2021 maxiFED - Your Health and Actuarial Consulting ...
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maxiFED 20 21
maxiFED
The maxiFED range
has been designed to
offer mature couples,
families and individuals
a comprehensive
medical aid solution that
provides ample cover
for members with a
demanding lifestyle,
or who are in their
later years. These
options leave very little
to chance.
Contents Comprehensive cover,
Comprehensive cover, complete peace of mind 2 Specialised radiology
complete peace of mind
PET scans
@FedhealthMed at your service 3 Surgery and hospitalisation
Fedhealth website Stoma therapy
Fedhealth Family Room Terminal care and private nursing
LiveChat and chatbot Post-active treatment
Fedhealth Member App
Fedhealth WhatsApp bot These benefits show we really care 19
Network GP, specialist and hospital locator 24-hour Fedhealth Nurse Line
Paed-IQ
maxiFED comprehensive healthcare 5 Fedhealth Baby Programme
In-hospital benefit Emotional wellbeing programme
Chronic disease benefit Emergency transport/ response Plans for every Generous in-hospital, Don’t pay for certain We pay more
Threshold MediTaxi
life stage chronic, screening and benefits till you need from Risk
Day-to-day benefits from Risk SOS Call Me
Screening benefit Upgrades within 30 days of a day-to-day benefits them with our 30-day
Out-of-Hospital Expenses Benefit (OHEB) life-changing event upgrade policy
Savings Child rates for financially dependent
Additional benefits children up to the age of 27
Only pay for three children
Unlimited private hospital cover for peace of mind 7
Cover for hospital admissions Cover for day-to-day expenses 21
Prescribed Minimum Benefits and how Fedhealth Unlimited network GP consultations Boasting an 84-year track record, Fedhealth Medical
covers them Treatment for 30 days after discharge from hospital
Co-payments on certain procedures (post-hospitalisation benefit) Scheme has a solvency rate of 43.43% (as at 31 December
Treatment for emergencies Take-home medicine 2019), and a Global Credit Rating of AA-, retained for
Specialised radiology AA-
Day clinic/ doctor’s room procedures 9 Trauma treatment at a casualty ward 14 consecutive years.
covered from the in-hospital benefi Female contraception
In-hospital dentistry for children under 7
A closer look at our chronic 11 Medical Savings Account
medicine benefit OHEB
Prescribed minimum benefit conditions Threshold benefit Our financial health and expertise aside, it’s our philosophy
Chronic disease benefit Maternity benefit
Chronic disease list Doula benefit of being run ‘by members for members’ that helps us really
Medication for additional chronic conditions Postnatal midwifery benefit put our members first in everything we do.
The Medicine Price List Early childhood benefits
Chronic conditions on the Chronic Disease List (CDL) Fedhealth Baby Programme
covered on all options Paed-IQ
Additional chronic conditions Fedhealth pays more benefits from Risk than other
Obtaining chronic medicine Additional benefits 25 schemes, to help our members’ day-to-day savings last
Comprehensive managed care programmes
Programmes and wellness initiatives by Fedhealth 13 - Weight Management Programme longer. Some of these valuable benefits include unlimited
Corporate wellness days - Conservative Back & Neck Rehabilitation Programme
Health Risk Assessments - Oncology disease management network GP visits, as well as seven days’ take-home
Sisters-on-Site - Mental Health Programme
medication following a hospital stay, and trauma
Fedhealth Conservative Back and - GoSmokeFree Smoking Cessation
Neck Rehabilitation programme - Programme treatment at a casualty ward whether you’re admitted
Mental health programme - Aid for AIDS (HIV Management)
Weight management programme - Diabetes Care to hospital or not.
GoSmokeFree smoking cessation programme
Aid for AIDS (HIV management) In-hospital benefit 26
Paed-IQ Our maxiFED range comprising maxima EXEC and
Diabetes Care Co-payments & chronic disease benefit 29
maxima PLUS gives comprehensive cover that affords
A proactive stance on health: screening benefits 15 Day-to-day benefit 30
members total peace of mind.
Examining our cancer cover 17 Contributions 33 These options are structured to provide generous
Oncology disease management
Independent Clinical Oncology Network (ICON) maxiFED rate calculations 34 in-hospital, screening and chronic cover, and
Chemotherapy and associated medicine
Contact details 35
day-to-day cover, through a Medical Savings
Radiotherapy
Specialised medication Account (MSA), a Threshold benefit and an
Consultations and visits
Pathology Out-of-Hospital Expenses Benefit (OHEB) (the
Radiology
General radiology latter on maxima PLUS only).
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Fedhealth website
@FedhealthMed The Fedhealth website, fedhealth.co.za, provides easy-to-navigate
information on the various Fedhealth options, step-by-step
instructions on how to submit claims etc., Scheme news, and also
at your service hosts the informative Living Fedhealthy blog – filled with lifestyle
and wellness topics.
Fedhealth Family Room
Fedhealth’s online member portal makes members’ interaction
with the Scheme more hassle-free, informative and rewarding.
Here, members can:
Using the latest technology to our advantage,
we employ the following platforms to enable • Manage their membership by updating contact details, viewing
and submitting claims, seeing how much Savings they’ve
members to manage their Fedhealth got left, registering for chronic medication and obtaining
membership and interact with us... hospital authorisations.
LiveChat and chatbot
LiveChat is a functionality that’s available to members via
fedhealth.co.za. 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 and is also
accessed through fedhealth.co.za
Fedhealth Member App
Our app has been designed to help simplify your interaction with
Fedhealth. Available from the Google Play Store and Apple App
store, it lets you download your e-card, view your option’s
benefits, and set medication reminders, to name but a few.
Fedhealth WhatsApp bot
This Fedhealth service is completely private and secure, and
easy to use – simply choose from self-service actions like getting
your tax certificate or seeing your e-card to share with your GP.
To get started, just add the number 060 070 2479 as a contact
and then type ‘hi’ to get the conversation started, from your
mobile device.
Network GP, specialist and hospital locator
Members may access the provider locator via the Fedhealth
website or the Fedhealth Family Room to find a GP, specialist or
hospital on the Fedhealth network. Go to www.fedhealth.co.za/
provider-locator
maxiFED 2021 l 4
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3 3 / myFED
l maxiFED 2021
maxiFED
Comprehensive healthcare BENEFIT STRUCTURE
On maxiFED, members enjoy the following benefits:
• In-hospital benefit – No overall annual limit for hospitalisation.
