COMPREHENSIVE OPTION RANGE Maxima Standard 2018COMPREHENSIVE OPTION RANGE. Maxima Standard. 2018. 1. 1 Overview of benefits 5. Risk and Savings benefits 5 Examples of what each benefit

COMPREHENSIVE OPTION RANGE

Maxima Standard

2018

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1 Overviewofbenefits 5

RiskandSavingsbenefits 5

Examplesofwhateachbenefitcovers 6

Someimportantwords 7

About healthcare providers 7

About medicines and payment for medicines 7

About limits to what we pay 7

About treatment and payment for treatment 7

360 Care: Let the healing begin (with your FP) 8

PrescribedMinimumBenefits(basiclevelofcoverforadefinedsetofconditions) 8

2 Emergencies 9

Youarecoveredforemergencymedicalexpenses 9

Emergencymedicalservices:call0860333432 9

You must contact us within two working days if it was an emergency 9

Contact us within two working days if you needed trauma treatment 10

3 HospitalvisitsandtreatmentpaidfromtheMajor

MedicalBenefit 11

Aboutlimitsandco-paymentsforhospitalstays 11

No overall yearly limit 11

Therearelimitsandrestrictionsforspecifictreatmentsandconditions 11

Differentcoverfordifferenttypesofhospitaltreatments 11

Hospitalcostswecoverinfull 11

Medicineyoureceiveinhospital 11

Doctorvisitswhileyou’reinhospital 12

Bloodandpathologyserviceswhileyou’reinhospital 13

Maternitybenefit 13

Spinalsurgery 13

Oncology(cancer) 14

Full cover for services through ICON 14

IfyouhavereachedyourlimitfortheOncologybenefit 14

Limitsforspecifictreatments 14

Oncology Disease Management Programme (ODM) 14

Specialised radiology (for example, MRI or CT scans) 14

Othertreatmentsorproceduresthatyoureceiveinhospital 15

Sometreatmentandproceduresdoneoutofhospital 16

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Services like physical rehab and treatment in sub-acute facilities 16

Nursing instead of hospitalisation 16

Procedures performed in day wards, day clinics and doctor’s rooms 16

Doctor appointments with network FPs 16

Female contraception 16

Sometreatmentafterahospitalvisit 17

Medicine you get while in hospital to take at home 17

Treatmentinthe30daysafteryourhospitalvisit(post-hospitalisationbenefit) 17

Prosthesisbenefittable 17

External prosthesis 17

Internal prosthesis 17

ImprovedClinicalPathwayServices(ICPS)andJointCarefornon-PMBhip

andkneereplacements 18

4 TohavehospitalorothertreatmentcoveredbytheMajorMedicalBenefit 19

Youmusthaveauthorisation 19

Contact us at least 48 hours before the hospital stay or the procedure 19

When you contact us, have this information ready 19

5 Screeningandimmunisationbenefits 21

Screeningbenefit&ActiveDiseaseRiskManagementprogrammes 21

Immunisationbenefitforchildren 22

6 Chronicmedicine(coveredbyChronicDiseaseBenefit) 23

Whatischronicmedicine? 23

Limits 23

Toclaimunderthisbenefit 23

List of chronic conditions 23

List1:ConditionsthatarePrescribedMinimumBenefitconditions 23

IfyourconditionisonList1(PrescribedMinimumBenefits) 24

List 2: Additional chronic conditions covered on your option 24

If your condition is on List 2 (Additional Chronic Conditions) 24

CoverfortreatmentforHIV/Aids 27

HowtoapplyfortheChronicDiseaseBenefit 27

Step 1: Collect the information needed to apply 27

Step 2: Apply 27

Step 3: We will give you a response right away 27

Step 4: You get your medicine access card 27

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Wewillgiveyoutreatmentguidelines 28

Ifthereisaco-paymentonyourmedicine 28

Wewillapproveachroniccondition,notindividualchronicmedications 28

Chronicmedicationdeliveredtoyourdoor 28

7 Payingforday-to-dayexpenses(Day-to-DayBenefits) 29

Thebasicsofthetwobenefitsforday-to-daymedicalexpenses 29

The Savings Account 29

TheThresholdBenefit 29

You must pay while you are in the self-payment gap 29

Examples of expenses that will increase the self-payment gap 29

WhentheThresholdBenefitkicksin,existinglimitsapply 30

Coverfordoctors,specialistsandmedicines 30

FPs in the Fedhealth network 30

FPs not in the Fedhealth network 30

Specialists in the Fedhealth network 30

Specialists not in the Fedhealth network 30

Prescribed medicine 30

Dispensing fees for prescribed medicine 31

Over-the-counter medicine 31

Female contraception 31

Pregnancy 31

Specialised radiology (for example, MRI or CT scans) 31

Allcoverinday-to-daybenefits 34

8 Howtoclaim 39

If the healthcare professional or the hospital claims on your behalf 39

If you need a refund because you paid the medical expense 39

You must claim within four months of the date of the treatment 39

Sendyourclaimsto 39

Ifyouhavebeeninacaraccident 39

9 Aboutyourschemeandmembership 41

Members 41

Dependants 41

Who can be registered as a dependant 41

Criteria for children 41

Adding a newborn baby 41

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You must give us these documents for registering dependants 41

Membershipcards 42

Removingadependantfromyourmembership 42

Howwecommunicatewithyou 42

We email and SMS your claim status 42

Make sure we have your correct email address and cell number 42

Youcanfindyourclaimandbenefitinformationonourwebsite 42

You can message Fedhealth free of charge with the FedChat Mobile App 43

Fedhealth Family Room 43

MaximaStandardcontributionstable 44

Optionchanges 45

You can upgrade to a higher option 45

Payingforyourmedicalaid 45

You must pay by the third of each month 45

Our bank details 45

Leavingthescheme 45

Three months of notice to leave 45

Last contribution 45

Amount in Savings Account – if you spent less than you paid in 45

Amount in Savings Account – if you spent more than you paid in 45

Whistle-blowingonfraud 45

10 Extraservices 47

24-hour Nurse Line on 0860 333 432 47

Fedhealth Baby 47

11 Servicecentresandcontactdetails 49

Medscheme Client Service Centres 49

Contact us 49

Pleasenote:AllFedhealthbenefitsaresubjecttoregisteredSchemeRules,andassuch,thisdocumentonlyaimstoprovideasummaryofsuchbenefits.ForthefullSchemeRules,pleasevisitfedhealth.co.zaorcontacttheFedhealthCustomerContactCentreon0860002153toobtainacopy.

SAVINGS**

THRESHOLD BENEFIT*

CHRONIC DISEASE BENEFIT*

MAJOR MEDICAL BENEFIT*

FOUNDATION BENEFIT*

Riskand Savings benefitsYourschemeworksbytakingyourcontributionanddividingitintotwoparts.The one part goes towards RiskBenefits, the other goes to a SavingsAccount.

*Risk benefitsForriskbenefits,theschemepoolstogethermembers’contributions and uses the money to fund a set of benefits,includingtheFoundationBenefit,MajorMedicalBenefit,ChronicDiseaseBenefitandThresholdBenefit.

Theschemehasrulesforwheneachoftheriskbenefitsisallowedtopayout.Theseschemerulesgivelimitsforwhatthebenefitcanpayoutforparticularconditions,treatmentsandmedicines.Becausetheschemeappliesitsrulesconsistently,wecanbeconfidentthat:

• We treat all members fairly and do not discriminate against any members

• The medical scheme is sustainable and will not run out ofmoney.

**Savings AccountThe part of your contribution that is paid to the Savings Account is not pooled with other members’ contributions.ThemoneyintheSavingsAccountisyour money and it gives you a level of control on your spending.Themoneythatisnotusedinoneyeariscarried over to the following year and this is called Carry-overSavings.Thismaybeusedafteryournewyear’sday-to-daybenefitshavebeendepleted.Anysavings balance not used will be paid out if you leave thescheme.

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OVERVIEWOFBENEFITS

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Examples of what each benefit coversEachbenefitiscarefullyplannedtocoverasetofmedicalexpensesformembersandtheirdependants.Thistablegivesageneralideaofwhatmaybecoveredbyeachbenefit.Youmustreadthefullmemberguidetofindoutwhatisandisnotcovered.

Nameofbenefit Examplesofwhatmaybecoveredunderthebenefit Sections

FoundationBenefit Various

Thisbenefitoffersmembersahostofvaluablebenefits.

ScreeningbenefitBirth&BabybenefitExtendedCarebenefit

MajorMedicalBenefit 3

Thisbenefithasnooverallyearlylimit,buttherearelimitsandrestrictionsforparticulartreatments.

Emergency treatment in hospitals or casualtyHospital stays and most treatment in hospitalSome treatments and procedures at day clinics and in doctor’s roomsFemale contraceptionSometreatmentafterahospitalvisit(30daybenefit)Doctor appointments with network FPsOncology treatmentThresholdBenefitwhenyourday-to-dayexpenseshaveadded up to your threshold level

ChronicDiseaseBenefit 6

Thisbenefithasanoverallyearlylimitandonlyprovides cover if your condition is one of the conditionscoveredonthisoption.Theremayberestrictionsforparticularmedicinesandtreatment.

Conditions that are covered include the 25 Prescribed MinimumBenefitchronicconditionsaswellasanadditional14conditions.The medicine for the treatment of these conditions that meet the criteria as set by the scheme will be covered by thisbenefit

Day-to-DayBenefits 7

Your day-to-day expenses are covered from:1.SavingsAccount2.Carry-overSavingsorself-payment3.ThresholdBenefit

Visits to doctors or specialistsPrescribedmedicineforillness(forexample,theflu)Over-the-counter medicineOtherday-to-daymedicalexpenses.Commonexamplesaredentistry, optometry, blood tests and physiotherapy

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Some important wordsHere are explanations of some important words used in this booklet:

About healthcare providers

Fedhealthnetwork: The Fedhealth network includes doctors, specialists, pharmacies and facilities that Fedhealth has an agreementwith.Itisalwaysinyourbestinteresttouseahealthcareproviderinthenetworkaswehaveagreedrateswiththem.PleaseusethenetworklocatoronourwebsiteorcontactusifyouwanttofindahealthcareproviderintheFedhealthnetwork.

DesignatedServiceProvider: This is a healthcare provider (for example, a doctor, pharmacy or hospital) that members mustuseinorderforthemnottoincuraco-paymentontheirtreatment.

About medicines and payment for medicines

MedicinePriceList: For every originator medicine which has one or more generic alternatives, the scheme has determinedaceilingprice(themaximumwewillpay)forthatgroupofgenericmedication.Thisceilingpricewillbehighenoughtopayinfullforatleastoneofthegenericmedicinesforthatparticulargroupofmedicine.

Genericmedicines: Generic medicines are medicines that are brought to market after patents have expired on originator medicines.Theycontaintheexactsameactiveingredients,strengthandformulationastheoriginatorproduct.However,theyareusuallymuchcheaperthantheoriginatorproduct.Choosingmedicinethattheschemecoversinfullensuresthatyouwillhavenooutofpocketco-payments.Forexample,ifanoriginatorproducthassevengenerics,theMedicinePriceListpricewillbeset–notatthecheapest–butatthecostofoneofthesegenerics.Whenanewgenericisintroducedfortheoriginatorproduct,theMedicinePriceListamountmayberecalculated.

Originator: Originator medicines are medicines that have been newly developed and subsequently patented by a pharmaceuticalcompany.

