the Prescribed Minimum Benefit Chronic Disease List however if a dispensing fee in
(CDL). The benefit covers medication for the list of CDL
chronic medication excess of 25%/R25 is charged,
the member will have to pay the
conditions paid from a formulary and must be obtained cover for PMBs! difference.
from either the DSP or a preferred provider, depending
on the option.
Chronic conditions on the Chronic Disease List
Chronic Disease Benefit (CDL)
This benefit covers the conditions on the CDL. Some Addison’s Disease
options cover additional conditions. Asthma
Option upgrades
Bipolar Mood Disorder any time of
Chronic Disease List Bronchiectasis the year within
Conditions on the Chronic Disease List are covered in full, Cardiac Failure
provided members use either the Scheme’s designated Cardiomyopathy
30 days of
service providers or preferred providers (depending COPD/ Emphysema/ Chronic Bronchitis diagnosis of a
on the option) as well as medicine on the formulary Chronic Renal Disease
dread disease.
applicable to their option. If the DSP or medicine on the Coronary Artery Disease
formulary are not used, the member will have to pay a Crohn’s Disease
40% co-payment on the cost of the medicine. Diabetes Insipidus
Diabetes Mellitus Type-1
Medication for additional chronic conditions Diabetes Mellitus Type-2
This option covers medicine for additional chronic Dysrhythmias
conditions. The medicine for these conditions is paid Epilepsy
from an annual limit and will be covered in full up to the Glaucoma
Medicine Price List rate. Haemophilia
HIV
The Medicine Price List Hyperlipidaemia
Medication will be covered at the Medicine Price List Hypertension
(MPL) rates up to the limits as specified on the chosen Hypothyroidism
option. MPL is a reference price list that benchmarks Multiple Sclerosis
each product against generically similar products. It does Parkinson’s Disease
not restrict the member’s choice but limits the amount Rheumatoid Arthritis
that the Scheme will refund for each product. The MPL Schizophrenia
reference price is set at a level to ensure that a number Systemic Lupus Erythematosus
of medicines will be available without any co-payment. Ulcerative Colitis
PAGE 11 / flexiFED 3 flexiFED 3 / PAGE 12
Programmes and wellness
initiatives by Fedhealth
These benefits are funded from Risk and does not affect members’ Savings/Wallet:
Corporate wellness days
Corporate wellness days provide the opportunity to create awareness, education, prevention, GoSmokeFree Smoking Cessation Programme
screening and targeted interventions that support positive lifestyle changes. These days are Fedhealth is encouraging members who smoke to sign up for the GoSmokeFree service that’s
well-received, as it is convenient for Fedhealth members to have these services at their place available at 200 pharmacies countrywide, including Dis-Chem, Clicks, Pick n Pay and independent
of work. In addition to the clinical value that can be derived from wellness days, they provide pharmacies. All smokers have a yearly benefit for the GoSmokeFree programme which is payable
Fedhealth with the opportunity to market the Scheme to clients and potential clients. from risk benefits. The service comprises a pre-quit assessment and support sessions and features
an individual plan to help with smoking cessation. Visit gosmokefree.co.za to find out more about
Health Risk Assessments this benefit.
This benefit aims to identify members who are at risk of developing lifestyle diseases, and either
help them prevent the onset through suitable lifestyle interventions, or help them manage their Aid for AIDS (HIV Management)
disease with practical advice and utilisation of Scheme benefits. A Health Risk Assessment can be Fedhealth offers the Aid for AIDS (AfA) programme to help members who are HIV-positive
requested at participating pharmacies and BASA registered biokineticists. manage their condition. The benefits of being on the programme (over and above the payment
of the necessary medicine and pathology claims), include clinical and emotional support with the
Sisters-on-Site utmost confidentiality.
Fedhealth partnered with SOS Corporate Wellness (Sisters-on-Site) to offer a nursing Sister-on-Site
at our members’ workplaces. With the employer’s influence, we aim to identify and address the Paed IQ
organisation’s specific areas of concern. By helping members change their behaviour patterns and Paed IQ is a 24/7 telephone advisory service available to all parents with children under the age of
choose healthier lifestyles, we aim to reduce healthcare expenditure (particularly on day-to-day 14 years. This service aims to support and advise parents on any healthcare related childcare issues.
utilisation), absenteeism, turnover rates, worker’s compensation claims and tardiness. Call 0860 444 128 to access this great service.