Our maxima EXEC and maxima PLUS options give members • Chronic disease benefit – Members are covered for conditions on the
the peace of mind that most of their healthcare needs will Chronic Disease List (CDL). Covered in full up to the Medicine Price
be met. This range leaves nothing to chance, with ample List if the member uses medicine on the comprehensive formulary
and obtains it from one of our Preferred Providers: Clicks, Dis-Chem,
in-hospital, chronic, screening and day-to-day cover covered
MediRite and Pharmacy Direct.
by the Risk benefit, as well as value-added additional benefits.
In addition, it also features a Medical Savings Account for • Threshold – The Threshold benefit pays for comprehensive day-to-day
day-to-day expenses and a Threshold benefit. maxima PLUS expenses once claims have accumulated to the Threshold level.
also has an Out-of-Hospital Expenses Benefit (OHEB). Please
see the following pages for more detail on the maxiFED Risk • Day-to-day benefits from Risk – We provide comprehensive
day-to-day benefits on maxiFED, like unlimited Fedhealth Network GP
benefits and what they offer members.
visits, once the Savings is depleted.
• Screening benefit – This benefit pays for lifestyle screenings,
wellness screenings like finger prick glucose and total cholesterol,
blood pressure, waist circumference and body mass index (BMI),
and physical screenings.
• Out-of-Hospital Expenses Benefit (OHEB) – This benefit covers
day-to-day expenses, after the Savings Account has run out of funds,
up to the Fedhealth Rate until the benefit limit is reached. There are
maximum amounts for specific treatments and conditions.
• Savings – The funds in the member’s Medical Savings Account (MSA)
will be used first when he or she has day-to-day medical expenses.
• Additional benefits – Members can enjoy lots of additional valuable
benefits like the free Fedhealth Nurse Line, emotional wellbeing
programme and MediTaxi.
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Unlimited private All our options have an unlimited in-hospital benefit.
Members must obtain pre-authorisation for all planned
Fedhealth has appointed our network specialists,
network GPs, network hospitals and Designated
hospital admissions and in the case of an emergency Service Provider pharmacies, Clicks, Dis-Chem,
hospital cover admission, they must obtain authorisation within two
working days after going to hospital.
MediRite group of pharmacies located in Checkers
and Shoprite supermarkets, Pharmacy Direct,
Dis-Chem Direct and Clicks Direct Medicines, courier
for peace of mind The in-hospital benefit covers hospital costs as well as the
accounts from doctors, specialists e.g. the anaesthetist
and other healthcare providers like the x-ray department.
pharmacies for the provision of PMBs. Members must
make use of a Fedhealth network specialist and a
nominated network GP in order for the cost to be
refunded in full.
This benefit also covers selected procedures performed
in day wards, day clinics and doctor’s rooms. Should the member not use these DSPs for the treatment
of a PMB condition, the Scheme will reimburse treatment
Cover for hospital admissions at the non-network rate. Co-payments are applicable to
We cover the hospital account from the in-hospital the voluntary use of non-DSPs. Referral must be obtained
benefit. Specialists and GPs who are on the Fedhealth from a Fedhealth Network GP for consultations with
network are covered in full. Specialists and GPs who are Fedhealth Network Specialists. If referral is not obtained,
not on the Fedhealth network, are covered up to the there will be a co-payment on specialist claims paid from
Fedhealth Rate. the Risk benefit. The co-payment depends on your option.
Referral by a medical practitioner and pre-authorisation Please note: Qualification for reimbursement as a PMB is
is required for physical therapy (physiotherapists), not based solely on the diagnosis (condition), but also on
which is covered up to the Fedhealth Rate. the treatment provided (level of care). This means that
although a member’s condition may be a PMB condition,
Prescribed Minimum Benefits and how Fedhealth the Scheme would only be obliged to fund it in full if the
covers them
We pay for Prescribed Minimum Benefits or PMBs refer to a basic
treatment provided was deemed to be PMB level of care.
unlimited level of cover for a defined set of conditions. Co-payments on certain procedures
For some treatments and procedures, members must
private By law, all medical schemes are required to cover pay an amount out of their own pocket. This is called a
the treatment of 270 hospital-based conditions and co-payment. Co-payments apply to the hospital account
hospitalisation! 27 chronic conditions, i.e the Chronic Disease List (CDL), and/or certain procedures, depending on the option.
in full without co-payment or deductibles, as well as
any emergency treatment and certain out-of-hospital Treatment for emergencies
treatment. To qualify as an emergency, the condition must be
unexpected and require immediate treatment. (This
This means that all schemes must provide PMB level means that if there is no immediate treatment, the
of care at cost for these conditions. The Medical Schemes condition might result in lasting damage to organs, limbs
Act 131 of 1998 allows schemes to require members or other body parts, or even in death).
to make use of Designated Service Providers (DSPs)
in order for a member to be entitled to funding in
full. Schemes may also apply formularies – a list of
medicines which should be used to treat PMBs, and
managed care protocols – based on evidence-based
medicine and cost-effectiveness principles to manage this
benefit.
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Gynaecology Injection of tendon/ligament/ Oral and Maxillofacial Surgery
Bartholin cyst - drainage/excision/ trigger points/ganglion cyst Apisectomy
marsupialisation Injection therapeutic carpal tunnel Frenectomies
Cauterization of warts Insertion or removal of K wires or Gingival Graft
Cervical cerclage other internal fixatives Implantology
Day clinic/ doctor’s Colposcopy
Fine needle aspiration - cytology
LETZ of cervix
Radical nail bed removal
General Surgery
Orthodontic Attachment
Pulpotomy and fillings
Wisdom or Impacted
room procedures
Dilatation and Curettage Anal dilatation/Anoscopies/ Teeth removal
Endometrial ablation fissures and fistula repair Extractions
Hysteroscopy Breast biopsy/ removal lump
Insertion of IUD (Intra-uterine Colonoscopy Plastic and Reconstructive
covered from the Device)
Labiaplasty
Drainage of abscesses/
haematomas/cysts
(subcutaneous/submucosal)
Surgery
Repair wound with layers (scalp/
axillae/trunk/limbs
in-hospital benefit Urology - Adults
Bilateral total orchidectomy for
prostate cancer
Excision lipoma/cysts/tumours
Excision of sweat glands (axilla/
inguinal) and simple repair
Repair wound lesions (scalp/
hands/neck/feet/face)
Excision of benign lesions (scalp/
Bladder biopsy (cancer and other Gastroscopy/ neck/hands/feet/trunk/limbs)
conditions) oesophagogastroduodenoscopy Excision of malignant lesions
Bouginage for urethral stricture Haemorrhoidectomy (+ flap if required)
Circumcision Inguinal hernia repair
The following procedures will be paid from the in-hospital Cystoscopy & ureteral dilation Lymph node/muscle/skin/bone Procedures performed in a
benefit if done in a day clinic, day ward or an outpatient section
DJ stent removal post pyeloplasty and breast biopsy doctor’s rooms or suitably
Hydrocelectomy for vaginal Proctoscopy and removal equipped procedure room
of a hospital. Please note that some may incur a procedure hydrocoele of polyps
co-payment. Overnight admissions will not be covered except Inguinal hernia repair Resection/debridement of multiple The following procedures will be
for Prescribed Minimum Benefits. Open cystolithotomy for nails (6 plus) paid from the in-hospital benefit
bladder stone Sigmoidoscopy if performed in a doctor’s room or
Prostate biopsy (cancer and Umbilical hernia repair suitably equipped procedure room,
These procedures must be pre-authorised. If the procedure is other conditions) Wound debridement (skin/ up to 100% of the Fedhealth Rate.