Formulary: Thisisanapprovedlistofmedicineforeachofthechronicconditionscoveredbythescheme.Ifaformularyapplies,weonlycovermedicinethatislistedontheformulary.TheMedicinePriceList(MPL)alsoappliestomedicinesinaformulary.

About limits to what we pay

FedhealthRate: These are the rates that the scheme sets every year for each and every medical service, procedure, treatmentetc.Theseratesareadjustedannuallybyinflationandareusedasthebasisforalltariffnegotiations.

Healthcareprofessionaltariff: This is the reimbursement rate that has been negotiated or set for the payment of professionalservicesandwillusuallybeamultipleoftheFedhealthRate.

Co-payment: Thisisanamountthatyoumustpayfromyourownpocketforaparticulartreatmentorservice.

About treatment and payment for treatment

Treatmentprotocol: Aplanforacourseoftreatment.

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OVERVIEWOFBENEFITS

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360 Care: Let the healing begin (with your FP)Do you recall there was a time when the family doctor treated Mom, Dad, the kids and Granny as well? He or she got to know the familyinsideandout,andwasawareofalltheirailmentsandallergies.Thismeantthateveryoneknewwheretoturnwhentheyfeltpoorly–asinglemedicalprofessionaltheycouldtrustforexpertmedicaladvice.

This is the inspiration behind our 360 Care initiative, in which your family practitioner or FP as we like to call them becomes the coordinator of your care, working directly with you, the member, to ensure that your health needs are met safely, timeously and cost effectively.Inanutshell,thismeansthatyourFP,whowillhavethebestunderstandingofyourhealthstatusandtreatmenthistory,willreferyoutotheappropriatespecialiststodelivertherightcareattherighttime.

We believe that 360 Care improves the quality of healthcare by facilitating access to the appropriate specialist care, and that it preventsunsafecombinationsoftreatmentsincludingmedicines.Italsopreventsunnecessaryduplicationofcostlyclinicaltestsandtreatments–whichcontributetorisinghealthcarecostsandincreasesinmembers’contributions.Finally,wehaveintroducedelectronichealthrecordswhichallowthehealthcareproviderstreatingyoutoeasilyaccessandexchangeyourmedicalinformation.

In addition, your FP will refer you and be able to make an appointment for you with a specialist much quicker than you might be abletodoyourself.So,simplyvisityourNetworkFP(anunlimitedbenefitonyouroption)forareferraltotherelevantspecialist.Non-networkFPsmayalsobeconsulted,butthesevisitswillbepaidfromyourSavingsandmayresultinaco-paymentfromyou.

Under 360 Care, you will require a FP referral to visit: cardiologists, dermatologists, gastroenterologists, gynaecologists, neurologists, neurosurgeons, orthopaedic surgeons, otorhinolaryngologists (ENT), paediatric cardiologists, paediatricians, physicians,plasticandreconstructivesurgeons,psychiatrists,pulmonologists,rheumatologists,surgeonsandurologists.AFPreferral is not necessary for: children under the age of two visiting a paediatrician, female members visiting a gynaecologist for their annualcheck-up,visitstooncologists,ophthalmologists,radiologists(generalorspecialised)orpathologyservices.ReferralmustbeobtainedfromanFPifspecialistconsultationispaidfromtheriskbenefit.Ifreferralisnotobtainedtherewillbea20%co-paymentonspecialistclaimspaidfromtheriskbenefit.

Trusting your FP to coordinate your specialist care means having a healthcare practitioner with the information at hand to give you andyourlovedonesthebestpossiblecare.Justwhatyourpreciousfamilydeserves.

Prescribed Minimum Benefits (basic level of cover for a defined set of conditions)All medical schemes are required by law to cover 270 hospital based conditions and 25 chronic conditions in full without co-paymentordeductibles,aswellasanyemergencytreatmentandcertainoutofhospitaltreatment.ThismeansthatallschemesmustprovidePMBlevelofcareatcostfortheseconditions.

The Medical Schemes Act 131 of 1998 allows schemes to require members to make use of Designated Service Providers (DSPs) in order foramembertobeentitledtofundinginfull.Schemesmayalsoapplyformularies–alistofmedicineswhichshouldbeusedtotreatPMBs,andmanagedcareprotocols–basedonevidence-basedmedicineandcost-effectivenessprinciplestomanagethisbenefit.

Fedhealth has appointed their network specialists, network FPs and four preferred provider pharmacies, Clicks, Dis-Chem, Medi-Rite andPharmacyDirectfortheprovisionofPMBs.Thesepharmaciescanguaranteepricecertaintyalthoughmembersarewelcometouseanypharmacyoftheirchoicewithoutpenalty.MembersmustmakeuseofaFedhealthnetworkspecialistandanetworkFPinorderforthecosttoberefundedinfull.ShouldthemembernotusetheseDSPsforthetreatmentofaPMBcondition,theschemewillreimbursetreatmentatthenon-Fedhealthnetworkrate.Co-paymentsareapplicabletothevoluntaryuseofnon-DSPs.ReferralmustbeobtainedfromanFPforconsultationswithFedhealthNetworkSpecialists.Ifreferralisnotobtainedtherewillbea20%co-paymentonspecialistclaimspaidfromtheriskbenefit.ItisimportanttonotethatqualificationforreimbursementasaPMBisnotbasedsolelyonthediagnosis(condition)butalsoonthetreatmentprovided(levelofcare).

This means that although your condition may be a PMB condition, the scheme would only be obliged to fund it in full if the treatmentprovidedwasdeemedtobePMBlevelofcare.

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You are covered for emergency medical expensesThistableshowsthatthecostofmedicalcareinemergencieswillbepaidfromtheMajorMedicalBenefit.

Toqualifyasanemergency,theconditionmustbeunexpectedandneedimmediatetreatment.(Thismeansthatifthereis no immediate treatment, the condition might result in lasting damage to organs, limbs or other body parts, or even in death).

AmbulanceServicescall0860333432

UnlimitedcoverwithEuropAssistance

Treatmentincasualty ClaimswillbepaidfromtheMajorMedicalBenefitonlyif...A member visits the trauma unit of a clinic or hospital and is admitted into hospital immediately for further treatmentA member visits the trauma unit of a clinic or hospital for emergency treatment for afracture,forexample.

ClaimswillbepaidfromtheDay-to-DayBenefitif…A member visits the trauma unit of a clinic or hospital for a non-emergency and is not immediately admitted into hospitalPlease note that if a member visits their FP for an emergency treatment such as stitches and the procedure takes place in the doctor’s consulting rooms, this will be paidfromday-to-daybenefitsandnotfromtheMajorMedicalBenefit

A R550 co-payment will apply to all visits to the trauma unit of a clinic or hospital if thememberisnotadmittedtohospitaldirectly.

Traumacounselling After a traumatic experience, for example, being a victim of crime or being in a car accident, Fedhealth provides emotional and practical support through ICAS.CallICASon0800212695.

Emergencymedicalservices:call0860333432

You can contact Europ Assistance for a range of emergency services on 0860333432. These services include:Emergency road or air responseMedical advice in any emergency situationDelivery of medication and bloodPatient monitoringCare for stranded minors or frail companions24-hourFedhealthNurseLine.

You must contact us within two working days if it was an emergency

Inanemergencyyoumustgetanauthorisationnumberfromuswithintwoworkingdaysaftergoingtohospital.If you do not, you will have topayapenaltyofR1000.

If you cannot contact the Authorisation Centre yourself, then your doctor or a family member or the hospital can contact usonyourbehalf.

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EMERGENCIES

Contact us within two working days if you needed trauma treatment

If you visit casualty for trauma treatment, you must get an authorisation number from us withintwoworkingdaysofthetreatment.Ifyoudonot,theclaimwillbepaidfromtheDay-to-DayBenefit.

Goingtohospitalinanemergency:

AN EXAMPLE

Whatthememberdoes Howtheexpenseisfunded

Kateisinvolvedinacaraccident.Abystandercallsthe number that they see on the Fedhealth sticker onKate’scar.

An ambulance is sent by Europ Assistance to transporthertohospital.Shereceivesemergencymedical care in casualty and is discharged the sameday.

KatewillhavetopaythefirstR550oftheaccount.TheSchemewillpaythebalancefromtheMajorMedicalBenefit,aslongasKatecontactstheschemewithintwoworkingdaysoftheemergencytreatment.

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About limits and co-payments for hospital staysNooverallyearlylimitThereisnooverallyearlylimitfortheMajorMedicalBenefit.

TherearelimitsandrestrictionsforspecifictreatmentsandconditionsHospitalcostsarecoveredunlimitedfromtheMajorMedicalBenefit.Casemanagementandmanagedcareprotocolsapplytocertainbenefits.Theseprotocolshavebeenintroducedtoensurebestqualitytreatmentatbestrates.ConsulttheMajorMedicalBenefittablesinthissectionfordetailontheseprotocolsandlimits.

Forsometreatmentsandprocedures,youmustpayanamountoutofyourownpocket.Thisiscalledaco-payment.Co-paymentsapplytothehospitalbillandareusuallypaidupfronttothehospital.

Different cover for different types of hospital treatments

Whenyougotohospital,therearedifferentaccountsfromdifferentproviders.Wecovertheseaccountsdifferently.Hereisasummary.Pleasereadthefullsectionfordetails.

• Theaccountforhospitalcosts.Examplesofwhatthiswouldincludeare:wardfees,theatrefees,supplies,andmedicinethatwasdispensedbythehospital.Inmostcases,hospitalcostswillbecoveredinfullbytheMajorMedicalBenefit.However, for some treatments:

- you might have to pay an amount out of your own pocket, referred to as a co-payment -theremightbelimitstotheamountwecover.Forexampleprosthesis.• Theaccountsfromdoctorsorspecialists.Forexample,ifyouhadanappendectomy,youwouldreceiveaseparateaccountfromthespecialistwhoperformedtheprocedure.IfthedoctororspecialistisintheFedhealthnetwork,wewillcoverthisinfull.

• Theseparateaccountsfromothervariousproviders,forexample,physiotherapists,X-raydepartments.Wecovertheseatdifferentrates.Seepage12.

Hospital costs we cover in full

We have agreed rates with hospitals and we will therefore pay the full hospital bill for:• accommodation in a general ward (you pay the difference if you go to a private ward)• high care ward and intensive care unit• theatrefees.

Medicine you receive in hospital

Medicinethatyouusewhileyouareinhospital Nolimit,wepaythefullcost,subjecttomanagedcareprotocols

Medicinesthatareprescribedinhospitalforyoutousewhenyougohome(take-outmedicines)

Sevendaysofmedicineforeachhospitalevent. We pay the full cost

Specialisedmedicine(alsoseepage14) Thereisnobenefitforspecialisedmedicineonthisoption

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HOSPITALVISITSANDTREATMENTPAIDFROMTHEMAJORMEDICALBENEFIT

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Doctor visits while you’re in hospital

While you are in hospital, you are under the care of specialists (such as paediatricians or cardiologists) and other doctors (suchasfamilypractitioners).Thesearecovereddifferentlytodoctorappointmentsoutofhospital.Youmustrememberthatthereimbursementratesbelowarefortheprofessionalfeesonly.