Fedhealth Conservative Back and Neck Rehabilitation Programme Diabetes Care
Fedhealth has an established intervention for members suffering from back and neck problems. We provide members with diabetes access to a comprehensive programme that is tailored to
Built on the principle of active muscle reconditioning, it’s supported by clinical studies showing their needs and other chronic conditions they might have. This includes continued access to
that exercise reduces pain and can normalise function in many instances. The programme a treating doctor, authorised chronic medication, blood and laboratory tests, a Health Coach,
takes a comprehensive and holistic approach to chronic back and neck pain and offers online tools and information to empower the member. Members can call 0860 002 153 or email
individualised treatment to qualifying members. After an initial assessment, beneficiaries receive diabeticcare@fedhealth.co.za
treatment twice a week for six weeks and a home based protocol for long-term care.
Email backandneck@fedhealth.co.za for more information about the programme.
Weight Management Programme
The Weight Management Programme is an intervention expertly designed for qualifying
Fedhealth members with a high BMI and waist circumference. Members participate in a
12-week, biokineticist-led intervention plan that gives them access to a dietician and psychologist
with the goal to lose the excess weight and lead healthier, more rewarding lives. Once the
programme is completed, ongoing advice and monitoring is available for continued support. Email
weightmanagement@fedhealth.co.za for more information. This benefit is available every two years.
PAGE 13 / flexiFED 3 flexiFED 3 / PAGE 14
A proactive stance on health:
screening benefits
Packed with screenings for every life stage, Fedhealth’s screening benefit was created to stretch members’ day-to-day
benefit by paying more from Risk. The Scheme pays for screenings for women’s, children’s, cardiac, as well as general
health (like an annual flu vaccine).
Screening benefit
This benefit covers the tests and assessments done to help members either prevent illness or address specific
conditions they may already have.
Women’s Health
Cervical cancer screening (Pap Women; ages 21 to 65 1 every 3 years
smear)
Men’s Health
Prostate Specific Antigen (PSA) Men; ages 45 to 69 1 every year
Children’s Health
Immunisation Programme (as per Birth to 12 years Various
State EPI)
Cardiac Health
Cholesterol screening All lives; aged 20 and older 1 every 5 years
(full lipogram)
Over 45’s
Breast cancer screening with All lives; aged 45 and older 1 every 3 years
mammography
Colorectal cancer screening (faecal All lives; ages 50 to 75 1 every year
occult blood test)
Pneumococcal vaccination All lives; aged 65 and older 1 per lifetime
General
Flu vaccination All lives 1 every year
HIV finger prick test by a contracted All lives 1 every year
wellness network provider
Health risk assessments
Wellness screening (BMI, blood All lives 1 every year
pressure, finger prick cholesterol &
glucose tests)
Preventative screening All lives 1 every year
(waist-to-hip ratio, body fat %,
flexibility, posture & fitness)
PAGE 15 / flexiFED 3 flexiFED 3 / PAGE 16
Radiotherapy Stoma therapy
What about Radiotherapy will be paid from the oncology
benefit, provided a valid authorisation has been
Stoma therapy will be paid from Risk. Pre-authorisation is
not required.
obtained. The treating doctor must submit a
cancer? treatment plan to Oncology Disease Management.
Once treatment has been authorised, the member and
doctor will be sent an authorisation letter.
Terminal care and private nursing
Accommodation in a hospice or terminal care facili-
ty for the care of patients in terminal stage of life will be
covered from the Terminal Care Benefit covered up to
Specialised medication R32 300 per family per year. Pre-authorisation must
Oncology Disease Management On flexiFED 3, oncology is covered up to R290 400 per fam- There is no specialised medication benefit on this option. be obtained from the Hospital Authorisation Centre.
Fedhealth supports cancer patients in their time of ily per year at the designated service provider, ICON, subject Private nursing will be paid from the Alternatives to
need, and diagnosed members are encouraged to to Level 1 treatment protocols. A 40% co-payment applies Consultations and visits Hospitalisation benefit, where this is available.
where a DSP provider is not used. Oncologist consultations and hospital visits are paid from
register on the Fedhealth Oncology Programme by
the oncology benefit while the member has either an ac- Post-active treatment
calling 0860 100 572. The Scheme offers all members
tive chemotherapy or radiotherapy authorisation. Prior to Post-active refers to the time when the member actually
the opportunity to change to a higher option within Independent Clinical Oncology Network (ICON)
starting treatment, consultations are paid from the Savings had last active treatment (e.g., hormone therapy,
30 days of a life-changing event or diagnosis. This The Scheme has contracted with ICON for the provision
Account/ Wallet . Hospital visits are pre-authorised at the chemotherapy or radiotherapy). “For life” means that the
ensures that those with cancer can get access to of active oncology treatment. ICON is a network of
same time as the authorisation for chemotherapy or radia- member will remain on the oncology programme as long
medication that will help them to remain economically oncologists that includes 75% of all practicing oncologists in
tion treatment.You will receive an authorisation letter de- as the cancer is in remission. Whilst in remission, a list of
active, with all the support they require to deal with South Africa. To find an ICON network specialist, call 0860
tailing the number of visits authorised and the period for appropriate consultation, radiology and pathology
this stressful diagnosis. 002 153.
