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Saver Options
Saver optionsChoose from:
Maxima SaverMaxima EntrySaver
Unlimited hospitalisation, plus the benefi t of Day-to-Day and Chronic cover.
Those who want all the perks associated with top-notch hospital cover, but also require a medical aid option that covers their day-to-day healthcare spending, should consider our saver options.
Single, young professionals can benefi t from both saver options, as they pro-vide quality hospital cover complemented by a Medical Savings Account that handles day-to-day healthcare expenses.
Unlimited hospitalisation at all private hospitals is available on Maxima Saver, whilst members can enjoy unlimited hospitalisation at Network Hospitals only on Maxima EntrySaver.
As an added benefi t, both options allow all benefi ciaries to visit a nominated Network GP for unlimited consultations covered from Risk and on Maxima Saver, there’s a Basic Dentistry benefi t that is also covered from Risk. These Risk benefi ts apply once Savings is depleted.
Both options also provide a Chronic Disease Benefi t that covers 25 chronic conditions at 100% of the Medicine Price List.
Max
ima
Ran
ge
Chronic Disease Benefit
Day-to-Day Benefit
Other healthcare professionals
Major Medical Benefit
Hospitalisation
Network GPs and Specialists
Non-network GPs and Specialists
maxima saver
From R1 751pm From R1 327pm
maxima entrysaver
Up to 100% of Fedhealth Rate
Up to 150% of Fedhealth Rate Up to 100% of Fedhealth Rate
Unlimited cover at cost with Fedhealth Network GPs and Specialists
No overall annual limit Network hospitals only No overall annual limit
PMB chronic conditions only from Medi-Rite pharmacies and subject to a restrictive formulary. Covers up to 100% of the
Medicine Price List
R2 160 per member p.a.R2 568 per member p.a.
Unlimited specialised radiology paid from the Major Medical Benefit if pre-authorised
Unlimited GP visits at a nominated GP on the Fedhealth GP Network
Basic dentistry
RIS
K B
ENEFITS
Savings
MajorMedicalBenefit
ChronicDiseaseBenefit
DAY-TO-D
AY B
EN
EFITS
SchemeFundedDay-to-Day
How the scheme worksMajor Medical Benefi t
All costs for hospitalisation are covered from this benefi t and must be pre-author-ised - Network Hospitals apply to Maxima EntrySaver.
Chronic Disease Benefi tMedication for approved chronic diseases is covered from this benefi t.
Day-to-Day Benefi tDay-to-day expenses are covered from Savings. Once Savings is depleted, some
Scheme Funded Benefi ts still apply.
saver options Maxima Saver & Maxima EntrySaver
FR - Fedhealth Rate ICON - Independent Clinical Oncology Network MPL - Medicine Price ListHPT - Healthcare Professional Tariff DSP - Designated Service Provider
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major medical benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised - Network Hospitals apply to Maxima EntrySaver
maxima saver maxima entrysaver
BENEFIT ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED
Overall annual limit (OAL) Unlimited Unlimited at network hospitals only
Healthcare Professional Tariff (HPT)
- Fedhealth Network GPs and Specialists
- Non-Fedhealth Network GPs and Specialists
- Other Healthcare Professionals
Covered at cost
Covered at 100% of FR
Covered at 150% of FR
Covered at cost
Covered at 100% of FR
Covered at 100% of FR
Prescribed Minimum Benefits (PMBs) Unlimited in state hospitals
Hospitalisation costs Unlimited at negotiated tariff Unlimited at negotiated tariff at network hospitals only.R5 000 co-payment on voluntary use of a non-network hospital
Co-payments See details on page 2
Alternatives to hospitalisation
- Sub-acute facilities and physical rehabilitation facilities
- Nursing services, private nurse practitioners & nursing agencies
PMB level of care only
Unlimited at negotiated tariff
Ambulance services Unlimited with Europ Assistance
Appliances, external accessories, orthotics Subject to Savings
Blood, blood equivalents and blood products Unlimited
Additional medical services (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics)
Unlimited (See HPT above)
Maxillo-facial surgery
- Surgical extraction of impacted wisdom teeth
Unlimited, subject to approval (See HPT above)
Co-payment applies to surgical extraction of impacted wisdom teeth
Unlimited, subject to approval (See HPT above)
No benefit for surgical extraction of impacted wisdom teeth
Emergency treatment in a casualty ward Unlimited at FR