SpecialistswhoareintheFedhealthnetwork We pay professional fees in full

SpecialistswhoarenotintheFedhealthnetwork Wepay100%oftheFedhealthRateforprofessionalfees. You must pay the rest direct to the specialist

FamilypractitionerswhoareintheFedhealthnetwork We pay professional fees in full

FamilypractitionerswhoarenotintheFedhealthnetwork

Wepay100%oftheFedhealthRateforprofessionalfees. You must pay the rest direct to the healthcare professional

Dietetics,occupationaltherapyandspeechtherapy PaidfromtheDay-to-DayBenefit.Doesnotaccumulatetothreshold.PaidfromthresholduptoR11100perfamilyperyear

Physicaltherapy(physiotherapyandbiokinetics) Wepay100%oftheFedhealthRateforprofessionalfees.Youmustpaytherestdirecttothehealthcareprofessional.Subjecttoreferralbyamedicalpractitioner.Mustbepre-authorisedandsubjecttotreatment protocols

Beforeyougotohospital,youshouldtrytomakesurethatyourdoctorandspecialistareintheFedhealthnetwork.

Goingtohospitalforanoperation:

AN EXAMPLE

Whatthememberdoes Howtheexpenseisfunded

Alice’ssonneedstohavehistonsilsout.AlicemadesurethatthesurgeonandtheanaesthetistareintheFedhealthnetwork.She gathers the required information from her doctor and then phonesFedhealthtogetanauthorisationnumber.

The child has the operation and leaves the hospital on the sameday.

Alice receives two invoices by email:- An invoice from the anaesthetist- An invoice from the ear-nose-and-throat (ENT) specialist

Shesendstheaccountstotheschemeforpayment.

ThehospitalsendsitsaccountdirecttoFedhealth.

The scheme covers the cost of the anaesthetist and the specialist infullbecausetheyareintheFedhealthnetwork.

Theschemecoversthehospitalaccountinfull.Benefits,limitsandmanagedcareprotocolsapply.

Note: if the surgeon and the anaesthetist were not in the Fedhealth network,Alicewouldpaythedifferencebetween100%oftheFedhealth Rate and the cost directly to the healthcare service provider.

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Blood and pathology services while you’re in hospital

Blood,bloodequivalentsandbloodproducts We cover the full cost

Pathology(bloodtests) Wepay100%oftheFedhealthRateforprofessionalfees.You must pay the rest direct to the healthcare professional

Maternity benefit

Medicalexpensesduringpregnancy SeeDay-to-Daybenefitsonpage31

Medicalexpensesrelatedtothedelivery PaidfromMajorMedicalBenefit

Expensesforward,medicines,materialsetc.Includesdeliveryinhospital,aregisteredbirthingunitorathomeIncludesthehireofawaterbath

We cover the full cost

Gynaecologistandpaediatrician WillbecoveredinfullifintheFedhealthnetwork.IftheyarenotintheFedhealthnetwork,theywillbecoveredupto100%oftheFedhealth Rate

FundingforDoula(laboursupportduringnaturalchildbirth)

R1 270 per delivery

Afterdelivery:Post-natalmidwiferybenefit

Fourconsultationsin-orout-of-hospitalperpregnancyat100%of the Fedhealth Rate

Infanthearingscreeningbenefit Hearing test done with an audiologist until the age of eight weeks

Spinal surgery

ThereisaR4000co-paymentonthehospitalbill.ThereisnobenefitiftheConservativeBackandNeckRehabilitationProgrammehasnotbeencompleted.

ConservativeBackandNeckRehabilitationProgrammeFollowingheadaches,backandneckpainisthemostcommoncauseofillhealthandincapacityamongsthumanbeings.Itoftenhassignificantfinancialandsocialimplications,andisamajorsourceofdiscomfort.

The Fedhealth Conservative Back and Neck Rehabilitation Programme is designed to ease the pain of eligible members andhelpthemavoidspinalsurgery.Qualifyingmembersandbeneficiarieswillbeenrolledineitheraphysiotherapyprogramme, or a six-week multidisciplinary programme that involves assessment and treatment by a family practitioner, physiotherapistandbiokineticist.Positiveoutcomesincludeimprovedflexibility,reducedpainandstiffness,andthereforeabetterqualityoflife.Theprogrammehasalsobeenproventopostpone,limitorassistinavoidingsurgery.Wheresurgeryiswarranted,itwillbepermittedwithinSchemeRules.

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Pleasenote:Shouldyoudeclinetoparticipateintheprogrammepriortosurgery,therewillbeNObenefitforspinalsurgery.Inotherwords,theSchemewillnotpayforthehospital,surgeon,prosthesisoranythingrelatedtotheprocedure.And,ifspinalsurgeryisstill necessary following successful completion of the programme, and you do receive authorisation from the Scheme, you will still haveaco-paymentofR4000onthehospitalbill.Thisdoesnotapplytoemergencytreatment/PMB.

How can you access the programme? There are a number of ways to access the programme:

• The telephonic helpline on 0860002153• YoucouldbeidentifiedbytheSchemethroughpredictivemodelling• The Scheme might intervene prior to authorising your back and neck surgery• Managers might refer their employees to be assessed for eligibility • ReferralbyyourFPorspecialist.

Oncology (cancer) FullcoverforservicesthroughICONThe Scheme has contracted with Independent Clinical Oncology Network (ICON) for oncology treatment and you must use an ICON serviceproviderforalloncologyrelatedtreatment.IfyouhavenotreachedyourlimitfortheoncologybenefittheMajorMedicalbenefitwillcoveryourtreatmentforthefollowinginfulluptothebenefitlimitaccordingtotheScheme’slevel1protocols:• Oncologist consultations• Visits, treatment and materials for chemotherapy and radiotherapy• Approved medication• Radiology and pathology

ICONisanetworkofoncologiststhatincludes75%ofallpracticingoncologistsinSouthAfrica.Forinformation,visitwww.cancernet.co.za or call 0860100572.

WepayICONoncologistsinfull.IfyoudonotuseanICONoncologist,youmustpay40%ofthecostfromyourownpocket.Thisappliestoallcarethattakesplaceeitherin-orout-of-hospital.

IfyouhavereachedyourlimitfortheOncologybenefitOnceyourbenefitlimitshavebeenreachedwewillonlycoverPMBs.YoumustmakeuseoftheDesignatedServiceProvider,ICON.Ifyouuseanyotherserviceprovider,youmustpay40%ofthecostfromyourownpocket.Youcannotgetthe40%backfromyourDay-to-DayBenefits.

Limitsforspecifictreatments

Oncology:chemotherapy,radiotherapy,approvedmedication,relatedconsultations,pathologyandgeneralradiology

We pay up to a limit of R423 200

Specialisedmedicine(e.g.biologicals) Thereisnobenefitforspecialisedmedicineonthisoption

Brachytherapymaterials R42 200

OncologyDiseaseManagementProgramme(ODM)Ondiagnosisofcancer,itisimportantthatyouregisterontheOncologyDiseaseManagementProgramme(ODM).Youoryourtreating doctor can call them on 0860100572andregister.Theprogrammeaimstohelpyourdoctortoensurebesttreatmentandsupport. ChangesinyouroncologymedicineneedtobegiventoODMassoonaspossible.Pleasefaxthechangedtreatmentplanto 0214662303 or email [email protected].

Specialisedradiology(forexample,MRIorCTscans)Wecoverspecialisedradiology(forexampleMRIorCTscans)upto100%oftheFedhealthRate,whetheryouhaveitin-orout-of-hospital.YoumustpaythefirstR2100fornon-PMBscans.Youmustgetseparateauthorisationforaspecialisedradiologicalprocedure,whetherittakesplacein-orout-of-hospital.

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Other treatments or procedures that you receive in hospital

Alllimitsinthissectionareperfamilyperyear,unlessotherwiseexplained.Allco-paymentsinthissectionarepereventandapplicableonthehospital/facilitybillonly.

Appliances,externalaccessoriesandorthotics(e.g.compressionstockingsforDVT)

Paidfromtheday-to-daybenefit.Doesnotaccumulatetothreshold.PaidfromthresholduptoR11100perfamilyperyear.Sub-limitofR4130perbeneficiaryforfootorthotics

Arthroscopicprocedures:other Youpayaco-paymentofR2300onthehospitalbill.(Seepage12forcover for doctors and specialists)

Arthroscopicprocedures:Hipandwrist Youpayaco-paymentofR2300onthehospitalbill.(Seepage12forcover for doctors and specialists)

Colonoscopy,UpperGIendoscopy Youpayaco-paymentofR2300onthehospitalbill.(Seepage12forcover for doctors and specialists)

Cornealgraft WepayuptoalimitofR19700perpersonregisteredonthescheme.(See page 12 for cover for doctors and specialists)

Jointreplacements Youpayaco-paymentofR4000onthehospitalbill.(Seepage12forcover for doctors and specialists)

Non-PMBhipandkneereplacementswithDSP

No co-payment if you use one of the scheme’s DSPs, ICPS or JointCare,fornon-PMBhipandkneejointreplacements.Seepage18

Involuntarynon-useofDSPfornon-PMBhipandkneereplacements

You pay a co-payment of R4 000 on the hospital bill

Voluntarynon-useofDSPfornon-PMBhipandkneereplacements

You pay a co-payment of R25 000 on the hospital bill

Allopenherniarepairs Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)

HIV:ImmunedeficiencyrelatedtoHIVinfection

Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)

Organtransplantincludingimmunosuppressionmedication

WepayuptoalimitofR423200.(Seepage12forcoverfordoctorsand specialists)

Rhizotomiesandfacetpainblocks(limitedtooneofeitherprocedureforeachbeneficiaryeachyear)

Youpayaco-paymentofR4000onthehospitalbill.(Seepage12forcover for doctors and specialists)

Balloonsinuplasty Youpayaco-paymentofR4000onthehospitalbill.(Seepage12forcover for doctors and specialists)

Laparoscopicherniarepairs(bilateralinguinal,repeatedinguinalherniasandnissen/toupeyrepairsonly)


Laparoscopicprocedures Youpayaco-paymentofR4000onthehospitalbill.(Seepage12forcover for doctors and specialists)

Maxillo-facialsurgery Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)

Post-hospitalisationbenefit Wepayforupto30daysafterdischargeat100%oftheFedhealthRate.Seepage17.

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16

PsychiatricServices:accommodationinageneralward,procedures,ECT,materialsandhospitalequipment,consultationsandvisits,medicinesandinjectionmaterial

WepayuptoalimitofR23900.(Seepage12forcoverfordoctorsand specialists)

Renaldialysis(chronic):consultations,visits,allservices,materialsandmedicinesassociatedwiththecostofrenaldialysis

WepayuptoalimitofR423200at100%oftheFedhealthRate

Specialisedradiology(forexample,MRIorCTscans),whethertheprocedureisperformedin-orout-of-hospital

Unlimitedat100%oftheFedhealthRate(aslongasyougetseparateauthorisation)You pay a co-payment of R2 100 for non-PMB scans

Spinalsurgery Youpayaco-paymentofR4000onthehospitalbill.(Seepage12forcoverfordoctorsandspecialists).NobenefitunlessConservativeBackandNeckRehabilitationProgrammehasbeencompleted.Seepage13.Subjecttointernalprosthesisbenefitlimit.Seepage18

Terminalcare WepayuptoalimitofR29500at100%oftheFedhealthRate

Wisdomteeth(surgicalremovalofimpactedwisdomteeth)


Some treatment and procedures done out of hospitalTosaveyourDay-to-DayBenefit,wepayforvarioustreatmentsthatarenotdoneinhospitalfromtheMajorMedicalBenefit.ThishelpsmembersbecauseitmeansthatyourDay-to-DayBenefitwilllastlongereachyear.