which these visits are authorised. codes has been defined and claims for these services are
automatically paid for life from the oncology benefit. Should
We require a clinical summary of each member’s
Chemotherapy and associated medicine
Chemotherapy and medicine directly associated with
Pathology the condition regress, the active treatment benefit will be
case: this must contain the history, ICD–10 codes, the Oncology-related pathology claims are paid from the reinstated upon submission of a new treatment plan.
the treatment of cancer will be paid from the oncolo-
clinical findings of the doctor, as well as the test oncology benefit while the member is receiving treatment
gy benefit, provided a valid authorisation has been ob-
results confirming the cancer and the specific type (either chemotherapy or radiotherapy), provided that the
tained. The treating doctor must submit a treatment plan to
of cancer. The proposed treatment plan must be member has a valid authorisation. A list of appropriate
Oncology Disease Management, cancerinfo@fedhealth.
submitted so that the oncology team can approve the pathology codes has been defined and claims for these
co.za. Once treatment has been authorised, the mem-
appropriate therapy. Our caring agents will guide the services are automatically paid from the oncology benefit
ber and doctor will receive an authorisation letter. Treat-
member through the process. (i.e. a separate pre-authorisation is not required).
ment for conditions not directly related to the treatment of
the cancer (e.g. depression) as well as treatment for the
Members can access the oncology benefit by obtaining long-term conditions that may develop as the result of
Radiology
pre-authorisation from a staff member within the chemotherapy or radiotherapy, will be funded from an
Oncology Disease Management team. The team General radiology
alternative benefit (i.e. the Chronic Disease Benefit or the Sav-
comprises a number of highly skilled healthcare General oncology-related radiology claims are paid from
ings Account/ Wallet.
the oncology benefit while the member is receiving
professionals who work in conjunction with the
treatment (either chemotherapy or radiotherapy),
treating doctor to ensure that treatment provided is
provided that the member has a valid authorisation. A list of
both clinically appropriate and cost-effective. A set
appropriate radiology codes has been defined and claims
of cancer guidelines and protocols are used during
the pre-authorisation process. These guidelines are At Fedhealth you can for these services are automatically paid from the oncology
benefit (i.e. a separate pre-authorisation is not required).
continually updated as new products are launched
and new treatment protocols established. In addition, upgrade your option Specialised radiology
our team is supported by a number of oncologists and
haematologists from the private, public and academic
any time of the year on Specialised radiology (e.g. CT scans, MRIs, angiography,
radioisotopes) requires a separate pre-authorisation.
sectors. diagnosis of cancer. These pre-authorisations must be obtained from the
Authorisation Centre. Specialised radiology is paid from
Risk. A co-payment of R2 300 for non-PMB MRI/CT scans
will apply.
PET scans
PET scans are limited to two per family per annum
restricted to staging of malignant tumours. PET scans are
paid from the oncology benefit.
Surgery and hospitalisation
Claims for surgery and hospitalisation will be paid from the
in-hospital benefit, provided that the member obtains a
valid authorisation from the Authorisation Centre.
PAGE 17 / flexiFED 3 flexiFED 3 / PAGE 18Cover for +
Threshold benefit
To access the Threshold benefit, members need to submit all day-to-day
claims to accumulate to the Threshold level. All day-to-day expenses
day-to-day expenses accumulate to the Threshold level at cost. Thereafter, certain claims will be
paid from the Threshold benefit. These include basic dentistry and unlimited
nominated network GP visits.
Maternity benefit
Here is a breakdown of the different ways in which we cover We pay for antenatal scans, antenatal classes, an amniocentesis as well as 12
day-to-day expenses, depending on the option: ante- and postnatal
consultations with a midwife, network GP and gynaecologist.
Paid from
Doula benefit for labour support during natural childbirth Risk and not
Day-to-day benefits paid by Fedhealth We pay up to R3 000 per delivery for a Doula (natural labour coach).