Female health benefit: contraceptives Unlimited at MPL
Immune deficiency related to HIV infection Unlimited (See HPT above)
saver options Maxima Saver & Maxima EntrySaver
MPL - Medicine Price ListHPT - Healthcare Professional Tariff FR - Fedhealth Rate
[ 2
major medical benefit (continued)
maxima saver maxima entrysaver
BENEFIT ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED
Pathology, radiology (general) Unlimited at FR
Post-hospitalisation benefit Up to 30 days after discharge at FR
Post-natal midwifery benefit 4 consultations per pregnancy at FR
Prostheses
- Internal
- External
PMBs only
R9 430 at cost
PMBs only
PMBs only
Psychiatric services R20 300 (See HPT on page 1) PMBs only
Renal Dialysis (chronic)
- Haemodialysis and peritoneal dialysis R213 000 at FR PMBs only in state facilities
Specialised medication benefit (eg. biologicals) - oncology & non-oncology No benefit
Specialised radiology Unlimited at FR
Take-out medicines 7 days medication per hospital event at MPL
Terminal care benefit R26 500 at FR
co-paymentsmaxima saver maxima entrysaver
PROCEDURE CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY
All open hernia procedures, Back & neck pain, Spinal surgery, Bunion procedures, Cataract surgery, Elective caesar-ean sections, Gastritis/ dyspepsia/ heartburn, Hysterectomy (unless for cancer), Nasal procedures, Scopes (upper GI endoscopy, colonoscopy, cystoscopy), Skin biopsy/ excision, Tonsil/ adenoid procedures, Varicose vein procedures R5 000
Dental admissions R5 000 No benefit
Surgical extraction of impacted wisdom teeth R5 000 No benefit
Arthroscopic proceduresAnkle, Knee, Shoulder R5 000
Laparoscopic proceduresDiagnostic, Nissen/ Toupey R5 000
All arthroscopic and laparoscopic procedures not listed above Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered
saver options Maxima Saver & Maxima EntrySaver[ 3
maxima entrysaver network hospitals
Please note that this list may change/ expand during the year. Please contact the Fedhealth Customer Contact Centre on 0860 002 153 or refer to the website for the latest Maxima EntrySaver Network Hospital list
HOSPITAL PROVINCE SUBURB
Life Beacon Bay Hospital Eastern Cape East London
Life Mercantile Hospital Eastern Cape Korsten
Life St George’s Hospital Eastern Cape Centrahill
Life St James Hospital Eastern Cape Southernwood
Life St Mary's Private Hospital Eastern Cape Umtata
Horizon Eye Care Centre Free State Bloemfontein
Mediclinic Hoogland Free State Bethlehem
Life Pasteur Hospital Free State Bloemfontein
Life Rosepark Hospital Free State Bloemfontein
Netcare Bougainville Hospital Gauteng Hercules
Life Brenthurst Clinic Gauteng Johannesburg
Life Carstenhof Clinic Gauteng Midrand
Cormed Clinic Gauteng Vanderbijlpark
Life Dalview Clinic Gauteng Brakpan
Life Flora Clinic Gauteng Roodepoort
HOSPITAL PROVINCE SUBURB
Life Fourways Hospital Gauteng Fourways Gardens
Life The Glynnwood Gauteng Benoni
Louis Pasteur Hospital Gauteng Pretoria Central
Midvaal Private Hospital Gauteng Three Rivers
Life Robinson Private Hospital Gauteng Randfontein
Life Roseacres Clinic Gauteng Primrose
Life Chatsmed Garden Hospital Kwa-Zulu Natal Chatsworth
Durdoc Clinic Kwa-Zulu Natal Durban Central
Life Entabeni Hospital Kwa-Zulu Natal Durban
Maxwell Clinic Kwa-Zulu Natal Qualbert
Life Mount Edgecombe Hospital Kwa-Zulu Natal Mount Edgecombe
Life Westville Hospital Kwa-Zulu Natal Westville
Zoutpansberg Private Hospital Limpopo Polokwane
Life Cosmos Hospital Mpumalanga Witbank
HOSPITAL PROVINCE SUBURB
Life Peglerae Hospital North West Rustenburg
Mediclinic Kimberley Northern Cape Kimberley
Life Bay View Private Hospital Western Cape Mossel Bay
Netcare Blaauwberg Hospital Western Cape Bloubergrant
Mediclinic Cape Gate Western Cape Cape Gate
Mediclinic Cape Town Western Cape Mill Street
Ceres Private Hospital Western Cape Ceres
Life Claremont Hospital Western Cape Claremont
Life Kingsbury Hospital Western Cape Claremont
Mediclinic Geneva Western Cape George
Mediclinic George Western Cape George
Melomed Mitchells Plain Medical Centre
Western Cape Cape Town
Life West Coast Private Hospital Western Cape Vredenburg
saver options Maxima Saver & Maxima EntrySaver[ 4
EPI - Expanded Programme on Immunisation
screening benefitThis benefit provides access to a number of screening and preventative programmes aimed at improving members’ health
maxima saver maxima entrysaver
BENEFIT CRITERIA ALL LIMITS ARE PER BENEFICIARY