Serviceslikephysicalrehabandtreatmentinsub-acutefacilitiesInmanycases,youmightbeabletobetreatedinasub-acutefacilityratherthanahospital.ThereisnolimitforthecoverwegiveforthisanditispaidfromtheMajorMedicalBenefit.TreatmentissubjecttoPrescribedMinimumBenefitlevelofcareonlyandtomanagedcareprotocols.

NursinginsteadofhospitalisationIf it is possible to use nursing services (including private nurse practitioners and nursing agencies) instead of going to hospital, we willcovertheexpensefromtheMajorMedicalBenefit.Subjecttomanagedcareprotocols.

Proceduresperformedindaywards,dayclinicsanddoctor’sroomsTheMajorMedicalBenefit(notDay-to-DayBenefits)coversmorethan60proceduresthatdonotrequireanovernightstayinhospitalandcansafelybeperformedindaywards,dayclinicsandthedoctor’srooms.Anexampleisatonsillectomy.

DoctorappointmentswithnetworkFPsIfyouuseanFPintheFedhealthnetwork,theappointmentispaidoutoftheMajorMedicalBenefitandnotfromyourSavings.

FemalecontraceptionInmostcases,femalecontraception,includingthecontraceptivepill,contraceptiveringsandIUDs,iscoveredbytheMajorMedicalBenefit.However,theMajorMedicalBenefitwillnotcover:

• Femalecontraceptionthatisprescribedforreasonsotherthancontraception(forexample,forskinproblems).Examplesofcontraceptive pills that we do not cover are Cyprene-35 ED, Diane–35, Tricilest, Ginette and Minerva

• CostsofconsultationsorotherexpensesrelatedtotheIUD.TheMajorMedicalBenefitcoversthecostoftheIUDitself,(forexample,Mirena)butdoesnotcoveranyrelatedcosts.WecoverthecostofanIUDeverysecondyear.

Othercostsforcontraceptionwillusuallybecoveredbysavings.

17

Some treatment after a hospital visit

MedicineyougetwhileinhospitaltotakeathomeThe scheme covers up to seven days of medicine that a doctor prescribes for you in hospital to take home with you (take-outmedicine).

TogetcoverfromtheMajorMedicalBenefit,themedicinemust both be dispensed by the hospital and be shown on theoriginalhospitalaccount.Ifyouaregivenaprescriptionfor take-out medicine and take this prescription to a pharmacy, the claim will be paid from your Day-to-Day Benefit(SavingsAccount)andnotfromtheMajorMedicalBenefit.

Treatmentinthe30daysafteryourhospitalvisit (post-hospitalisationbenefit)ToprotectyourDay-to-DayBenefit,theschemecoverscertain treatments up to 30 days after discharge from hospitalfromtheMajorMedicalBenefit.Thistreatmentissubjecttoprotocols.Thedaythatyouaredischargedcountsasthefirstdayofthe30daysofcover.

Thisbenefitcoverstreatmentat100%oftheFedhealthRate.Itpaysfor:• Complicationsthatmightarisefromhospitalisation.• Physiotherapy, occupational therapy, speech therapy, general radiology, pathology tests and dietetics (limited to two consultationswithadieticianperhospitaladmission).

Thefollowingconditionsapplytothe30-daypost-hospitalisationbenefit:• Onlytreatmentasaresultofahospitaleventwillbecovered.Thetreatmentmustberelatedtotheoriginaldiagnosis.• Youmustgetanauthorisationnumberforthisbenefitinadditiontotheauthorisationnumberforthehospitaladmission.Ifyoudonotgetaseparateauthorisationnumberfromus,theclaimwillbepaidfromtheDay-to-DayBenefitsandnotfromtheMajorMedicalBenefit.

Prosthesis benefit table

ExternalprosthesisWepayforexternalprosthesesuptoalimitofR11100perfamilyperyearatcost.ThisispaidoutoftheMajorMedicalBenefit.

InternalprosthesisThereisaseparatebenefitforinternalprosthesis.Thebenefitdoesnotincludeosseo-integratedimplantsforreplacingteeth.Hipandkneebilateralreplacementswillbeallowedforuptodoubletheamountforasinglehipandkneereplacement.

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18

Internalprosthesisexpense Cover Limitsperfamily

Aortastentgrafts 100%ofcost R55 700

Detachableplatinumcoils 100%ofcost R48 300

Cardiacstents 100%ofcost R26 500

Cardiacvalves 100%ofcost R26 500

Cardiacpacemakers 100%ofcost R26 500

Intraocularlenses(perlens) 100%ofcost R3 100

Shoulderreplacement 100%ofcost R26 500

Elbowreplacement 100%ofcost R26 500

Hipreplacement(SeeICPS&JointCarebelow) 100%ofcost R26 500

Kneereplacement(SeeICPS&JointCarebelow) 100%ofcost R26 500

TotalanklereplacementBonelengtheningdevicesSpinalplatesandscrewsCarotidstentsPeripheralarterialstentgraftsEmbolicprotectiondevicesOtherapprovedspinalimplantabledevices

100%ofcost100%ofcost100%ofcost100%ofcost100%ofcost100%ofcost100%ofcost

Seecombinedbenefitlimitforallunlisted internal prostheses*

*Combinedbenefitlimitforallunlistedinternalprostheses 100%ofcost R23800

Improved Clinical Pathway Services (ICPS) and JointCare for non-PMB hip and knee replacements

We’reallaboutthecoordinationofyourcaretoensureyourecoverquickerandmoreeffectively.That’swhywehaveappointedImprovedClinicalPathwayServices(ICPS)andJointCareasthedesignatedserviceproviders(DSPs)fornon-PMBhipandkneereplacements.AclinicalpathwaymeansthatanetworkofrelevanthealthcarepractitionerswilloverseeeverystepofyourhiporkneereplacementjourneywithyourFP,fromFPreferraltosurgery,rightthroughtoyourfullrehabilitation.Asthepatient,youbenefitsincethiscoordinatedapproachhasbeenproventoresultinbetterhealthoutcomesandpatientsatisfaction.So,you’llbeback on your feet before you know it thanks to a managed process that includes your pre-op assessment, a rapid recovery plan, withpre-operativestrengthening,physiologicalanaesthesia,minimallytraumaticsurgery,andpostoperativephysiotherapy.

Pleasenote:SinceICPSandJointCarearetheFedhealthDSPsforhipandkneereplacements,youwillhaveaR25000co-paymentifyouvoluntarilydeclinetousethemfornon-PMBhiporkneereplacements.

Contact ICPS on 0860 002 153orviawww.icpservices.co.za,andJointCareon011 883 3310.

19

You must have authorisation YouneedauthorisationbeforetheMajorMedicalBenefitwillcoveranyclaim,forexample,aplannedoremergencyhospitaladmission,specialisedradiology,selectedprocedures,30-daypost-hospitalisationbenefitorcasualtytreatment.

Contactusatleast48hoursbeforethehospitalstayortheprocedureYoumustcontactusatleast48hoursbeforeanytreatmentthatisnotanemergencyorthatisplanned.Youmustwritedowntheauthorisationnumberwegivetoyouandtakeitwithyoutohospital.

You must get a separate authorisation number for specialised radiology and for treatment covered in the 30 days after thehospitalvisit.Ifindoubt,pleasedocontactustofindoutifyouneedanauthorisationnumber.

Whenyoucontactus,havethisinformationreadyWe need the following information to authorise your treatment:

1. Fedhealthmembershipnumber2.Dateofbirthofpatient3.Reasonforadmission,ICD10andapplicabletariffcodesfortheproposedtreatment

(your doctor must give these to you)4.Dateofadmissionandtheproposeddateoftheoperationortreatment5.Thetreatingdoctor’snameandtelephoneandpracticenumbers6.Nameofthehospitalwithtelephoneandpracticenumbers7.ForaCTscan,MRIprocedureorsimilarprocedure,thenameoftheradiologicalpractice.

Phone us: 0860002153 Monday to Thursday 08h30 – 19h00Friday 09h00 – 19h00

Email us: [email protected]

AllcostscoveredfromtheMajorMedicalBenefitneedtobepre-authorisedbytheAuthorisationCentreon

0860 002 153

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04

TOHAVEHOSPITALOROTHERTREATMENTCOVEREDBYTHEMAJORMEDICALBENEFIT

20

21

Screening benefit

Thisbenefitcoversvariousscreeningandpreventativeprogrammesthataimtoimproveyourhealth.

Screeningtest Beneficiariesregisteredontheschemewhoqualifyforthebenefit

Limitofscreeningtests

Women’sHealth

Breastcancerscreeningwithmammography Women, 45 to 74 years old 1 every 3 years

Cervicalcancerscreening(Pap smear) Women, 21 to 65 years old 1 every 3 years

Children’sHealth–seetableontherightfortheimmunisationbenefit

CardiacHealth

Cholesterolscreening(fulllipogram) Everyone 20 years old and older 1 every 5 years

General

Fluvaccination Everyone 1 every year

HIVtestby contracted wellness network provider

Everyone 1 every year

Healthriskassessments

Wellnessscreening(BMI,bloodpressure,fingerprickcholesterolandglucosetests)


Preventativescreeningbycontractedwellnessnetworkprovider(waist-to-hipratio,bodyfat%,flexibility,postureandfitness)


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SCREENINGANDIMMUNISATIONBENEFITS

Active Disease Risk Management programmes

The Scheme offers the following two programmes to help you address certain health issues:

Programme Beneficiariesregisteredontheschemewhoqualifyforthebenefit

Limitofbenefit

WeightManagementProgramme Qualifyingmembers 1perbeneficiaryperyear

SmokingCessationProgramme Everyone 1perbeneficiaryperyear

Immunisation benefit for children

Ageofchild Vaccine

Atbirth Tuberculosis (Bacilles Calmette Guerin)OPV(0) Oral Polio Vaccine

6Weeks OPV(1) Oral Polio VaccineRV(1)RotavirusVaccineDTaP-IPV//Hib(1)Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilusinfluenzae type b CombinedHepB(1) Hepatitis B VaccinePCV7(1)PneumococcalConjugatedVaccine

10Weeks DTaP-IPV//Hib(2) Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilusinfluenzae type b CombinedHepB(2)Hepatitis B Vaccine

14Weeks RV(2)RotavirusVaccine (should not be administered after 24 weeks)DTaP-IPV//Hib(3) Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilusinfluenzae type b CombinedHepB(3) Hepatitis B VaccinePCV7(2)PneumococcalConjugatedVaccine

9Months MeaslesVaccine(1)PCV7(3)PneumococcalConjugatedVaccine

18Months DTaP-IPV//Hib(4) Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilusinfluenzae type b CombinedMeaslesVaccine(2)

6Years TdVaccine Tetanus and reduced strength of diphtheria Vaccine

12Years TdVaccine Tetanus and reduced strength of diphtheria Vaccine

22

23

What is chronic medicine?TheChronicDiseaseBenefitcoverschronicmedicine.Chronicmedicineismedicinethatistakenforapersistentorotherwiselong-lastingcondition.Examplesofconditionsthatrequireongoingmedicinearehypertension,diabetesandasthma.Thisoptioncoverschronicmedicinefor39chronicconditions.

LimitsTheoveralllimitisR5410peryearperbeneficiary,uptoalimitofR10800peryearforeachfamily.

ToclaimunderthisbenefitYour condition:• must be in the list of chronic conditions (given below); and•mustmeetasetofdefinedcriteriatoqualifyforthebenefit(referredtoasclinicalentrycriteria).