At Fedhealth, we pride ourselves on the fact that we cover more from Risk than any other medical schemes,
day-to-
to help our members’ day-to-day benefits last even longer. Postnatal midwifery benefit day
We pay for four consultations per pregnancy with a midwife. This benefit
a. Consultations with a network GP applies to consultations both in- and out-of-hospital. benefits
Members can see their GP as often as they need once their Threshold level has been reach by visiting a
nominated network GP. Early childhood benefits
a. Consultations with a paediatrician
We cover b. Treatment for 30 days after discharge from hospital
We pay for follow-up treatment that may be required after a hospital event for up to 30 days after the date We pay for one consultation per child up to 24 months with a network pae-
more from of discharge. This treatment includes physiotherapy, x-rays and pathology, but does not cover follow-up diatrician without referral from a GP.
consultations with specialists or GPs.
Risk so b. Infant hearing screening benefit
We pay for a screening test from birth up to the age of 8 weeks with an
day-to-day c. Take-home medicine
We pay for seven days of take-home medication when the member is discharged from hospital. The audiologist. This benefit is covered up to the Fedhealth Rate.
benefits medication must be dispensed by the hospital and must reflect on the original hospital account.
c. Childhood illness specialised drug benefit
last longer! d. Specialised radiology We pay for specialised drugs for children up to 18 years old.
We pay for MRI/ CT scans whether they are performed in- or out-of-hospital. A co-payment of R2 300 applies
for non-PMB MRI/ CT scans. Optometry benefits
We pay for a comprehensive consultation and one pair of single vision or bi-
e. Trauma treatment at a casualty ward focal lenses and a frame up to R210 per beneficiary every 24 months. These
We pay for emergency treatment, like stitches, at a casualty ward. Whether the member is admitted benefits are provided by an optometrist in the Iso Leso optical network.
to hospital or not, authorisation must be obtained within 48 hours and a co-payment of R600 per visit for
non-PMBs applies. Dentistry benefits
Paid from Savings/ Wallet or self-funded. Once the Threshold level has been
f. Female contraception reached, the following benefits will be paid from the Threshold benefit: two
We pay for female contraception including oral, patches, contraceptive rings, certain injectables, and IUDs annual consultations per beneficiary incl. x-rays, scaling and polishing, fill-
that include Mirena®. It must be prescribed by a GP or gynaecologist and is not applicable to pills prescribed ings, extractions and root canal. Subject to contracted dentists and limited
for acne. to a list of approved procedures, dental tariff codes and protocols.
g. In-hospital dentistry for children under 7
We pay for dentistry performed in-hospital for children up to the age of 7. The hospital account and
anaesthetist costs are paid from the in-hospital benefit while the dentist’s account comes from day-to-day
benefits.
Medical Savings Account
The Savings Account pays for day-to-day expenses first (from the beginning of the year) and pays
expenses up to the actual cost. In some cases, if the member has money available in their Savings
Account, they can use this to pay co-payments. However, a co-payment for a Prescribed Minimum Benefit
(PMB) condition cannot be paid from the Savings Account. The Savings Account works differently to other
benefits in that the member carries any remaining amount over to the next year.
MediVault & Wallet
Once the Savings Account runs out, the member will either have to pay for all their day-to-day
medical expenses out of their own pocket or they can access their MediVault. On the flexiFED op-
tions, members are allocated money for day-to-day medical expenses available in their personal Medi-
Vault. This amount is based on their family composition, and is not pro-rated, i.e. even if they only join in
August, they’ll have the same amount available as they would have in January. To access these funds, they
can transfer it, in full upfront, or in part as needed, to their Wallet.
PAGE 19 / flexiFED 3 flexiFED 3 / PAGE 20These benefits 24-hour Fedhealth Nurse Line
Our professional nurses are always on the
other end of the line to provide advice on
MediTaxi
MediTaxi is a medical taxi service available
to Fedhealth members who’ve had hospital
show we really care issues like medical emergencies, symptoms,
medication side-effects, stress management
and teenage support.
authorisations in Cape Town, Johannesburg,
Pretoria and Durban. Members can access
the 24/7 MediTaxi benefit to take them to
follow-up doctor’s appointments, if they’ve
Paed-IQ undergone an authorised operation or
A South African based medical information medical treatment that prevents them from
company that provides information and driving. Limited to two return trips per
services to parents and caregivers that member/ beneficiary per annum.