Women’s HealthBreast cancer screening with mammographyCervical cancer screening (PAP smear - test only) Liquid based Cytology will be reimbursed up to the rate for a standard PAP smear
Women; ages 50 to 74Women; ages 21 to 65
1 every 3 years1 every 3 years
Children’s HealthImmunisation Programme As per State EPI As per State EPI
Cardiac HealthCholesterol screening (full lipogram) All lives; aged 20 and older 1 every 5 years
GeneralFlu vaccination All lives 1 every year
chronic disease benefitMedication for approved chronic diseases is covered from this benefit
maxima saver maxima entrysaver
Limit Unlimited
Conditions covered 25 Chronic Conditions below
Formulary Restrictive formulary
Designated Service Provider (DSP) Medi-Rite pharmacy
HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS
Limit Unlimited
Non-compliance with DSP and/ or formulary requirements will attract a co-payment of 40%. All medicine claims are subject to the Medicine Price List (MPL), a generic reference price list, and the maximum negotiated dispensing fee. Where the dispensing fee has not been negoti-ated, a maximum dispensing fee of 26% / R26 will apply.
25 CHRONIC CONDITIONS
Addison’s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, COPD/ Emphysema/ Chronic Bronchitis, Chronic Renal Disease,
Coronary Artery Disease, Crohn’s Disease, Diabetes Insipidus, Diabetes Mellitus type 1 & 2, Dysrhythmias, Epilepsy, Glaucoma, Haemophilia, Hyperlipidaemia, Hypertension,
Hypothyroidism, Multiple Sclerosis, Parkinson’s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus, Ulcerative Colitis
saver options Maxima Saver & Maxima EntrySaver[ 5
day-to-day benefitDay-to-day expenses are covered directly from available funds in Savings - with no Threshold benefit available. However, once Savings is depleted, various Scheme Funded Benefits still apply to each option.
benefit maxima saver maxima entrysaver
Appliances, external accessories and orthotics Subject to Savings Subject to Savings
Alternative healthcare
Accupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including prescribed medication) Subject to Savings Subject to Savings
Additional medical services
Audiology, dietetics, occupational therapy, orthoptics, podiatry, psychologists, social workers and speech therapy Subject to Savings Subject to Savings
Dentistry (Advanced)
Including oral surgery, osseo-integrated implants, orthognathic surgery and orthodontic treatment Subject to Savings Subject to Savings
Dentistry (Basic)
Removal of teeth and roots and suturing of traumatic wounds. Oral medical procedures: diagnosis and treatment of oral and associated conditions, plastic dentures and dental technician fees for all such dentistry
Subject to Savings. Once Savings is depleted the following benefits will be paid from Risk:2 Annual consultations per beneficiary including scaling and polishing. Subject to a contracted list of dentists and limited to a list of approved proce-dures, dental tariff codes and protocols. Plastic dentures limited to one set per beneficiary every two years
Subject to Savings
Optometry
Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, readers and optometric examinations
Subject to Savings Subject to Savings
Biokinetics, Chiropractics, Radiology (General), Pathology and PhysiotherapySubject to Savings Subject to Savings
General Practitioners
- Fedhealth Network GPs
- Non-Fedhealth Network GPs
Subject to Savings. Unlimited GP visits at nominated Fedhealth Network GP once Savings is depleted
Subject to Savings
Subject to Savings. Unlimited GP visits at nominated Fedhealth Network GP once Savings is depleted
Subject to Savings
Maternity Subject to Savings Subject to Savings
Over-the-counter medication Subject to Savings Subject to Savings
Prescribed medication Subject to Savings Subject to Savings
Radiology (Specialised) Paid from the Major Medical Benefit if pre-authorised Paid from the Major Medical Benefit if pre-authorised
Specialists
- Fedhealth Network Specialists
- Non-Fedhealth Network Specialists
Subject to Savings
Subject to Savings
Subject to Savings
Subject to Savings
Benefits that set us apartWhat sets us apart is that together with our first-rate medical aid options, we offer unique value-added benefits. With some of these tangible benefits we pay more from Risk than other schemes to ensure that members’ day-to-day medical spending not only goes further, but also works harder when they really need it.