performed without pre-authorisation, the full amount will be Renal calculus removal & subcutaneous tissue) Pre-authorisation must be obtained
paid from the Savings account or self-funded by the member stent insertion and should no pre-authorisation
Scope and pyelogram ENT Surgery take place, reimbursement will be
and will not accumulate towards the Threshold level.
Second stage urethroplasty Adenoidectomy restricted to the member’s
post stage 1 Antrostomy available Savings account or
If authorisation is requested after the procedure has taken Testicular biopsy for infertility Diathermy to nose and pharynx self-funded by the member.
place, there will be a R1 000 penalty that will be paid from the Urethrocystoscopy for bladder (under LA) This will not accumulate to the
outlet obstruction DPP (Diagnostic Proof Puncture) Threshold Level:
Savings account or self-funded by the member, and will not
Varicocelectomy for varicocele ENT Endoscopy Gastroscopy (no general
accumulate to the Threshold level. Vasectomy Middle ear procedures anaesthetic will be paid for)
Vasostomy (mastoidectomy, tympanoplasty/ Colonoscopy (no general
stapedectomy) anaesthetic will be paid for)
Urology - Paediatrics Myringotomy (including aspiration Flexible sigmoidoscopy
Circumcision for intact prepuce and incision) and/or grommets Indirect laryngoscopy
Glandulo-cavernous shunt for Nasal bleeds (control) Removal of impacted
priapism Reduction of nose fracture wisdom teeth
Hydrocelectomy for congenital Rhinoplasty Intravenous administration of
hydrocoele Septoplasty bolus injections for medicines
Meatotomy for meatal stenosis Sinus related surgery that include antimicrobials and
Orchidopexy for undescended (ethmoidectomy/sinusotomy and Immunoglobulins (payment of
testis lavage) immunoglobulins is subject to the
We cover Urethrocystoscopy for urinary Tonsillectomy Specialised Medication Benefit)
incontinence Turbinectomy Fine needle aspiration biopsy
certain procedures Tympanoplasty Excision of nailbed
unlimited from Orthopaedics
Arthrocentesis Ophthalmology
Drainage of abscess or cyst
Injection of varicose veins
the hospital benefit Arthrodesis of hand/elbow/foot
Arthroscopy
Cataract surgery
Foreign body removal
Excision of superficial benign
tumours
if done in a day Arthrotomy of finger/hand/elbow/
knee/hip/toe
Intra ocular injection e.g. Avastin,
including Glaucoma
Superficial foreign body removal
Nasal plugging for epistaxis
ward, day clinic or Aspiration/intra-articular injection Laser Surgery Cauterisation of warts
of joints Posterior and Anterior Vitrectomy Bartholin cyst excision
doctor’s room! Bunionectomy Probing & repair of tear ducts
Carpal Tunnel release Pterygium (conjunctiva)
Cast/application removal Removal of pterygium
Ganglionectomy Strabismus repair
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Additional chronic conditions covered on these options Obtaining chronic medicine
Acne (up to the age of 21) maxima PLUS, maxima EXEC
Members can obtain their chronic
Allergic rhinitis (up to the age of 18) maxima PLUS, maxima EXEC,
medicine from any of our preferred
Alzheimer’s Disease maxima PLUS provider pharmacies. These
Angina maxima PLUS, maxima EXEC preferred provider pharmacies
ensure price certainty for members
Ankylosing Spondylitis maxima PLUS, maxima EXEC,
when obtaining medication.
A closer look Anorexia Nervosa
Attention Deficit Hyperactivity
maxima PLUS, maxima EXEC
maxima PLUS, maxima EXEC, Fedhealth’s preferred providers are
the MediRite group of pharmacies
at our chronic
Disorder (from 6 to the age of 18)
located in Checkers and Shoprite
Barrett’s Oesophagus maxima PLUS, maxima EXEC
supermarkets, Dis-Chem, Clicks
We provide unlimited Benign Prostatic Hyperplasia maxima PLUS and Pharmacy Direct, a courier
medicine benefit chronic medication
cover for PMBs!
Bulimia Nervosa
Conn’s Syndrome
maxima PLUS, maxima EXEC
maxima PLUS, maxima EXEC
pharmacy. Members may use any
pharmacy, however if a dispensing
fee in excess of 25%/R26.50 is
Cushing’s Syndrome maxima PLUS, maxima EXEC charged, the member will have to
Cystic Fibrosis maxima PLUS pay the difference.
Prescribed Minimum Benefit conditions Deep Vein Thrombosis maxima PLUS, maxima EXEC
Medicine for HIV and AIDS must
All options have a benefit for the 27 chronic conditions Depression maxima PLUS, maxima EXEC be obtained from Pharmacy Direct
on the Prescribed Minimum Benefit Chronic Disease List otherwise a 40% co-payment will
Dermatomyositis maxima PLUS, maxima EXEC
(CDL). The benefit covers medication for the list of CDL apply.
Eczema (up to the age of 18) maxima PLUS, maxima EXEC,
conditions paid from a formulary and can be obtained Chronic conditions on the Chronic Disease
from a preferred provider. Gastro-Oesophageal Reflux Disease maxima PLUS, maxima EXEC
List (CDL) covered on both options
Generalised Anxiety Disorder maxima PLUS, maxima EXEC
Addison’s Disease
Chronic Disease Benefit Gout maxima PLUS
Asthma
This benefit covers the conditions on the CDL. These
Bipolar Mood Disorder Hypoparathyroidism maxima PLUS
options cover additional conditions.