Inotherwords,justbecauseyouhaveoneoftheconditionsonthelistbelow,doesnotmeanthatwewillcovertheexpensesoutoftheChronicDiseaseBenefit.Theconditionmustalsomeetasetofdefinedcriteria.Ifyouneedinformationonthecriteria,pleasecontactus.

ListofchronicconditionsThisbenefitcoversmedicineandtreatmentforasetof39chronicconditionsaswellasHIV/Aids.ThesearegiveninList1belowandList2onpage24.

List1:ConditionsthatarePrescribedMinimumBenefitconditionsSeesection1,‘PrescribedMinimumBenefits(basiclevelofcoverforadefinedsetofconditions),foranexplanationofPrescribedMinimumBenefits.

Addison’s DiseaseAsthmaBipolar Mood DisorderBronchiectasisCardiac FailureCardiomyopathyChronic Renal DiseaseCOPD/Emphysema/ChronicBronchitisCoronary Artery DiseaseCrohn’s DiseaseDiabetes InsipidusDiabetes Mellitus type 1 & 2Dysrhythmias

EpilepsyGlaucomaHaemophiliaHyperlipidaemiaHypertensionHypothyroidismMultiple SclerosisParkinson’s DiseaseRheumatoid ArthritisSchizophreniaSystemic Lupus ErythematosusUlcerative Colitis

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CHRONICMEDICINE(COVEREDBYCHRONICDISEASEBENEFIT)

24

IfyourconditionisonList1(PrescribedMinimumBenefits)

IfyouhavenotreachedyourlimitfortheChronicDiseaseBenefit:

Medicinesthatwecover(formulary)

Iftheconditionqualifiesforthebenefit,wecovermedicinesontherestrictiveformularyonly,andonlyuptotheceilingpricegivenintheMedicinePriceList.Ifyouuseamedicinenotonthislist,youmustpay40%ofthecostfromyourownpocket.Youcannotgetthe40%backfromyourDay-to-DayBenefits.

Serviceprovidersyoushoulduse

Iftheconditionqualifiesforthebenefit,youcanuseanyserviceprovider.TheSchemepaysuptoanagreedratefordispensingfees.Youwillpaythedifferenceifthepharmacychargesmore.Medi-Rite,Dis-Chem,ClicksandPharmacyDirectdonotchargemorethantheagreedrate.

IfyouhavereachedyourlimitfortheChronicDiseaseBenefit:


Iftheconditionqualifiesforthebenefit,wecovermedicinesontherestrictiveformularyonly,andonlyuptotheceilingpricegivenintheMedicinePriceList.Ifyouuseamedicinenotonthislist,youmustpay40%ofthecostfromyourownpocket.Youcannotgetthe40%backfromyourDay-to-DayBenefits.

Serviceprovidersyoushoulduse Iftheconditionqualifiesforthebenefit,youcanuseanyserviceprovider.TheSchemepaysuptoanagreedratefordispensingfees.Youwillpaythedifferenceifthepharmacychargesmore.Medi-Rite,Dis-Chem,ClicksandPharmacyDirectdonotchargemorethantheagreedrate.

List2:Additionalchronicconditionscoveredonyouroption

Ankylosing SpondylitisAnorexia NervosaAttentionDeficitDisorder(inchildrenonlyuptoageof18)Bulimia NervosaDepressionDermatomyositisGeneralised Anxiety Disorder

NarcolepsyObsessive Compulsive DisorderPanic DisorderParaplegia/Quadriplegia(associatedmedicine)Post-Traumatic Stress SyndromeSclerodermaTourette’s Syndrome

IfyourconditionisonList2(AdditionalChronicConditions)

IfyouhavenotyetreachedyourlimitfortheChronicDiseaseBenefit


Iftheconditionqualifiesforthebenefit,wecovermedicinesontherestrictiveformularyonly,andonlyuptotheceilingpricegivenintheMedicinePriceList.Ifyouuseamedicinenotonthislist,youmustpay40%ofthecostfromyourownpocket.

Serviceprovidersyoushoulduse Iftheconditionqualifiesforthebenefit,youcanuseanyserviceprovider.TheSchemepaysuptoanagreedratefordispensingfees.Youwillpaythedifferenceifthepharmacychargesmore.Medi-Rite,Dis-Chem,ClicksandPharmacyDirectdonotchargemorethantheagreedrate.

Thereisnobenefitatallfortheadditionalchronicconditionsonceyourchronicbenefitisusedup.

25

Havingachroniccondition:

AN EXAMPLEWhatthememberdoes Howtheexpenseisfunded

Lilyhasasthma and her doctor prescribes medicine thatshemusttakeregularly.

She decides to apply online on www.fedhealth.co.za ratherthanonthephone.Herdoctorgivesherthedetailsthattheonlineapplicationasksfor.

Chronic Medicine Management (CMM) at Fedhealth tell her that the application is accepted because her asthmameetstheclinicalcriteria.

Lily then gets the Medicine access card in the post aswellasbyemail.Shecantakeittoanypharmacytogetherwithherscripttobuyhermedicine.Sincethe Scheme pays up to an agreed rate for dispensing fees, Lily will pay the difference if the pharmacy sheuseschargesmore.Medi-Rite,Dis-Chem,Clicksand Pharmacy Direct do not charge more than the agreedrate.IfLilywantstomakeuseofPharmacyDirect, a courier pharmacy, she can register with them and have her chronic medication delivered to anagreedaddress.

When Lily is buying her medicine, the pharmacist tells her that the prescribed medicine will not be covered in full but that there is a generic medicine thatwouldbecoveredinfull.Shedecidestochangeto the generic so that the full cost of the medicine is covered.

BecauseasthmaisaPrescribedMinimumBenefitcondition, she will receive treatment guidelines with herletterfromCMM.Thesewilltellheraboutwhichotherexpensesarecoveredbyriskbenefits(thescheme).

LilyhasnotreachedthelimitfortheChronicDiseaseBenefit, so the cost of the medicine is covered in full, as long as the prescribed medicine is on the restrictive formulary and the costs fall within the ceiling price given on the Medicine PriceList.IfLilyusesmedicinethatisnotontherestrictiveformulary,thenLilywouldhavetopay40%ofthecostfromherownpocket.

IfLilyhadreachedthelimitfortheChronicDiseaseBenefit, becauseasthmaisaPrescribedMinimumBenefitcondition,wewouldcovermedicinesthatareontherestrictiveformulary.This means that there might be some medicines that we do not coveratall.IfLilyusesmedicinesthatarenotontherestrictiveformulary,thenLilywouldhavetopay40%ofthecostfromherownpocket.

We would only cover the medicine up to the ceiling price given ontheMedicinePriceList.

Lilycangethermedicinefromanypharmacy.SincetheScheme pays up to an agreed rate for dispensing fees, Lily willpaythedifferenceifthepharmacysheuseschargesmore.Medi-Rite, Dis-Chem, Clicks and Pharmacy Direct do not chargemorethantheagreedrate.

IfLilyhadaconditionthatisnotaPrescribedMinimumBenefit,therewouldbenocoveraftertheChronicDiseaseBenefithasreachedthelimit.

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26

27

CoverfortreatmentforHIV/Aids

ThereisunlimitedcoverforHIV/Aidstreatmentandpreventativemedicine.

Toqualifyforthisbenefit,youmustberegisteredonthescheme’sHIV/Aidsdiseasemanagementprogramme,AidforAids(AfA).YouhaveaccesstotheHIV/Aidsmedicinebenefitonlywhenyouareregistered.

AfA is a comprehensive HIV disease management programme with access to:

• anti-retrovirals and related medicines• post-exposure preventative medicine• preventative medicine for mother-to-child transmission• post-exposurepreventativemedicineafterrape.

Theprogrammegivesongoingpatientsupportandmonitorsthediseaseandresponsetotherapy.TojoinAfA,calltheminconfidenceon0860100646.YourdoctormayalsocallAfAonyourbehalf.

How to apply for the Chronic Disease Benefit

STEP 1:CollecttheinformationneededtoapplyYouwillneedthefollowinginformationtoapply.Ifyouneedhelpgatheringthisinformation,pleasecontactus.• Membership number• Dependant code• ICD10 code• Drug name, strength and quantity• Prescribing doctor’s practice number• Diagnostictestresults,e.g.TotalCholesterol,LDL,HDL,glucosetests,thyroid(dependingonyourcondition).

STEP 2:ApplyYou have a choice of how to apply:Applybytelephone: You can call Chronic Medicine Management (CMM) between 08h30 and 17h00, Monday to Thursdayand09h00to17h00onFridays.Phone0860002153.Applyonourwebsite: Go to www.fedhealth.co.za.Youwillneedtoregisteronthewebsitebeforeyoucanapply.Onceyouhaveregistered,clickon“myauthorisations”andthenselect“mychronicapplication”.Selectthepersonthatyouwanttoapplyforandthenclickonthe“Chronic”authorisationbuttonatthebottomofthepage.Thenselect“NewChronicApplication”.Askyourdoctororpharmacisttoapplyonyourbehalf.TheycandoanonlineapplicationorcontactourProviderCallCentreon0861112666.

STEP 3:WewillgiveyouaresponserightawayWewillreplytoyourapplicationrightaway.Ifweneedmoreinformation,wewillletyou,yourdoctororyourpharmacistknowexactlywhatinformationtogivetous.

If we do not approve the application, we will give you the reasons why, and you will have the opportunity to ask us to reviewourdecision.

STEP 4:YougetyourmedicineaccesscardIfweapproveyourapplication,wewillgiveyouamedicineaccesscard.Yourmedicineaccesscardwillrecordthemedicalconditionforwhichwehaveapprovedtreatment.

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We will give you treatment guidelines

The scheme has set up treatment guidelines if you have applied for conditions on List 1 to ensure that you have access to appropriatetreatmentforyourcondition.YouwillreceivedetailsofthetreatmentguidelineswithyourletterfromCMM.

If there is a co-payment on your medicine

Ifyoufindthatthemedicineyourdoctorhasprescribedforyouhasaco-payment,becauseitcostsmorethantheceilingpricegiven in the Medicine Price List, you can ask your pharmacist to help you to change it to a generic medicine that the scheme covers infull.Ifthemedicinehasaco-paymentbecauseitisnotintheformulary,thenyoushoulddiscussapossiblealternativewithyourprescribingdoctor.

We will approve a chronic condition, not individual chronic medications

Thankstoastreamlined,simplifiedapprovalprocessforchronicmedicationcalledDiseaseAuthorisation,youcanapplyforapprovalofachroniccondition,asopposedtoasinglechronicmedication. ThismeansthattheSchemewillapproveanentirelistofmedicationforyourspecificcondition(knownasabasketofmedicine).So,ifyourdoctorshouldeverchangeyourmedication,youwillmostlikelyalreadybeapprovedforit–providedit’sinthebasket.Onamore practical level it means that when you need to change or add a new medicine for your condition, you can do this quickly and easilyatyourpharmacywithanewprescription,withouthavingtocontactFedhealthatall. If you would like to check what medicine is available to you in your condition’s basket, visit www.fedhealth.co.za and log in as a membertouseourhandyDiseaseAuthorisationMedicineSearchtool.Ifyouarenotregisteredonthesite,click‘Register’andfollowtheinstructions.

Chronic medication delivered to your door

To give you the added convenience of having your chronic medication delivered directly to you (home, work, temporary address or nearestPostOffice),youcanuseourpreferredprovider,PharmacyDirect,forfree-of-chargecourierservices.