Benefits unique to Fedhealth:• Unlimited visits to a nominated Network GP – paid from Risk once Savings is depleted on both Saver
options• Child rates for financially dependent children up to 27 years of age – so student dependants pay rates
applicable to children, provided they’re unmarried and not earning more than the maximum social pension• Upgrades to higher options any time of the year within 30 days of diagnosis of a dread disease, or in the
case of a life changing event – which means the member’s never locked into an option, and can upgrade should something dramatic happen that changes their circumstances during the year. *New contributions will apply
Where we pay more from Risk than other schemes:• Post-hospitalisation treatment for up to 30 days after discharge from hospital (physiotherapy, pathology,
occupational therapy, speech therapy and general radiology) – that means most follow-up treatment for a full 30-day period paid directly from Risk not to deplete the member’s day-to-day benefit
• 7 days of take-home medication - after discharge from hospital paid for – provided the medication is dispensed by the hospital and reflects on the original hospital account
• Specialised radiology like MRI and CT scans - paid from Risk and never from Savings – no matter what option the member’s on, whether performed in or out-of-hospital
• Trauma treatment at a casualty ward - whether admitted to hospital or not, emergency treatment, like stitches, is always paid from Risk and never from the member’s day-to-day benefit
• Cover for female contraception - including oral, patches, certain injectables as well as IUDs that include Mirena®, contraceptive rings and implants on all comprehensive and saver options. *Must be prescribed by a GP or gynaecologist and not applicable to pills prescribed for acne
• The Screening Benefit - health screenings for women and children, cardiac screenings as well as an annual flu vaccine funded from Risk and not from the member’s day-to-day benefit.
How we add value:• The Fedhealth Baby Programme• 24-Hour Fedhealth Nurseline• FREE trauma counselling for practical and emotional support• Emergency transport/ response through Europ Assistance• Comprehensive managed care programmes: Aid for AIDS (AfA) for those living with HIV/AIDS, AsthmaCare ensures that asthma patients still lead a normal life, DiabeticCare assists diabetics in managing their blood sugar, CardioCare to prevent heart attacks in Coronary Heart Disease sufferers, and Oncology Disease Management that supports cancer sufferers with comprehensive care including cover for chemotherapy, radiotherapy, approved medication, related consultations, pathology and general radiology.
And then members still get:• Professional and extreme sports cover - injuries sustained during sporting activities are covered within the
benefits and rules of the Scheme, provided the treatment is received within the borders of South Africa• In-hospital dentistry for children under 8 - we cover the hospital and anaesthetist costs from the Major
Medical Benefit while the dentist’s account comes from day-to-day benefits. *The Authorisation Centre must be contacted at least 48 hours before the procedure. Authorisation will be granted provided no dental authorisation was granted for the same child within at least six months of the required admission date. This benefit does not apply to Maxima EntrySaver
• Easy membership for child dependants - who are at an age and status to afford their own medical aid, meaning no underwriting required for child dependants moving from their parent’s medical aid onto their own at Fedhealth.
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contributionsmaxima saver
Risk Savings TOTAL Annual Savings
Member 1 571 180 1 751 M 2 160
Adult Dependant 1 279 147 1 426 M + AD 3 924
Child Dependant 452 52 504 M + AD + CD 4 548
maxima entrysaverRisk Savings TOTAL Annual Savings
Member 1 113 214 1 327 M 2 568
Adult Dependant 753 145 898 M + AD 4 308
Child Dependant 338 65 403 M + AD + CD 5 088
[ 7