Bronchiectasis Menopause maxima PLUS
Chronic Disease List Cardiac Failure Motor Neuron Disease maxima PLUS
Conditions on the Chronic Disease List are covered in Cardiomyopathy
Muscular Dystrophy maxima PLUS
full, provided members use the Scheme’s preferred COPD/ Emphysema/ Chronic Bronchitis
Myasthenia Gravis maxima PLUS
providers as well as medicine on the comprehensive Chronic Renal Disease
formulary. If medicine on the formulary is not used, the Narcolepsy maxima PLUS, maxima EXEC
Coronary Artery Disease
member will have to pay a 40% co-payment on the cost Crohn’s Disease Obsessive Compulsive Disorder maxima PLUS, maxima EXEC
of the medicine. Diabetes Insipidus Osteoporosis maxima PLUS
Diabetes Mellitus Type-1 Paget’s Disease maxima PLUS
Medication for additional chronic conditions
Diabetes Mellitus Type-2 Pancreatic Disease maxima PLUS
These options cover medicine for additional chronic
Dysrhythmias
conditions. The medicine for these conditions is paid Panic Disorder maxima PLUS, maxima EXEC
Epilepsy
from an annual limit and will be covered in full up to the Paraplegia/ Quadriplegia maxima PLUS, maxima EXEC
Glaucoma (associated medicine)
Medicine Price List rate.
Haemophilia
Pemphigus maxima PLUS
The Medicine Price List HIV
Polyarteritis Nodosa maxima PLUS, maxima EXEC
Medication will be covered at the Medicine Price List Hyperlipidaemia
Post-Traumatic Stress Disorder maxima PLUS, maxima EXEC
Option upgrades
(MPL) rates up to the limits as specified on the chosen Hypertension
option. MPL is a reference price list that benchmarks Hypothyroidism Pulmonary Interstitial Fibrosis maxima PLUS, maxima EXEC any time of the year
each product against generically similar products. It does Multiple Sclerosis Scleroderma maxima PLUS, maxima EXEC within 30 days of
not restrict the member’s choice but limits the amount
that the Scheme will refund for each product. The MPL
Parkinson’s Disease Stroke maxima PLUS diagnosis of a dread
Rheumatoid Arthritis
reference price is set at a level to ensure that a number Schizophrenia
Thromboangitis Obliterans maxima PLUS, maxima EXEC
disease.
of medicines will be available without any co-payment. Thrombocytopaenic Purpura maxima PLUS, maxima EXEC
Systemic Lupus Erythematosus
Tourette’s Syndrome maxima PLUS, maxima EXEC
Ulcerative Colitis
Valvular Heart Disease maxima PLUS, maxima EXEC
Zollinger-Ellison Syndrome maxima PLUS, maxima EXEC
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Programmes and wellness
initiatives by Fedhealth
These benefits are funded from Risk and do not affect members’ Savings:
Corporate wellness days
Corporate wellness days provide the opportunity to create awareness, education, prevention,
screening and targeted interventions that support positive lifestyle changes. These days are Weight Management Programme
well-received, as it is convenient for Fedhealth members to have these services at their place The Weight Management Programme is an intervention expertly designed for qualifying
of work. In addition to the clinical value that can be derived from wellness days, they provide Fedhealth members with a high BMI and waist circumference. Members participate in a
Fedhealth with the opportunity to market the Scheme to clients and potential clients. 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
Health Risk Assessments programme is completed, ongoing advice and monitoring is available for continued support. Email
This benefit aims to identify members who are at risk of developing lifestyle diseases, and either weightmanagement@fedhealth.co.za for more information. This benefit is available every two years.
help them prevent the onset through suitable lifestyle interventions, or help them manage their
disease with practical advice and utilisation of Scheme benefits. A Health Risk Assessment can be GoSmokeFree Smoking Cessation Programme
requested at participating pharmacies and BASA registered biokineticists. Fedhealth is encouraging members who smoke to sign up for the GoSmokeFree service that’s
available at 200 pharmacies countrywide, including Dis-Chem, Clicks, Pick n Pay and independent
Sisters-on-Site pharmacies. All smokers have a yearly benefit for the GoSmokeFree programme which is payable
Fedhealth partnered with SOS Corporate Wellness (Sisters-on-Site) to offer a nursing Sister-on-Site from risk benefits. The service comprises a pre-quit assessment and support sessions and features
at our members’ workplaces. With the employer’s influence, we aim to identify and address the an individual plan to help with smoking cessation. Visit gosmokefree.co.za to find out more about
organisation’s specific areas of concern. By helping members change their behaviour patterns and this benefit.
choose healthier lifestyles, we aim to reduce healthcare expenditure (particularly on day-to-day
utilisation), absenteeism, turnover rates, worker’s compensation claims and tardiness. Aid for AIDS (HIV Management)
Fedhealth offers the Aid for AIDS (AfA) programme to help members who are HIV-positive
Fedhealth Conservative Back and Neck Rehabilitation Programme manage their condition. The benefits of being on the programme (over and above the payment
Fedhealth has an established intervention for members suffering from back and neck problems. of the necessary medicine and pathology claims), include clinical and emotional support with the
Built on the principle of active muscle reconditioning, it’s supported by clinical studies showing utmost confidentiality.
that exercise reduces pain and can normalise function in many instances. The programme
takes a comprehensive and holistic approach to chronic back and neck pain and offers Paed IQ
individualised treatment to qualifying members. After an initial assessment, beneficiaries may Paed IQ is a 24/7 telephone advisory service available to all parents with children under the age of
receive treatment up to twice a week for six weeks and a home based protocol for long-term care. 14 years. This service aims to support and advise parents on any healthcare related childcare issues.
Email backandneck@fedhealth.co.za for more information about the programme. Call 0860 444 128 to access this great service.