PharmacyDirecthasaproventrackrecordoffriendlyprofessionalserviceandontimedeliveries.Formoreinformation,visitwww.pharmacydirect.co.za or get in touch by calling 0860027800,MondaystoFridaysfrom07h30to17h00.Remembertoinclude your Fedhealth membership number on all communication!

29

Paying for day-to-day expenses (Day-to-Day Benefits)

Theschemegivesanoveralllimitfortheamountofcoveryouandyourfamilyhaveforday-to-daymedicalexpenses.Examples of day-to-day medical expenses are:

• visits to doctors or specialists• short-termcoursesofmedicine(forexample,antibioticsfortheflu)• optometry (glasses)• visitstothedentist.

Theseday-to-dayexpensesmaybepaidoutoftwodifferentbenefitsundertheoverallDay-to-DayBenefit.Thewaythebenefitsworkwillaffectthelimitsthataregiveninthetableonpage34,somakesureyoureadthiswholesection.

Thebasicsofthetwobenefitsforday-to-daymedicalexpensesThelimitsofallthebenefitsbelowdependonthesizeofyourfamily.Pleaserefertotheratestableonpage44.

TheSavingsAccountpaysforday-to-dayexpensesfirst(fromthebeginningoftheyear)andpaysexpensesuptotheactualcost.Insomecases,ifyouhavemoneyavailableinyourSavingsAccount,youcanusethistopayco-payments.However,aco-paymentforaPrescribedMinimumBenefitconditioncannotbepaidfromyourSavingsAccount.

TheSavingsAccountworksdifferentlytootherbenefitsinthatyoucarryanyremainingamountovertothenextyear.Therearealsoimplicationsifyouleavethescheme–seepage45.

TheThresholdBenefit is intended to cover medical expenses if you still have day-to-day medical expenses even after yourSavingsAccountisusedup.

Youmustpaywhileyouareintheself-paymentgapTheremightbeagapbetweenwhentheSavingsAccountrunsoutandtheThresholdBenefitkicksin.Duringthisgap(referredtoasaself-paymentgap),youwillhavetopayforallday-to-daymedicalexpensesoutofyourownpocket.

ThegapoccursbecausetheThresholdBenefitkicksinonlywhenallyourday-to-dayexpenseshaveaddeduptothethresholdlevelattheFedhealthRate.

Whenyouareintheself-paymentgap,youmuststillcontinuetosubmitallyourclaims.Eventhoughwewon’tbeabletorefundthem,theywillstilladduptowardsyourthresholdlevel.

Examplesofexpensesthatwillincreasetheself-paymentgapThe following expenses will increase your self-payment gap:

• Usingalternativehealthcare(e.g.homeopathy)orhavingmedicinesprescribedfromalternativehealthcareproviders• Claiming for services that are charged above the Fedhealth Rate, for example if you go to doctors or specialists that

are not in the Fedhealth network• Claiming for medicines that are more expensive than the ceiling price given in the Medicine Price List• Claiming for more than the yearly limits, for example, for advanced dentistry and optical limits• Claiming for over-the-counter medicines• Using pharmacies that are not in the Fedhealth network• ClaimingforanyAdditionalMedicalServicee.g.speechtherapy• Claimingforappliances,externalaccessoriesandorthoticse.g.hearingaids.

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PAYINGFORDAY-TO-DAYEXPENSES(DAY-TO-DAYBENEFITS)

30

WhentheThresholdBenefitkicksin,existinglimitsapplyOnceyouhavereachedtherequiredthresholdlevel,yourday-to-dayexpenseswillbepaidfromtheThresholdBenefit.Manyofyourday-to-dayexpenseswillbecoveredunlimited,butanyexistinglimitswillstillapply.Forexample,ifafamilyspendsR10000onoptometry,amaximumofR9700willadduptowardstheirthresholdlevelbecausethelimitforoptometryisR9700perfamily.OncethisfamilyisintheThresholdBenefit,theywillhavenomorecoverforoptometryfromtheThresholdBenefitastheirlimitwillhavebeenreached.

AlsotheThresholdBenefitpaysonlyuptotheFedhealthRateandthereisa20%co-payment on all claims paid from the Threshold Benefit.Youhavetopayanydifferencefromyourownpocket.

Cover for doctors, specialists and medicines

FPsintheFedhealthnetworkIfyouuseanFP(familypractitioner)intheFedhealthnetwork,yourconsultationispaidoutoftheMajorMedicalBenefitandneverfromyourSavings.Thiscoverstheconsultationonly.TofindanFPintheFedhealthnetwork,gotoourwebsite,theFedhealthMember App or call 0860002153.

Even if you’re in the self-payment gap, Fedhealth gives unlimited cover for FP consultations, as long as you use an FP who is in the Fedhealthnetwork.ThismeansthatyoualwayshaveunlimitedcoverforFPs,aslongasyouuseanFPintheFedhealthnetwork.

PleasenotethatamaximumoftwomentalhealthFPconsultationsperbeneficiaryperyearwillbecoveredfromRisk.(Combinedlimitwithout-of-networkFPs).

FPsnotintheFedhealthnetworkIf you do not use an FP in the Fedhealth network, the consultation will be paid from Savings and will add up to the threshold level at100%oftheFedhealthRate.WhenintheThresholdBenefit,theseconsultationsarepaidat100%oftheFedhealthRate.PleasenotethatamaximumoftwomentalhealthFPconsultationsperbeneficiaryperyearwillbecoveredfromSavingsandThreshold.(CombinedlimitwithnetworkFPs).

SpecialistsintheFedhealthnetworkSpecialistsintheFedhealthnetworkhaveagreedtoasetrateforconsultations.Ifyouhavesavingsavailable,theconsultationwillbepaidoutofthisbenefitatthisrate.Itwillalsoadduptowardsthethresholdlevelatthisrate.Ifyouareintheself-paymentgap,youwillhavetopayfortheconsultationfromyourownpocketbutalsoonlyatthesetrate.WhenyoureachthethresholdlevelandtheThresholdBenefitkicksin,wecovervisitstospecialistsintheFedhealthnetworkinfull.Beforeyouconsultaspecialist,pleaseseeyourFPtoobtainareferral.Ifreferralisnotobtainedtherewillbea20%co-paymentonspecialistclaimspaidfromtheRiskbenefit.

SpecialistsnotintheFedhealthnetworkIfyoudonotuseaspecialistintheFedhealthnetwork,theconsultationwillbepaidfromyourSavingsAccountuptocost.

TheexpensewilladduptothethresholdlevelattheFedhealthRate.WhenintheThresholdBenefit,theconsultationsarealsopaidattheFedhealthRate.Beforeyouconsultaspecialist,pleaseseeyourFPtoobtainareferral.Ifreferralisnotobtainedtherewillbea20%co-paymentonspecialistclaimspaidfromtheRiskbenefit.

PrescribedmedicineThereisalimitforprescribedmedicine.Forexample,theindividuallimitisR5410.IfyouhavealreadyspentR3000accordingtothe ceiling prices given in the Medicine Price List when you reach the threshold level, then you will only have R2 410 available to spendfromtheThresholdBenefitforprescribedmedicine.WhenyouareintheThresholdBenefit,yougetcoverforprescribedmedicineonlyattheceilingpriceoftheMedicinePriceList.Youareresponsibleforpayingthedifference.

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DispensingfeesforprescribedmedicinePharmacieschargeadispensingfeeforeachprescribedmedicinethattheysell.TheschemehasagreedspecialratesfordispensingfeeswithpharmaciesintheFedhealthnetwork.IfyouuseapharmacyintheFedhealthnetwork,wewillcovertheagreeddispensingfeeinfullfromyoursavings.

TofindapharmacyintheFedhealthnetwork,gotothewebsite,theFedhealthMemberApporcall0860002153.

If you buy from a pharmacy not in the Fedhealth network, then you might have to pay the difference between the agreeddispensingfeeandthedispensingfeethatthepharmacycharges.

Over-the-countermedicineMedicineswithascheduleof0,1or2canbeboughtfromthepharmacywithoutaprescriptionfromyourdoctor.ThecostwillbepaidoutofyourSavingsAccountandtheamountwillnotadduptowardsyourthresholdlevel.

TheThresholdBenefitdoesnotcoverover-the-countermedicine.

FemalecontraceptionInmostcases,femalecontraceptioniscoveredbytheMajorMedicalBenefit–seepage16.However,contraceptivepillsarepaidfromyourSavingsAccount if they are prescribed for reasons other than contraception (for example,forskinproblems).ExamplesofcontraceptivepillsthatwedonotcoverundertheMajorMedicalBenefitincludeCyprene-35ED,Diane–35,Tricilest,GinetteandMinerva.

The consultation and the cost of procedures for IUDs are paid from your SavingsAccount.OnlythecostoftheIUDitselfispaidfromtheMajorMedicalBenefit.WecoverthecostofanIUDeverysecondyear.

PregnancyPregnancycostsarecoveredfromtheSavingsAccount.YoushouldselectagynaecologistintheFedhealthnetwork.Consultationswillbecoveredinfullatthesetrateandwilladduptothethresholdlevelinfull.Ifthespecialistisnotinthenetwork,thenonlytheFedhealthRatewilladduptothethresholdlevel.Usinga gynaecologist in the Fedhealth network will ensure that in-hospital claims are coveredinfullandyouwillnothavetopayanyco-payments.

Atotaloftwo2Dultrasoundscansperpregnancywilladduptothethresholdlevel.

Specialisedradiology(forexample,MRIorCTscans)Wecoverspecialisedradiology(forexampleMRIorCTscans)upto100%oftheFedhealthRate,whetheryouhaveitinoroutofhospital.YoumustpaythefirstR2100fornon-PMBscans.Youmustgetseparateauthorisationforaspecialisedradiologicalprocedure,whetherittakesplacein-orout-of-hospital.

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Over-the-countermedicine:


Andy feels unwell and decides to follow his pharmacist’s recommendationtotakeanover-the-counterflumedicine.

HechoosesapharmacywithintheFedhealthnetwork.

Whethertheexpenseiscovereddependsonhisbenefits:

If Andy has enough money in his Savings Account to cover the medicine, he will not have to pay anything from his own pocket.

If Andy does not have enough money in his Savings Account, hewillhavetopaythepharmacyhimself.

The cost of over-the-counter medicine does not add up to the thresholdlevel.

Visitingadoctor(FamilyPractitioner):


Maryhasfluandwantstoseeherdoctor,DrChris.Shegoesonto www.fedhealth.co.zatoconfirmifDrChrisisontheFedhealthnetwork.Shefindsoutthatheis.

She has a consultation with the doctor and he prescribes a courseofantibioticsforher.

Mary then goes to the pharmacy to buy the medicine that was prescribedforher.Shemakessurethatsheasksforagenericversion of the antibiotics and she makes sure that she goes to a pharmacyintheFedhealthnetwork.

TheconsultationBecause Dr Chris is in the Fedhealth network, Fedhealth hasagreedasetratefortheconsultation.Thisishowtheconsultation will be funded:

Theconsultationispaidoutofriskbenefits(MajorMedicalBenefit).

TheprescribedmedicineMary had not reached the limit for prescribed medicine and had asked for a generic of the medicine which fell within the ceilingpriceontheMedicinePriceList.So:

If she has money in the Savings Account, it will pay the expenseandthefullamountaddsuptothethresholdlevel.