enhance the level of care they can offer their
children. SOS Call Me
Fedhealth’s user-friendly call back service
Fedhealth Baby Programme free to all Fedhealth members and their
Free baby goodies, support and advice for dependants. Members can select three
all parents-to-be. Pregnant members or options on the service: 1. Emergency Medical
dependants receive a Fedhealth baby bag Services (EMS), 2. Nurse Line and 3. MediTaxi.
filled with baby product samples, discount
vouchers and a baby handbook. They also Upgrades within 30 days of a
have access to professional advice when they life-changing event
need it. Members can upgrade to a higher option
with better benefits ANY time of the year in
Emotional wellbeing programme the case of marriage of the main member,
Available to all Fedhealth members and pregnancy or the diagnosis of a dread disease
beneficiaries, our emotional wellbeing within 30 days of the life-changing event
programme provides telephonic advice and taking place. Some dread diseases that qualify
support to help members deal with issues like include: cancer, renal failure, multiple sclerosis,
Giving our members more stress at work, relationship issues, bullying at diabetes, stroke, neurological disorders, HIV/
value and support when school and teenage troubles. AIDS, cardiac conditions, Parkinson’s disease,
Alzheimer’s disease, Amyotrophic lateral
they need it. Following these telephonic sessions, we sclerosis (ALS) a.k.a. motor neurone disease.
can also put the member in touch with a
psychologist for one-on-one sessions at a Child rates for financially dependent
reduced rate, should they need it. Plus, we’ll children up to the age of 27
send the member useful communications Fedhealth charges child rates for financially
about financial, legal and trauma advice. This dependent children up to the age of 27. This
life coaching/ lifestyle wellness service is run means that student dependants pay rates
by a care centre and is available, night or day, applicable to children, as long as they’re
via the telephone, email, SMS and a call-back unmarried and not earning more than the
facility. maximum social pension.
Emergency transport/ response Only pay for three children
Through our partner Europ Assistance, The Scheme only charges for three child
we provide all members with emergency dependants, the fourth and subsequent
transport. children are covered for free.
PAGE 21 / flexiFED 3 flexiFED 3 / PAGE 22The
MediVault & Wallet
Members are allocated funds for day-to-day medical expenses available in their personal MediVault. This amount is
based on their option and family composition, and is not pro-rated, i.e. even if they only join in August, they’ll have the
same amount available as they would have in January. To access these funds, members can transfer it, in full upfront,
or in increments of R600, to their Wallet. Members only have to pay back the money that has been transferred from
their MediVault to their Wallet – over a period of 12 months, e.g. from April 2020 to April 2021. Members may also
choose a shorter repayment term.
How much is in the MediVault flexiFED 3
M R10 800
M+1 R16 200
M+2 R21 600
M + 2+ R25 200
How does the MediVault and Wallet work?
12
An allocated amount based on your Transfer funds from the MediVault to your Only pay back amounts
option and family composition will Wallet as and when required. transferred from the MediVault
be available in your MediVault. If Claims for day-to-day expenses will be paid to Wallet over a rolling
you don’t use it, you don’t pay for. it from your Wallet. 12-month or shorter period.
What if members prefer the traditional medical savings account system?
If members prefer the traditional medical savings account system, they can either:
Transfer their chosen amount Transfer only a portion of Or make the choice not to use
into their Wallet at the beginning their MediVault funds as they the facility at all and save on
of the year, which means they need it, meaning they pay less. their monthly contribution.
will pay more or less the same OR OR
amount they did before when
Savings was still included in their
contribution.
Activating the MediVault and transferring funds into the Wallet
Members can do so in three ways:
1 2 3
Call the Fedhealth Customer Login to the Fedhealth Family Call our USSD line on
Contact Centre on 0860 002 153 Room online member portal *134*999*memberno#
for assistance. and follow the prompts. and follow the prompts.
PAGE 23 / flexiFED 3 flexiFED 3 / PAGE 24flexiFED 3 day-to-day benefits paid from Risk
At Fedhealth, we pride ourselves on paying more from Risk, so the member’s day-to-day
benefit lasts longer.
Paediatric consultations
This benefit covers one consultation per beneficiary with a network paediatrician up to 24 months
of age. No GP referral required.
Unlimited network GP visits
Members on flexiFED 3 get unlimited consultations at a nominated Fedhealth Network GP once Optometry
the Threshold level has been reached. Each beneficiary can nominate up to two network GPs. This benefit covers one comprehensive consultation per beneficiary, one pair single vision or
bifocal lenses per beneficiary, frame per beneficiary (use Savings/ Wallet for enhanced frame)
Limited to two mental health consultations per beneficiary, per year. Up to two network GP con-
R210 per beneficiary every 24 months. Optical benefits provided by an Optical Network Provider.
sultations per beneficiary for non-nominated GPs allowed per year (referred to as
out-of-area); OR two non-network GP consultations per beneficiary up to the Fedhealth Rate.