Mental Health Programme Diabetes Care
Fedhealth’s Mental Health Programme is available to all qualifying members who have been We provide members with diabetes access to a comprehensive programme that is tailored to
diagnosed with mental health conditions including depression and bipolar mood disorder. their needs and other chronic conditions they might have. This includes continued access to
The programme uses innovative solutions for member empowerment and education with the a treating doctor, authorised chronic medication, blood and laboratory tests, a Health Coach,
aid of a dedicated Care Manager. Email mentalhealth@fedhealth.co.za for more information. online tools and information to empower the member. Members can call 0860 002 153 or email
diabeticcare@fedhealth.co.za
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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 Women; ages 21 to 65 1 every 3 years
(Pap smear)
A proactive Men’s Health
Prostate Specific Antigen (PSA) Men; ages 45 to 69 1 every year
stance on health: Children’s Health
Immunisation Programme (as per Birth to 12 years Various
screening State EPI)
Optical Screening Benefit (Tariff Children; ages 5 to 8 1 per lifetime
benefits
Code: 11001)
Cardiac Health
Cholesterol screening All lives; aged 20 and older 1 every 5 years
(full lipogram)
Over 45’s
Packed with screenings for every life stage, Fedhealth’s
Bone densitometry Women; aged 65 and older and 1 every 2 years
screening benefit was created to stretch members’
Men; aged 70 and older
day-to-day benefit by paying more from Risk. The
Scheme pays for screenings for women’s, children’s, Breast cancer screening with All lives; aged 45 and older 1 every 3 years
cardiac, as well as general health (like an annual mammography
flu vaccine). Colorectal cancer screening (faecal All lives; ages 50 to 75 1 every year
occult blood test)
On these options, the benefit even includes screening Pneumococcal vaccination All lives; aged 65 and older 1 per lifetime
and preventative programmes for older members like
bone densitometry screening. General
Flu vaccination All lives 1 every year
HIV finger prick test All lives 1 every year
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)
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l maxiFED 2021 & benefits guide maxiFED 2021 l 16Chemotherapy and associated medicine Radiology
Examining our
provided is both clinically appropriate and
cost-effective. A set of cancer guidelines and protocols Chemotherapy and medicine directly associated General radiology
are used during the pre-authorisation process. with the treatment of cancer will be paid from the General oncology-related radiology claims are
cancer cover
These guidelines are continually updated as new oncology benefit, provided a valid authorisation has paid from the oncology benefit while the member is
products are launched and new treatment protocols been obtained. The treating doctor must submit a receiving treatment (either chemotherapy or
established. In addition, our team is supported by a treatment plan to Oncology Disease Management, radiotherapy), provided that the member has a valid
number of oncologists and haematologists from the cancerinfo@fedhealth.co.za. Once treatment has been authorisation. A list of appropriate radiology codes
private, public and academic sectors. authorised, the member and doctor will receive an has been defined and claims for these services are
authorisation letter. Treatment for conditions not automatically paid from the oncology benefit
Oncology Disease Management On maxima EXEC, oncology is covered up to R600 600 directly related to the treatment of the cancer (e.g. (i.e. a separate pre-authorisation is not required).
Fedhealth supports cancer patients in their time of per family per year at a preferred provider, ICON, subject depression) as well as treatment for the long-term
need, and diagnosed members are encouraged to to Level 2 treatment protocols. DSP above limit. A 40% conditions that may develop as the result of Specialised radiology
register on the Fedhealth Oncology Programme by co-payment applies where a DSP provider is not used. chemotherapy or radiotherapy, will be funded from Specialised radiology (e.g. CT scans, MRIs, angiography,
calling 0860 100 572. The Scheme offers all members an alternative benefit (i.e. the Chronic Disease Benefit, radioisotopes) requires a separate pre-authorisation.
the opportunity to change to a higher option within On maxima PLUS, oncology is covered unlimited at a the Savings Account or OHEB on maxima PLUS). These pre-authorisations must be obtained from the
30 days of a life-changing event or diagnosis. preferred provider, ICON, subject to Level 3 treatment Authorisation Centre. Specialised radiology is paid
This ensures that those with cancer can get access protocols. Treatment will be covered up to the Fedhealth Radiotherapy from Risk. A co-payment of R2 380 for non-PMB
to medication that will help them to remain Rate if the preferred provider is not used. Radiotherapy will be paid from the oncology MRI/CT scans will apply on maxima EXEC.
economically active, with all the support they benefit, provided a valid authorisation has been
require to deal with this stressful diagnosis. Independent Clinical Oncology Network (ICON) obtained. The treating doctor must submit a PET scans
The Scheme has contracted with ICON for the provision treatment plan to Oncology Disease Management. PET scans are limited to two per family per annum
We require a clinical summary of each member’s of active oncology treatment. ICON is a network of Once treatment has been authorised, the member restricted to staging of malignant tumours. PET scans
case: this must contain the history, ICD–10 codes, oncologists that includes 75% of all practicing oncologists in and doctor will be sent an authorisation letter. are paid from the oncology benefit.
the clinical findings of the doctor, as well as the test South Africa. To find an ICON network specialist, call
results confirming the cancer and the specific type 0860 002 153. Specialised medication Surgery and hospitalisation
of cancer. The proposed treatment plan must be Specialised medication is medication that is focused Claims for surgery and hospitalisation will be
submitted so that the oncology team can approve on a defined group of patients, diseases, skills, paid from the in-hospital benefit, provided that
the appropriate therapy. Our caring agents will guide or philosophy. e.g. biologicals – oncology and the member obtains a valid authorisation from the
the member through the process. non-oncology Authorisation Centre.
Members can access the oncology benefit by Stoma therapy
obtaining pre-authorisation from a staff member At Fedhealth you can • On maxima EXEC we cover specialised medicine up
to R187 300 per family per year Stoma therapy will be paid from Risk. On maxima
within the Oncology Disease Management team.
The team comprises a number of highly skilled
upgrade your option • On maxima PLUS we cover specialised medicine up
to R375 800 per family per year
PLUS, stoma therapy will be paid from OHEB first
and once depleted, from Risk. Pre-authorisation is not
healthcare professionals who work in conjunction any time of the year on required.
with the treating doctor to ensure that treatment Consultations and visits
diagnosis of cancer. Oncologist consultations and hospital visits are paid Terminal care and private nursing
from the oncology benefit while the member has either Accommodation in a hospice or terminal care facility
an active chemotherapy or radiotherapy authorisation. for the care of patients in terminal stage of life will
Hospital visits are pre-authorised at the same time be covered from the Terminal Care Benefit covered
as the authorisation for chemotherapy or radiation up to R33 300 per family per year. Pre-authorisation
treatment.You will receive an authorisation letter must be obtained from the Hospital Authorisation
detailing the number of visits authorised and the Centre. Private nursing will be paid from the
period for which these visits are authorised. Alternatives to Hospitalisation benefit.
Pathology Post-active treatment
Oncology-related pathology claims are paid from the Post-active refers to the time when the member
oncology benefit while the member is receiving actually had last active treatment (e.g., hormone
treatment (either chemotherapy or radiotherapy), therapy, chemotherapy or radiotherapy). “For life”
provided that the member has a valid authorisation. means that the member will remain on the
A list of appropriate pathology codes has been oncology programme as long as the cancer is in
defined and claims for these services are remission. Whilst in remission, a list of appropriate
automatically paid from the oncology benefit consultation, radiology and pathology codes has
(i.e. a separate pre-authorisation is not required). been defined and claims for these services are
automatically paid for life from the oncology benefit.
