We let you be YOU - Fedhealth

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We let you be YOU - Fedhealth
flexiFED 3 member guide
2020
                    We let you be YOU.
We let you be YOU - Fedhealth
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
We let you be YOU - Fedhealth
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
We let you be YOU - Fedhealth
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!

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We let you be YOU - Fedhealth
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
We let you be YOU - Fedhealth
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
We let you be YOU - Fedhealth
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

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We let you be YOU - Fedhealth
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
We let you be YOU - Fedhealth
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
We let you be YOU - Fedhealth
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 18
Cover 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 20
These 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 22
The
                       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 24
flexiFED 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 26
flexiFED 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 28
flexiFED 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)

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flexiFED 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.

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