Dentistry benefits
Paid from Savings/ Wallet or self-funded. Once the Threshold level has been reached, the following
Maternity benefits will be paid from the Threshold benefit: two annual consultations per beneficiary incl. x-rays,
This benefit covers two x 2D scans, antenatal classes up to R1 090, scaling and polishing, fillings, extractions and root canal. Subject to contracted dentists and limited to
12 ante and/ or postnatal consultations with a midwife, network GP or gynaecologist, amniocentesis. a list of approved procedures, dental tariff codes and protocols.
Post-hospitalisation treatment benefit
Fedhealth Baby Programme
For up to 30 days after discharge from hospital, we cover follow-up treatment like physiotherapy,
We offer a free maternity programme for pregnant members and beneficiaries offering support,
x-rays or pathology.
advice and a handy baby bag.
Take-home medicine benefit
Doula benefit We pay for seven days of take-home medication after discharge from hospital – provided the
We cover R3 000 for a doula or labour coach per delivery during natural childbirth. medication is dispensed by the hospital and reflects on the original hospital account.
Postnatal midwifery benefit Specialised radiology benefit
We give members four consultations with a midwife in- and out-of-hospital per pregnancy. Unlimited at Fedhealth Rate. First R2 300 for each non-PMB MRI/ CT scan for member’s own
account.
Infant hearing screening benefit
Trauma treatment at a casualty ward
We provide newborns up to the age of eight weeks with one test with an audiologist up to the
We cover trauma treatment at a casualty ward whether the member is admitted to hospital or not.
Fedhealth Rate.
Unlimited up to the Fedhealth Rate. A co-payment of R600 per visit for non-PMBs applies.
Paed-IQ Female contraception benefit
Paed-IQ is a telephonic paediatric advice line for members with children up to the age of Oral, patches, contraceptive rings, certain injectables as well as IUDs that include Mirena are
fourteen. covered from Risk. These must be prescribed by a GP or gynaecologist, and are not applicable to
oral contraceptives prescribed for acne.
PAGE 25 / flexiFED 3 flexiFED 3 / PAGE 26flexiFED 3 additional benefits flexiFED 3 maternity benefit
Only the best will do for mothers and babies on Fedhealth! That’s why
we pride ourselves on providing rich maternity benefits across our
Additional valuable benefits that give members more support. flexiFED option range… so parents-to-be can focus on the joy of
their pregnancy journey, while we take care of the rest.
Fedhealth Nurse Line Aid for AIDS (HIV Management) Here are some of the maternity and childhood benefits members can expect
Members can access our 24-hour toll-free Fedhealth offers the Aid for AIDS (depending on the option):
line manned by professional nurses for their programme to help members who are
medical and related queries. HIV-positive manage their condition. Maternity benefits
• Two x 2D antenatal scans
Emotional Wellbeing Programme Diabetes Care • Twelve ante- and postnatal consultations with a midwife, network GP
We provide 24-hour telephonic support to This programme supports members with or gynaecologist
get members through life’s ups and downs, Diabetes by providing them with access • Antenatal classes up to R1 090
with the option to refer them to psychologists to a treating doctor, medication and blood • Amniocentesis
at reduced rates. tests to name a few. • Fedhealth Baby Programme – a free programme for all expecting
beneficiaries offering support, advice and a free Fedhealth baby bag filled
Emergency transport/ response MediTaxi with baby goodies
We provide emergency transport through A transport service for members who need • Private ward cover for delivery
follow-up medical visits following a hospital • Doula benefit – we offer R3 000 per delivery for a doula (birthing coach)
Europ Assistance to assist our members in
to assist mom during natural childbirth
an emergency situation. authorisation.
• Postnatal midwifery benefit – we provide four consultations per delivery
with a midwife in- and out-of-hospital
Comprehensive managed care SOS Call Me
programmes A USSD call-back service that enables
Great childhood benefits
We offer various programmes for members Fedhealth members to access Emergency
• Paed-IQ online parenting hub – free access to a 24/7 paediatric telephonic
with specific healthcare needs: Medical Services (EMS), the Fedhealth Nurse advice line
Line or MediTaxi. • Paediatric consultations – without referral from a GP up to 24 months of
Weight Management Programme age
Fedhealth designed our 12-week Upgrades within 30 days of a • Infant hearing screening benefit – we offer one test from birth up to the
biokineticist-led Weight Management life-changing event age of eight weeks with an audiologist up to the Fedhealth Rate.