Should the condition regress, the active treatment
benefit will be reinstated upon submission of a new
treatment plan.
17 l maxiFED 2021 maxiFED 2021 l 18These 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,
stress at work, relationship issues, bullying at diabetes, stroke, neurological disorders, HIV/
school and teenage troubles. AIDS, cardiac conditions, Parkinson’s disease,
Giving our Alzheimer’s disease, Amyotrophic lateral
members more Following these telephonic sessions, we
can also put the member in touch with a
sclerosis (ALS) a.k.a. motor neurone disease.
value and 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
support when send the member useful communications Fedhealth charges child rates for financially
they need it. 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.
19 l maxiFED 2021 maxiFED 2021 l 20maxiFED cover for day-to-day expenses
Here’s a breakdown of the different ways we cover day-to-day expenses depending on the option.
Day-to-day benefits paid by Fedhealth
At Fedhealth, we pride ourselves on covering more from Risk than other medical schemes to help our members’ day-to-day
benefits last longer
Unlimited network GP consultations
Members can see their GP as often as they need by visiting any network GP.
• maxima EXEC: Unlimited GP visits at Fedhealth Network GPs once Savings is depleted.
• maxima PLUS: Unlimited GP visits at Fedhealth Network GPs paid from Risk, never from Savings.
Treatment for 30 days after discharge from hospital (post-hospitalisation benefit)
We pay for follow-up treatment that may be required after a hospital event for up to 30 days
after the date of discharge. This treatment includes physiotherapy, x-rays and pathology, but
does not cover follow-up consultations with specialists or GPs.
Take-home medicine
We pay for seven days of take-home medication when the member is discharged from hospital.
The medication can either be dispensed by the hospital and reflect on the original hospital account,
or be dispensed by a pharmacy on the same day as the member is discharged from hospital.
Specialised radiology
We pay for MRI/ CT scans whether they are performed in- or out-of-hospital.
• maxima EXEC: Unlimited at Fedhealth Rate. First R2 380 for each non-PMB MRI/ CT scan for
member’s own account.
• maxima PLUS: Unlimited specialised radiology paid from Risk if pre-authorised.
Trauma treatment at a casualty ward
We pay for emergency treatment, like stitches, at a casualty ward. Whether the member is
admitted to hospital or not, authorisation must be obtained within 48 hours.
• maxima EXEC: Unlimited up to the Fedhealth Rate. Members pay a co-payment of R630 per
visit for non-PMBs.
• maxima PLUS: Unlimited up to the Fedhealth Rate.
Female contraception
We pay for female contraception including oral, patches, contraceptive rings, certain
injectables, and IUDs that include Mirena®. It must be prescribed by a GP or gynaecologist
and is not applicable to pills prescribed for acne.
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.
21 l maxiFED 2021 maxiFED 2021 l 22maxiFED cover for day-to-day expenses
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.
OHEB
Available on maxima PLUS only
After the Savings Account has run out of funds, day-to-day expenses are paid from the
Out-of-Hospital Expenses Benefit up to the Fedhealth Rate until the benefit limit is reached.
There are maximum amounts for specific treatments and conditions.
Threshold benefit
The Threshold benefit pays for certain day-to-day expenses once the member’s claims have
accumulated up to the required level. The Threshold level is reached through the accumulation
of claims paid from the member’s day-to-day benefit or self-funded through the year at the
Fedhealth Rate. Certain benefit limits do not accumulate to Threshold. Where limits do
accumulate, expenses will only accumulate up to this limit and this limit will also apply to refunds
from Threshold; a 10% co-payment will apply to all claims paid from the Threshold benefit on
maxima EXEC. No co-payment will apply to GP and specialist consultations in-network.
Maternity benefit
This benefit covers two 2D scans, antenatal classes up to R1 120, 12 ante- and/ or postnatal
consultations with a midwife, network GP or gynaecologist, amniocentesis. Thereafter, paid
from Savings and OHEB (maxima PLUS).
Doula benefit
We pay up to R3 000 per delivery for a Doula (a labour coach during natural childbirth).
Postnatal midwifery benefit
We pay for four consultations per pregnancy with a midwife. This benefit applies to consultations
both in- and out-of-hospital.
Early childhood benefits
a. Paediatric consultations
One consultation per beneficiary with a network paediatrician up to 24 months of age. No GP
referral required.
b. Infant hearing screening benefit
We pay for a screening test including the consultation from birth up to the age of 8 weeks with
an audiologist. This benefit is covered up to the Fedhealth Rate.
c. Childhood illness specialised drug benefit
Covered from the specialised medicine benefit.
Fedhealth Baby Programme
We offer a free maternity programme for pregnant members and beneficiaries offering support,
advice and a handy baby bag.
Paed-IQ
Paed-IQ is a telephonic paediatric advice line for members with children up to the age of 14.
23 l maxiFED 2021 maxiFED 2021 l 24maxiFED
additional benefits maxiFED in-hospital benefit
Additional valuable benefits that give members more support.
In-hospital benefit
Comprehensive managed care programmes Mental Health Programme
This benefit covers all treatments and procedures that have to be done in a hospital and that is covered by the
We offer various programmes for members with This programme offers support for members with
specific healthcare needs: substance-abuse or mental health issues like maxiFED options.
depression or bipolar mood disorder.
maxima EXEC maxima PLUS
Weight Management Programme
Fedhealth designed our 12-week biokineticist-led Weight GoSmokeFree Smoking Cessation Benefit All limits are per family per year unless otherwise specified
Management Programme for qualifying Fedhealth Programme Overall annual limit (OAL) Unlimited at negotiated tariff
members with a high BMI and waist circumference. All members who are smokers have access once per
Healthcare Professional Tariff in-hospital (HPT)
Access to a dietician and behavioural psychologist is also beneficiary per annum to have the GoSmokeFree
available. This benefit is available every two years. consultation paid from Risk. Fedhealth Network GPs and Covered unlimited. Paid in full
Specialists
Conservative Back & Neck Rehabilitation Programme Aid for AIDS (HIV Management) Non-network GPs Paid up to the Fedhealth Rate
This programme aims to help members with back Fedhealth offers the Aid for AIDS programme to Non-network Specialists Paid up to 200% of the Fedhealth Rate
and neck issues avoid spinal surgery through active help members who are HIV-positive manage their
condition. Other Healthcare Professionals Paid up to the Fedhealth Rate Paid up to 300% of the
muscle reconditioning.
Fedhealth Rate
Oncology disease management Diabetes Care Prescribed Minimum Benefits (PMB): To have the treatment for PMB conditions covered in full, you will have to
We provide comprehensive care for This programme supports members with Treatment for PMB conditions can use Fedhealth Network GPs and Specialists.