(If Mary had chosen a medicine that cost more than the ceiling price on the Medicine Price List, the difference would not add uptothethresholdlevel).

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FPnon-network:


Davidhasfluandwantstoseehisdoctor,DrMary.Hegoes onto www.fedhealth.co.zatoconfirmifDrMaryisontheFedhealthnetwork.Hefindsoutthatsheisnot.

He has a consultation with the doctor and she prescribes a course of antibiotics for him.

David then goes to the pharmacy to buy the medicine that was prescribed forhim.Hemakessurethathe asks for a generic version of the antibiotics and he makes sure that he goes to a pharmacy in the Fedhealth network.

TheconsultationBecause Dr Mary is not in the Fedhealth network, this is how the consultation will be funded:

IfDavidhasfundsavailableinhisSavingsAccount,theconsultationiscoveredinfull.However,onlytheFedhealthRateaddsuptothethresholdlevel.

TheprescribedmedicineDavid had not reached the limit for prescribed medicine and had asked for a generic ofthemedicinewhichfellwithintheceilingpriceontheMedicinePriceList.So:

If he has money in the Savings Account, it will pay the expense and the full amount addsuptothethresholdlevel.

(If David had chosen a medicine that cost more than the ceiling price on the Medicine PriceList,thedifferencewouldnotadduptothethresholdlevel).

Goingtoseeaspecialist:


John’sfamilydoctorhasreferred him to a specialist because of an ongoing sore throat.Hehasaconsultationwiththespecialist.

IfthespecialistisintheFedhealthnetworkThis is how the consultation will be funded:

IfJohnhasmoneyavailableinhisSavingsAccount,theconsultationiscoveredinfullatthesetrateandaddsuptothethresholdlevelinfull.

IfthespecialistisnotintheFedhealthnetworkThis is how the consultation will be funded:

IfJohnhasmoneyavailableinhisSavingsAccount,theconsultationiscoveredinfull.However,onlytheFedhealthRateaddsuptothethresholdlevel.

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All cover in day-to-day benefits

Inthetablebelow,certainexpensesaresubjecttolimits.Theselimitsapplytotheaccumulationofclaimstothethresholdlevel aswellastherefundofclaimsfromtheThresholdBenefit.Forexample,ifafamilyspendsR10000onoptometry,amaximumof R9700willadduptowardstheirthresholdlevelbecausethelimitforoptometryisR9700perfamily.OncethisfamilyisintheThresholdBenefit,theywillhavenomorecoverforoptometryfromtheThresholdBenefitastheirlimitwillhavebeenreached. AlsotheThresholdBenefitpaysonlyuptotheFedhealthRateandthereisa20%co-payment on all claims paid from the Risk BenefitexceptconsultationswithnetworkFPs.Networkspecialistconsultationswillnowalsoattractaco-paymentifnoFPreferralisobtained.Youhavetopayanydifferencefromyourownpocket.

Day-to-daymedicalexpense Limits HowtheSavingsAccountcoverstheexpense

Howtheexpenseaddsuptowardsthethresholdlevel

HowtheThresholdBenefitcoverstheexpense

Additionalmedicalservices:Audiology,dietetics,genetic counselling, hearing aid acoustics, occupational therapy, orthoptics, podiatry, private nursing*, psychologists, speech therapy, social workers

Limit of R11 100 per family per year for the total of all additional medical services in and out-of-hospital

At cost Does not add up to threshold level

Covered at Fedhealth Rate up to the limit

Alternativehealthcare:Acupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including medicines prescribed by alternative healthcare professionals)

No limit At cost Does not add up to threshold level

Not covered

Antenatalscans Two 2D antenatal scans per person per year

At cost Adds up at Fedhealth Rate to the maximum of the limit


Appliances,externalaccessoriesandorthotics: Hearingaids,wheelchairsetc.

Limit of R11 100 per family per year.Sub-limitofR4130perperson for foot orthotics in and out-of-hospital



*PrivatenursingthatfallsoutsidetheAlternativestoHospitalisationBenefit




Biokinetics,chiropractics The Additional Medical Services limit of R11 100 per family per year applies (combined limit)


Covered at Fedhealth Rateup to the limit

Dentistry(Advanced):Inlays, crowns, bridges, mounted study models, metal base partial dentures, osseo-integrated implants, orthognathic surgery, oral surgery, orthodontic treatment, periodontists, prosthodontists and dental technicians

Limit of R7 100 per person per year, up to an overall limit of R21 100 per family per year



Dentistry(Basic) No limit At cost Adds up at Fedhealth Rate

Covered at Fedhealth Rate

Femalecontraception SeeFemalecontraceptionpaidoutofMajorMedicalBenefit(page16)andFemalecontraceptionpaidoutofDay-to-DayBenefits(page31).

FamilyPractitioners:*Pleasenoteonlytwomentalhealthconsultationsperbeneficiarywillbepaidfromthemajormedicalbenefit

FedhealthNetworkFPs No limit – you are always covered even in the self-payment gap

Never paid from savings

Does not add up to threshold level

Covered from MajorMedicalBenefit

Non-FedhealthNetworkFPs No limit At cost Adds up at Fedhealth Rate


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

Limit of R3 180 per person per year, up to an overall limit of R9 700 per family per year



Over-the-countermedication No limit At cost Does not add up to threshold level

Not covered

Pathology No limit At cost Adds up at Fedhealth Rate


Physiotherapy The Additional Medical Services limit of R11 100 per family per year applies (combined limit)


Covered at Fedhealth Rateup to the limit

Prescribedmedication Limit of R5 410 per person per year, up to an overall limit of R10 800 per family per year

At cost Adds up at the MPL to the maximum of the limit

Covered up to MPL up to the limit

Radiology(General) No limit At cost Adds up at Fedhealth Rate


Radiology(Specialised) PaidfromtheMajorMedicalbenefitifpre-authorisedupto100%oftheFedhealthRate,whetheryouhaveitin-orout-of-hospital.YoumustpaythefirstR2100fornon-PMBscans

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SpecialistsexcludingPsychiatrists

FedhealthNetwork SpecialistsFP referral required for consultations to be paid from Risk benefit

No limit Up to set rate

Adds up at set rate

Covered at set rate (Fedhealth network specialists will only charge the setrate).20%co-payment if FP referral not obtained

Non-FedhealthNetworkSpecialistsFP referral required for consultations to be paid from Risk benefit

No limit At cost Adds up at Fedhealth Rate


Specialists:Psychiatrists

FedhealthNetwork PsychiatristsFP referral required for consultations to be paid from Risk benefit

The Additional Medical Services limit of R11 100 per family per year applies (combined limit)

Up to set rate

Does not add up to threshold level

Covered at set rate up to the limit (Fedhealth network specialists will only charge the setrate).20%co-payment if FP referral not obtained

Non-FedhealthNetworkPsychiatristsFP referral required for consultations to be paid from Risk benefit

The Additional Medical Services limit of R11 100 per family per year applies(combined limit)



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How to claimIfthehealthcareprofessionalorthehospitalclaimsonyourbehalfYourhealthcareprofessionalusuallysendsyourclaimtousonyourbehalf.Inthiscase,youdonotneedtoclaimaswell.If your healthcare professional tells you that they have not been paid, you can check your claims status on the Fedhealth website or contact us on 0860002153.

IfyouneedarefundbecauseyoupaidthemedicalexpenseIf your healthcare professional does not claim on your behalf, or if you have already paid, you must send us the:• proof of payment• theclaim(theaccount).Makesuretheaccountshows: - your membership number - theICD10andprocedurecodes -thepracticenumber.

Ifweapprovetheclaimaccordingtotheschemerules,Fedhealthwillrefundyoudirectlyintoyourbankaccount.Youmustmakesurethatwehaveyourcorrectbankdetails.Toupdateyourbankdetails,[email protected]

YoumustclaimwithinfourmonthsofthedateofthetreatmentTheschemewillonlyconsiderclaimsthatwereceivewithinfourmonthsofthetreatmentdate.Weprocessclaimsthatwereceiveafterfourmonthsonlytoshowontaxcertificates.Wewillnotpayanyclaimsthatwereceiveafterfourmonths.

Send your claims to:

Youcanemail,faxorposttheclaimstous.Email: [email protected] number: 0116713842

Postaladdress:Private Bag X3045Randburg2125

If you have been in a car accident

Ifyouwereinjuredinacaraccident,youmayhavetogothroughcertainprocedureswiththeRoadAccidentFundbeforetheschemewillpayanyclaims.

PleasecontacttheMVA/ThirdPartyRecoveryDepartmentatFedhealthformoreinformation:

Telephonenumber : 0800 117 222

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HOWTOCLAIM

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About your scheme and membershipPrincipalmembersandregistereddependantsarecoveredbythescheme.

MembersTheprincipalmembercanaddorremovedependants.Inthissection,weuse‘you’fortheprincipalmember.

DependantsWhocanberegisteredasadependantYou can register the following people as dependants:• Your spouse or partner• Your children• Otherfamilymembersif,accordingtotheschemerules,theyrelyonyouforfinancialcareandsupportandhavebeen approvedbytheScheme.

Before you add a dependant, if a company pays your medical aid contribution, you should check how much of the contributionyourcompanywillpay.

CriteriaforchildrenFedhealthwillchargethechildrateforyourchilddependantsuntiltheyturn27.However,thechildneedstobeeither:• a full-time student, who is living at home or in a residential situation at a tertiary education institution; or • livingathome,unmarried,andnotreceivingaregularincomegreaterthanthemaximumsocialpension.

AddinganewbornbabyYoumustregisterbabieswithin30daysaftertheyareborn.Thirdgenerationbabies(youradultchilddependant’sbaby)willnotbecoveredfromdateofbirthandwillbesubjecttonormalunderwriting.Ifacompanypaysyourmedicalaidcontribution,youmusttellthesalarydepartmentthatyouaregoingtoaddanewbornasadependant.Fedhealthdoesnotchargeforthebabyforthemonthinwhichthebabyisborn.

YoumustgiveusthesedocumentsforregisteringdependantsToregisteradependant,youmustfillinaMemberRecordAmendmentForm.Forthefollowingtypesofdependants,weneed this information:

Typeofdependant Extradocumentwemayneed

Anewbornbaby Acopyofthebaby’sbirthcertificateornotificationofbirthfromthehospitalThe baby’s ID number when they are registered

Abiologicaloradoptedchildovertheageof21years

Proof of registration from a full time tertiary institution for the current year if a full timestudent,oranaffidavitforthedependantconfirmingresidency,employment,income and marital status

Anadoptedchild Proof of legal adoption

Afosterchild Legal proof that the child is a foster child

Abrotherorsister,grandchild,nepheworniece,thirdgenerationbaby

Anaffidavitconfirmingresidency,employment,incomeandmaritalstatusofchildand both parents

Aparentorgrandparentoftheprincipalmember

Anaffidavitconfirmingresidency,employment,incomeandmaritalstatus

Aspouseorpartner Marriagecertificate,ifavailable

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ABOUTYOURSCHEMEANDMEMBERSHIP

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Membership cards

Wewillsendtwomembershipcardsforfamilieswithoneormoredependants.Pleasecontactusifyouwantmoremembershipcardsforyourdependants.

Removing a dependant from your membership

Toremoveadependant,youmustfillinaMemberRecordAmendmentForm.Ifacompanypaysyourmedicalaid,yourHRDepartmentmuststamptheformandsendittothescheme.