Programme for qualifying Fedhealth Our members can upgrade to a higher • Childhood immunisations – immunisation from birth up to 12 years as
members with a high BMI and waist option within 30 days of the diagnosis of a per the state EPI
circumference. Access to a dietician and dread disease or pregnancy. • Trauma treatment in a casualty ward – we cover emergency
behavioural psychologist is also available. treatment, like stitches, in a casualty ward, whether the member is
This benefit is available every two years. Child rates for financially dependent admitted to hospital or not. Authorisation must be obtained and
children up to the age of 27 a co-payment of R600 applies for non-PMBs
Conservative Back & Neck Rehabilitation Provided they’re unmarried and don’t earn • Childhood illness specialised drug benefit up to 18 years old
Programme more than the maximum social pension. • Child rates up to the age of 27 – financially dependent
This programme aims to help members with children up to 27 are covered under child rates, provided they
back and neck issues avoid spinal surgery Only pay for three children don’t earn more than the maximum social pension
through active muscle reconditioning. Fedhealth covers fourth and subsequent • Only pay for three children – we cover fourth and
children for free. subsequent children for free
Oncology disease management
Appliances
We provide comprehensive care for
We pay for breast pumps and nebulisers from the member’s
members with cancer.
Savings/ Wallet provided they have a NAPPI code. This will
accumulate to Threshold up to the appliances, external acces-
GoSmokeFree Smoking Cessation See page 71 for contact details
sories and orthotics limit.
Programme
All members who are smokers have access
once per beneficiary per annum to have the
GoSmokeFree consultation paid from Risk.
PAGE 27 / flexiFED 3 flexiFED 3 / PAGE 28flexiFED 3 in-hospital benefit flexiFED 3 in-hospital benefit
In-hospital benefit flexiFED 3
This benefit covers all treatments and procedures that have to be done in a hospital and that is covered by the flexiFED Dentistry
options. Surgical extraction of impacted wisdom teeth You pay a co-payment of R4 400 on the hospital bill
In-hospital dentistry benefit for children under 7 We cover the hospital and anaesthetist costs from the
flexiFED 3 in-hospital benefit. The dentist account will be paid
from Savings/ Wallet or self-funded
Overall annual limit (OAL) Unlimited at negotiated tariff
Oncology: oncologist consultations, visits, treatment and R290 400 at designated service provider* and paid from
Healthcare Professional Tariff in hospital (HPT)
materials for chemotherapy and radiotherapy, approved Level 1 treatment protocols. A 40% co-payment applies
Fedhealth Network GPs and Specialists Covered unlimited. Paid in full. medication, radiology and pathology where a DSP provider is not used
Non-network GPs Paid up to Fedhealth Rate Organ transplant including immunosuppression R290 400 (See HPT)
Non-network Specialists Paid up to Fedhealth Rate medication
Other Healthcare Professionals Paid up to Fedhealth Rate Corneal graft No benefit
Prescribed Minimum Benefits (PMB): Treatment for To have the treatment for PMB conditions covered Pathology, radiology (general) Unlimited at Fedhealth Rate
PMB conditions can be funded in two ways: in full, you will have to use Fedhealth Network GPs, Physiotherapy Subject to referral by a medical practitioner,
Specialists, Hospitals and DSPs where applicable. pre-authorisation and treatment protocols
Should you choose not to make use of network Psychiatric services: accommodation in a general ward, R26 200 (see HPT)
providers, the Scheme will only refund treatment up procedures, ECT, materials and hospital equipment,
to the Fedhealth Rate and you will have a co-payment consultations and visits, medicines and injection material
should the healthcare professional charge more
Renal dialysis (chronic): consultations, visits, all services, R290 400 up to the Fedhealth Rate at Designated
Hospitalisation costs: accommodation in a general Unlimited at negotiated tariff. Private ward cover for materials and medicines associated with the cost of renal Service Provider (DSP). A 40% co-payment applies where
ward, high care ward and intensive care unit, theatre maternity admissions dialysis a DSP provider is not used
fees, medicine, material and hospital apparatus
Childhood illness specialised drug benefit (up to the age Childhood illness specialised drug benefit for children up
Additional medical services (dietetics, occupational Paid from Savings/ Wallet or self-funded of 18) to the age of 18
therapy and speech therapy)
Specialised radiology Unlimited at Fedhealth Rate. First R2 300 for non-PMB
Alternatives to hospitalisation: MRI/ CT scans for the member’s account
Nursing services, private nurse practitioners & nursing Unlimited at negotiated tariff Spinal surgery No benefit unless Conservative Back & Neck
agencies Rehabilitation Programme has been completed. Member
Sub-acute facilities, physical rehabilitation facilities Unlimited at cost up to PMB level of care pays a co-payment of R6 500 on the hospital bill
Appliances, external accessories and orthotics Paid from Savings/ Wallet or self-funded Terminal care benefit R32 300 at Fedhealth Rate
Blood, blood equivalents and blood products Unlimited *Designated Service Provider (DSP) is ICON - Independent Clinical Oncology Network
Immune deficiency related to HIV infection Unlimited (see HPT)
Maternity - Healthcare Professional Tariff in-hospital (HPT)
Fedhealth Network GPs and Specialists Covered unlimited. Paid in full.