Diabetes by providing them with access to a treating be funded in two ways:
members with cancer.
doctor, medication and blood tests to name a few. Should you choose not to make use of network providers, the Scheme
will only refund treatment up to the Fedhealth Rate for non-network GPs
and 200% of the Fedhealth Rate for non-network specialists. You will
have a shortfall should the healthcare professional charge more
Hospitalisation costs: Unlimited at negotiated tariff. Private ward cover when available for
accommodation in a general ward, maternity admissions
high care ward and intensive care
unit, theatre fees, medicine, material
and hospital apparatus
Additional medical services In and out-of-hospital: Paid from Unlimited subject to medical
(dietetics, occupational therapy Savings. Does not accumulate to practitioner referral
and speech therapy) Threshold. Paid from Threshold up
to R18 700 per family per year
Alternatives to hospitalisation:
Nursing services, private nurse Unlimited at negotiated tariff
practitioners & nursing agencies
Sub-acute facilities, physical
rehabilitation facilities
Appliances, external accessories In & out-of-hospital: Paid from Unlimited at cost
and orthotics Savings. Does not accumulate to
Threshold. Paid from Threshold up
to R16 700 per family per year.
(R4 680 sub-limit per beneficiary
for foot orthotics)
Blood, blood equivalents and Unlimited
blood products
25 l maxiFED 2021 maxiFED 2021 l 26maxiFED in-hospital benefit maxiFED in-hospital benefit
Prosthesis benefit
Under this benefit, we cover internal and external prosthesis.
maxima EXEC maxima PLUS maxima EXEC maxima PLUS
Immune deficiency related to HIV Unlimited (see HPT) External prosthesis R18 600 at cost R23 400 at cost
infection
Internal prosthesis
Maxillo-facial surgery Unlimited, subject to approval Unlimited, subject to approval (see
Bi-ventricular pacemakers and See combined benefit limit for all unlisted internal prosthesis*
(see HPT) HPT)
implantable cardioverter
Surgical extraction of impacted You pay a co-payment of R4 600 defibrillators (ICDs), bone
wisdom teeth on the hospital bill lengthening devices, carotid stents,
In-hospital dentistry benefit for We cover the hospital and anaesthetist. Dentist will be paid from embolic protection devices, other
children under 7 day-to-day benefits approved spinal implantable devices
and intervertebral discs, peripheral
Oncology: oncologist R600 600 at preferred provider* Unlimited at preferred provider* arterial stent grafts, spinal plates and
consultations, visits, treatment and and paid from Level 2 treatment and paid from level 3 treatment screws, total ankle replacement
materials for chemotherapy and protocols. DSP* above limit protocols
radiotherapy, approved medication, Aorta stent grafts R63 100
radiology and pathology Cardiac pacemakers R52 500 R63 100
Reimbursement rate if you don’t Up to the Fedhealth Rate Up to the Fedhealth Rate Cardiac stents R54 000
use ICON within limit and a 40% co-payment
thereafter Cardiac valves R48 000
Organ transplant including R600 600 (See HPT) Unlimited (see HPT) Detachable platinum coils R54 600
immunosuppression medication Elbow, hip, knee and shoulder R37 500 R48 000
Corneal graft R35 000 per beneficiary replacement
Pathology, radiology (general) Unlimited up to the Fedhealth Rate Intraocular lenses (per lens) R3 400
Physiotherapy Unlimited subject to medical practitioner referral *Combined benefit limit for all *R31 500 *R38 900
unlisted internal prosthesis
Psychiatric services: R34 500 (See HPT) R43 500 (See HPT)
accommodation in a general ward,
procedures, ECT, materials and
hospital equipment, consultations
and visits, medicines and injection
material
Renal dialysis (chronic): R600 600 up to the Fedhealth Rate Unlimited up to the Fedhealth Rate
consultations, visits, all services, at Designated Service Provider at Designated Service Provider
materials and medicines associated (DSP). A 40% co-payment applies (DSP). A 40% co-payment applies
with the cost of renal dialysis where a DSP provider is not used where a DSP provider is not used
Specialised Medication (e.g. R187 300 at cost R375 800 at cost
biologicals) Benefit (oncology &
non-oncology)
Specialised radiology Unlimited at Fedhealth Rate. First Unlimited at Fedhealth Rate
R2 380 for non-PMB MRI/CT scans
for the member’s account
Spinal surgery No benefit unless utilisation of No benefit unless utilisation of
Conservative Back & Neck Conservative Back & Neck
Rehabilitation Programme has been Rehabilitation Programme has been
completed. You pay a co-payment completed
of R6 000 on the hospital bill
Terminal care benefit R33 300 at Fedhealth Rate
* ICON – Independent Clinical Oncology Network.
27 l maxiFED 2021 maxiFED 2021 l 28maxiFED co-payments & chronic disease benefit maxiFED day-to-day benefit
Co-payments Day-to-day benefits paid from Savings (OHEB on maxima PLUS)
Co-payments may apply on certain in-hospital procedures, which will be for the member’s account. Under the day-to-day benefit, we cover services like physiotherapy and dentistry.
maxima EXEC maxima PLUS maxima EXEC maxima PLUS
Co-payments per event applicable on the hospital/ facility bill only Benefit Limit per family per year
Arthroscopic procedures – hip, R2 600 No co-payments Tariff Up to the Fedhealth Rate
wrist, knee, shoulder, ankle, other Co-payments in Threshold 10% co-payment No co-payment
arthroscopic procedures,
Appliances, external accessories In and out-of-hospital: Paid from Paid from Savings, OHEB and
colonoscopy, upper GI endoscopy
and orthotics: Savings. Does not accumulate to Threshold. R16 700 per family per
Cataract surgery with CP*** Unlimited at cost at PMB level of care Hearing aids, wheelchairs, etc. Threshold. Paid from Threshold up year before and after threshold.