How we communicate with you

WeemailandSMSyourclaimstatusFedhealthwillemailandSMSaclaimstatustoyou.Thisshowstheclaimsthatwehavereceivedandprocessed.

MakesurewehaveyourcorrectemailaddressandcellnumberPlease ensure that Fedhealth has your correct cell phone number and email address by calling the FedhealthCustomerContactCentreon0860002153.

YoucanfindyourclaimandbenefitinformationonourwebsiteYoucanviewafullupdateofyourbenefitandclaimstatusbyregisteringontheFedhealthwebsite.Youwillhaveimmediateaccesstoallyourpersonalinformation.TheFedhealthwebsite carefully details all of the Fedhealth options and has a blog section devoted to LivingFedhealthy,whereyoucanlookforwardtoinformativehealthandlifestylecontentthatgetsposted.

In the MemberTools section of the website, you can obtain hospital pre-authorisation, apply for chronic medication and submit yourclaims.YoucanalsolocateNetworkPharmacies,FPsandSpecialistsusingthelocatortool.Allbrochure-ware,optionselectionformsandrelateddocumentationisalsoavailableaseasy-to-accessPDFdownloads.

Once logged in to your account you’re also able to updateyourpersonalinformation,conductbenefitenquiriesandsuccessfullytrackclaimsubmissionsandpaymentsduetoyou.

The site also features LiveChat - this is an innovative feature that allows you to raise any important medical aid questions you may haveonthesiteduringofficehours.Skilledconsultantsattendtoyourqueriesinapersonal,one-on-onecapacity,withouttheneedforphonecalls.Youarealsoabletoobtainhospitalandchronicdiseaseauthorisations on the site using LiveChat.

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YoucanmessageFedhealthfreeofchargewiththeFedChatMobileAppFedChatisavailableasafreedownloadtoApple,Windows,BlackberryandAndroidusers.ThisdedicatedInstantMessenger channel offers you the convenience of being able to communicate with Fedhealth service consultants during officehours,withoutthecostofaphonecallorSMS,asFedChat uses the same data you use for email and Internet browsing.

TheFedhealthFamilyRoom–thehubofyourrelationshipwithFedhealthOurbrandnewomni-channel online member community platform, the Fedhealth Family Room, gives you access to a host of membership management tools, news, articles and exclusive value-added programmes and discounts that arepersonalisedaccordingtoyourindividualprofile.Youcanjoincommunitiesbasedonyourinterests,lifestageandlifestyle,enjoyretaildiscountse.g.onbaby’snappies,andevengetfreeentryintosportsevents,plusmanymoregreatfeatures!

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HEALTHCARE SPENDINGExamples of healthcare spend available for various family structures,

as well as annual threshold levels and self-payment gaps

Annual Savings

Annual Threshold Level

Annual Self-Payment Gap

M 7 152 12 320 5 168

M + AD 13 392 21 780 8 388

M + AD + CD 15 552 24 948 9 396

* Up to a maximum of three children M - member AD - adult dependant CD - child dependant

Maxima Standard contributions table

CONTRIBUTIONSRand amounts paid monthly to the Scheme for cover

receivedaswellasannualbenefitvalues

Risk Savings TOTALAnnual

Threshold*

Member 2 714 596 3 310 12 320

Adult Dependant 2 370 520 2 890 9 460

Child Dependant* 818 180 998 3 168*

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Option changes

YoucanupgradetoahigheroptionYoucanupgradetoahigheroptionwithmorecomprehensivebenefitsanytimeoftheyear,butonlyondiagnosisofadreaddiseaseorinthecaseofalife-changingevent,forexamplepregnancy.

Theoptionupgradewillonlybeallowedwithin30daysofdiagnosis.Ingeneral,optionchangesareonlyallowedwitheffectfrom1Januaryeveryyear.

Paying for your medical aid

YoumustpaybythethirdofeachmonthYoupayyourcontributionstoFedhealtheachmonthforthepreviousmonth’scover(youpayinarrears).Youmustpaybythethirddayofeachmonth.Ifwedonotreceivepaymentbythethirddayofthemonth,wewillsuspendyourcover.

OurbankdetailsAccount name : Fedhealth Medical SchemeBank : NedbankBranch code : 19-84-05Account number : 1984 563 009

Pleaseuseyourmembershipnumberasreferencewhenmakingapayment.

Leaving the scheme

ThreemonthsofnoticetoleaveIfyouwanttoleaveFedhealth,youmustgiveusthreemonths’noticeinwriting.

LastcontributionBecause you pay at the start of the month for the previous month’s cover, your last contribution will be deducted in the monthafteryourlastdayofmembership.Wewilldeductyourlastcontributionbythethirddayofthemonthafteryourlastdayofmembership.

AmountinSavingsAccount–ifyouspentlessthanyoupaidinWepaythebalanceinyourSavingsAccounttoyournewmedicalscheme’ssavingsaccountfivemonthsafteryouhaveleftFedhealth.Thisensuresthatwecanpayoutanyoutstandingclaims.YoumustprovideuswiththenameofyournewschemeaswellasyourmembershipnumbersowecantransferyourSavingsAccountbalance.Ifyournewschemedoesnothaveasavingscomponent,thenwewillpaythebalancetoyou.Pleasemakesurewehaveyourup-to-datebankingdetailstomakethisrefund.

AmountinSavingsAccount–ifyouspentmorethanyoupaidinIf you leave the scheme and have spent more than the monthly contributions you have paid into the Savings Account, youwillhavetorefundtheschemewiththedifference.Youmustmaketherefundwithin10daysafterthelastdayofmembership.

Whistle-blowing on fraud

Weaskyoutohelpustocombatfraud.Ifyouknowofanythingthatmightinvolveahealthcareprofessionaloramemberusingthemedicalschemeinappropriately,pleasecontactus.Youdonothavetodiscloseyourname.FraudHotline:0800112811

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Extra servicesThesearetheextraservicesyougetfromFedhealth.Theydonotaffectanyoftheschemebenefits.

24-hourNurseLineon0860333432The 24-hour Fedhealth Nurse Line is available for:

• assessing day-to-day symptoms• emergency medical advice, including for poisoning• health education (for example, you can call if you need an explanation of medical terms, procedures and test results)• drug database (complete information on medicines, including when you should not take medicines, etc)• stress management• teenagesupport.

TheFedhealthBabyProgrammeWhenitcomestobaby,onlythebestwilldo.Assuch,Fedhealthoffersatop-notchbabyprogrammedesignedbyexpertstoofferthebestadvice,supportandpersonalisedcareduringeverystageofpregnancyandbeyond.Bestofall,it’s FREE! We offer you:

• AFedhealthbabybagfilledwithbabycareproducts,nappies,aHavingaBabyhandbookandmuchmore.

• Discounts and vouchers for the best baby brands including: -40%offLiving&Lovingmagazine -10%offPreggiBelliesexerciseclasses -15%offsafetyproductsforbabiesandtoddlersfrom4aKid -From10to25%offChelinostrollers,campcotsandcarseats -25%offBabyKabooshsleepingbags -25%offBabynasticsDVD -20%offBoobiBlankets -25%offLots4Totsbabyplaymats -20%offBabyLegendsHUGSEEZBabyWrapCarrier -FreeimmunisationemailremindersfromTum2mom.

• Ongoing communication and education in the form of emails and e-letters (toMomandDad),healthprofilingforeach trimester, funding for Doula assistance (labour support) during natural birth together with a new birth card, call out on estimated due date to check on member’s progress, and follow up on the birthwithinaweekoftheduedate.

• A Baby Medical Advice Line that’s on hand 24 hours a day for any pregnancyconcerns,pre-orpost-birth.

Any pregnant Fedhealth member or dependant may register for the FedhealthBabyProgramme.Simplycall0861116016 or email [email protected].

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EXTRASERVICES

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SERVICECENTRESANDCONTACTDETAILS

Medscheme Client Service CentresForpersonalassistance,visitoneofthefollowingMedschemeClientServiceCentres.

ThesebranchesareopenMondaytoFriday08h30–16h00

Bloemfontein – Shop C7, 1st Floor Middestad Centre, cnr Charles and West Burger StreetCapeTown–IconBuilding,GroundFloor,CnrLowerLongStreet&HansStrijdomAvenue,CapeTownDurban – Ground Floor, 102 Stephen Dlamini Road, Musgrave, DurbanPortElizabeth–1stFloor,Block6,GreenacresOfficePark,2ndAvenue,NewtonParkPretoria–NedbankPlaza,Shop17,GroundFloor,361StanzaBopapeStreet,ArcadiaRoodepoort–GroundFloor,ParkViewBuildingNumber10,ConstantiaOfficePark,VlakhaasAvenue,off Hendrik Potgieter Rd, Weltevreden Park X81, RoodepoortVereeniging – Ground Floor, 36 Merriman Avenue

Contact usFedhealthCustomerContactCentreMonday to Thursday 08h30 – 19h00Friday 09h00 – 19h00Tel: 0860 002 153email:[email protected]:www.fedhealth.co.zaPostal address: Private Bag X3045, Randburg 2125

HospitalAuthorisationCentreMonday to Thursday 08h30 – 17h00 Friday 09h00 – 17h00Tel: 0860 002 153 email:[email protected]:www.fedhealth.co.za

AmbulanceServicesEurop AssistanceTel: 0860 333 432

AidforAIDSMonday to Friday 08h00 – 17h00Tel: 0860 100 646Fax: 0800 600 773email:[email protected]:www.aidforaids.co.zaSMS (call me): 083 410 9078

ChronicMedicineManagementMonday to Thursday 08h30 – 17h00Friday 09h00 – 17h00Tel: 0860 002 153email:[email protected] address: P O Box 38632 Pinelands 7430

DiseaseManagementMonday to Friday 08h00 – 16h30Tel: 0860 002 153email:[email protected]

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FedhealthBabyMonday to Friday 08h00 – 17h00Tel: 0861 116 016email:[email protected]:www.babyhealth.co.za

FraudHotlineTel: 0800 112 811

MVAThirdPartyRecoveryDepartmentMonday to Friday 08h00 – 16h00Tel: 0800 117 222

OncologyDiseaseManagementMonday to Friday 08h00 – 16h00Tel: 0860 100 572Fax: 021 466 2303email:[email protected] address: P O Box 38632, Pinelands, 7430

TraumaCounsellingICASTel: 0800 212 695

Preferred Provider Pharmacies ClicksTel: 0860 254 257Tolocateastoregoto:www.clicks.co.zaand select Store Locator

Dis-ChemCare-Line: 0860 347 243Tolocateastoregoto:www.dischem.co.zaand select Store Locator

Medi-RitePharmacyTel: 0800 222 617Tolocateastoregoto:www.medirite.co.zaand select Store Locator

PharmacyDirectMonday to Friday 07h30 – 17h00Tel: 0860 027 800Fax:0866114000/1/2/3/4email:[email protected] (call me): 083 690 8934

Fedhealth Customer Contact Centre 0860 002 153

GroundFloor,ParkViewBuildingNumber10,ConstantiaOfficePark,VlakhaasAve,

offHendrikPotgieterRd,WeltevredenParkX81,Roodepoort•PrivateBagX3045,Randburg2125

www.fedhealth.co.za

Family takes care of family

Documents

COMPREHENSIVE OPTION RANGE Maxima Standard 2018COMPREHENSIVE OPTION RANGE. Maxima Standard. 2018. 1. 1 Overview of benefits 5. Risk and Savings benefits 5 Examples of what each benefit