(e.g. Gynaecologists & Paediatricians)
Non-network GPs Paid up to Fedhealth Rate
Non-network Specialists Paid up to Fedhealth Rate
Other Healthcare Professionals Paid up to Fedhealth Rate
Maxillo-facial surgery Unlimited, subject to approval (see HPT)
PAGE 29 / flexiFED 3 flexiFED 3 / PAGE 30flexiFED 3 co-payments flexiFED 3 in-hospital benefit & chronic disease benefit
Co-payments Prosthesis benefit
Co-payments may apply on certain in-hospital procedures, which will be for the member’s account. Under this benefit, we cover internal and external prosthesis.
flexiFED 3 flexiFED 3
Co-payments per event applicable on the hospital/ facility bill only External R12 100 at cost
Internal
Adenoidectomy, back & neck procedures, bunion No co-payment
procedures and conservative admissions, diagnostic Aorta Stent Grafts R61 100
cystoscopy, gastritis/ dyspepsia/ heartburn, nasal Bone lengthening devices, carotid stents, embolic See combined benefit limit for all unlisted internal
procedures, skin biopsy/ excision protection devices, other approved spinal implantable prosthesis*
devices and intervertebral discs, peripheral arterial
All open hernia surgery R4 400 stent grafts, spinal plates and screws
Arthroscopic procedures - knee, shoulder, ankle and R8 200 Cardiac pacemakers, cardiac stents, cardiac valves Unlimited at cost at PMB level of care
other Detachable platinum coils R52 900
Arthroscopic procedures: hip R8 200 Elbow, hip, knee and shoulder replacement See combined benefit limit for all unlisted internal
Arthroscopic procedures: wrist R8 200 prosthesis*
Total ankle replacement No benefit
Balloon sinuplasty No benefit
Intraocular lenses (per lens) R3 300
Colonoscopy, upper GI endoscopy R4 400 * Combined benefit limit for all unlisted internal prosthesis R26 100
Dental admissions No co-payment
Hysterectomy (unless for cancer) R3 800 Chronic disease Benefit
Inguinal hernia sugery R4 400 Cover for conditions that require long-term medication or can be life-threatening.
Joint replacements
flexiFED 3
Single hip and knee replacements with CP* No co-payment
Limit Unlimited cover for conditions on the CDL plus allergic
Single hip and knee replacements- voluntary non-use R27 400 rhinitis, acne and eczema. Attention Deficit Hyperactivity
of CP* Disorder, Depression, Generalised Anxiety Disorder,
Other joint replacements and involuntary non-use of R6 500 Post-Traumatic Stress Disorder subject to a limit of
CP* for single hip and knee replacements R3 000 per family
Laparoscopic hernia repairs (bilateral inguinal, repeated R6 500 Formulary Intermediate formulary
inguinal hernias & Nissen/ Toupet hernia repairs only), Preferred Provider MediRite, Dis-Chem, Clicks & Pharmacy Direct
laparoscopic procedures, spinal surgery**
Laparoscopic varicocelectomy R6 500
Rhizotomies and facet pain blocks (limited to 1 of No benefit
either procedure per beneficiary per year)
Surgical extraction of impacted wisdom teeth R4 400
Tonsillectomy
Under the age of 12 No co-payment
12 and over No co-payment
Varicose vein procedures R4 400
*Contracted Provider: Must use ICPS or JointCare for single non-PMB hip and knee joint replacements. Non-use of Contracted Provider (CP)
will result in co-payment.
** No benefit unless Conservative Back & Neck Rehabilitation Programme has been completed.
PAGE 31 / flexiFED 3 flexiFED 3 / PAGE 32You can also read