Other joint replacements, R4 600 No co-payments to R16 700 per family per year. (R4 680 sub-limit per beneficiary
laparoscopic hernia repairs (R4 680 sub-limit per beneficiary for foot orthotics)
(bilateral inguinal, repeated inguinal for foot orthotics)
hernias & Nissen/ Toupet hernia Alternative healthcare: Paid from Savings. Does not Paid from Savings and OHEB.
repairs only), laparoscopic Acupuncture, homeopathy, accumulate to or pay from Does not accumulate to or pay
procedures, rhizotomies and facet naturopathy, osteopathy and Threshold from Threshold
pain blocks (limited to 1 of either phytotherapy
procedure per beneficiary per (including prescribed medication)
year), surgical extraction of Additional medical services: In and out-of-hospital: Paid from Paid from Savings, OHEB and
impacted wisdom teeth Audiology, dietetics, genetic Savings. Does not accumulate to Threshold. R18 700 per family per
Spinal surgery** R6 000 No co-payment counselling, hearing aid acoustics, Threshold. Paid from Threshold up year before and after Threshold.
occupational therapy, orthoptics, to R18 700 per family per year
Joint replacements
podiatry, private nursing*,
Single hip and knee replacements No co-payment psychologists, social workers,
with CP* speech therapy
Single hip and knee replacements - R28 400 Dentistry advanced: R7 960 per beneficiary per year, Paid from Savings, OHEB and
voluntary use of non-CP* inlays, crowns, bridges, mounted R23 780 per family per year before Threshold. R7 960 per beneficiary
study models, metal base partial and after Threshold. Paid from per year, R23 780 per family per
Other joint replacements and R4 600 No co-payment
dentures, oral surgery, orthodontic Savings and Threshold year before and after Threshold
involuntary use of non-CP* for
treatment, periodontists,
single hip and knee replacements
prosthodontists and dental
* Contracted Provider: Must use ICPS Hip and Knee network or JointCare for single non-PMB hip and knee joint replacements. Non-use of technicians
Contracted Provider (CP) will result in co-payment.
** No benefit unless utilisation of Conservative Back & Neck Rehabilitation Programme has been completed. Osseo-integrated implants, Paid from Savings. Does not Paid from Savings and OHEB.
***Contracted Provider: Must use ICPS Cataract network for cataract surgery. Non-use of Contracted Provider (CP) will result in co-payment of R6 000. orthognathic surgery accumulate to or pay from Does not accumulate to or pay
Threshold from Threshold
Chronic disease benefit Dentistry (basic) Paid from Savings and threshold. Paid from Savings, OHEB and
Cover for conditions that require long-term medication or can be life-threatening. Unlimited once threshold is reached threshold. Unlimited once threshold
is reached
maxima EXEC maxima PLUS General Practitioners
Fedhealth Network GPs Paid from Savings then unlimited Paid from OHEB then unlimited
Limit R7 600 per beneficiary, subject R16 100 per beneficiary, subject
from Risk. Once Savings is from Risk. Once OHEB is depleted,
to an overall limit of R14 000 per to an overall limit of R30 200 per
depleted, Fedhealth gives unlimited Fedhealth gives unlimited cover for
family per year. Thereafter family per year. Thereafter
cover for GP consultations as long GP consultations as long as the
unlimited cover for conditions on unlimited cover for conditions on
as the member uses a GP who is on member uses a GP who is on the
the CDL. the CDL.
the Network Network
Formulary Comprehensive formulary
Non-network GPs Paid from Savings and Threshold. Paid from Savings, OHEB and
Preferred Provider MediRite, Dis-Chem, Clicks & Pharmacy Direct Does not accumulate to Threshold. Threshold. Unlimited accumulation
Paid from threshold up to the to and refund from Threshold up to
Fedhealth Rate the Fedhealth Rate
*Private nursing that falls outside the Alternatives to Hospitalisation Benefit.
29 l maxiFED 2021 maxiFED 2021 l 30maxiFED day-to-day benefit maxiFED day-to-day benefit
maxima EXEC maxima PLUS maxima EXEC maxima PLUS
Maternity benefit See maternity benefit on page 23. See maternity benefit on page 23. Specialists: psychiatrists
Thereafter, paid from Savings and Thereafter, paid from Savings, OHEB
Threshold. Limited to 2 x 2D and Threshold. Limited to 2 x 2D Fedhealth Network Psychiatrists Paid from Savings. Does not Paid from Savings, OHEB and
antenatal scans per pregnancy before antenatal scans per pregnancy before accumulate to Threshold. Paid accumulation to and refund from
and after Threshold and after Threshold at cost from Threshold up to the Threshold at cost. 10% co-payment
Additional Medical Services limit of if GP referral is not obtained.
Optometry Paid from Savings and Threshold. Paid from Savings, OHEB and R18 700 per family per year. Subject to Additional Medical
R3 600 per beneficiary per year, Threshold. R3 600 per beneficiary 10% co-payment if GP referral is Services limit of R18 700 per family
R11 000 per family per year before per year, R11 000 per family per not obtained per year before and after Threshold
and after Threshold year before and after Threshold
Non-network Psychiatrists Paid from Savings. Does not Paid from Savings, OHEB and
Over-the-counter medication Paid from Savings only. Does not accumulate to or pay from Threshold accumulate to threshold. Paid at accumulation to and refund from
the Fedhealth Rate from Threshold Threshold at the Fedhealth Rate.
Pathology & radiology Paid from Savings and Paid from Savings, OHEB up to the Additional Medical 10% co-payment if GP referral is
Threshold. Unlimited once and Threshold. Unlimited once Services limit of R18 700 per family not obtained. Subject to Additional
Threshold is reached Threshold is reached per year. 10% co-payment if GP Medical Services limit of R18 700
Physical therapy: Chiropractics, Paid from Savings. Does not Paid from Savings, OHEB referral is not obtained per family per year before and
biokinetics & physiotherapy accumulate to threshold. Paid from and Threshold. Unlimited once after Threshold
Threshold up to the Additional Threshold is reached
Medical Services limit of R18 700
per family per year
Prescribed medication Paid from Savings and Threshold. Paid from Savings, OHEB and
R7 650 per beneficiary per year, Threshold. R10 650 per beneficiary
R14 150 per family per year before per year, R21 190 per family per
and after Threshold year before and after Threshold
Radiology specialised Paid from Risk if authorised. First Paid from Risk if pre-authorised
R2 380 for non-PMB MRI/ CT scans
is for the member’s account
Specialists excluding psychiatrists
Fedhealth Network Specialists Paid from Savings and Paid from Savings, OHEB and
accumulation at cost to Threshold. accumulation at cost to Threshold.
Unlimited at cost once Threshold Unlimited at cost once Threshold
is reached. 10% co-payment if GP is reached. 10% co-payment if GP
referral is not obtained referral is not obtained
Non-network Specialists Paid from Savings and Threshold. Paid from Savings, OHEB and
Does not accumulate to Threshold. Threshold. Accumulation to and
Paid at the Fedhealth Rate from refund from Threshold at Fedhealth
Threshold. 10% co-payment if GP Rate only. 10% co-payment if GP
referral is not obtained referral is not obtained
31 l maxiFED 2021 maxiFED 2021 l 32You can also read
