COMPREHENSIVE OPTION RANGE Ultimax 2018 · COMPREHENSIVE OPTION RANGE. Ultimax. 2018. 1. 1 Overview of benefits 5 Risk and Savings benefits 5 Examples of what each benefit covers

COMPREHENSIVE OPTION RANGE

Ultimax

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

Limitsforspecifictreatments 14

Oncology Disease Management Programme (ODM) 14

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

Othertreatmentsorproceduresthatyoureceiveinhospital 15

Sometreatmentandproceduresdoneoutofhospital 16

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

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Nursing instead of hospitalisation 16

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

Doctor appointments with network FPs when your

Out-of-HospitalExpensesBenefithasrunout 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-PMB

hipandkneereplacements 18

4 TohavehospitalorothertreatmentcoveredbytheMajorMedicalBenefit 19

Youmusthaveourauthorisation 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 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

Thebasicsofthethreebenefitsforday-to-daymedicalexpenses 29

The Savings Account 29

Out-of-HospitalExpensesBenefit 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

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Adding a newborn baby 41

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

Ultimaxcontributionstable 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.

OHEB*

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,ChronicDiseaseBenefit,Out-of-HospitalExpensesBenefitandThresholdBenefit.

The scheme has rules for when each of the risk benefitsisallowedtopayout.Theseschemerulesgivelimitsforwhatthebenefitcanpayoutforparticularconditions,treatmentsandmedicines.Because the scheme applies its rules consistently, we canbeconfidentthat:

• We treat all members fairly and do not discriminate against any members• The medical scheme is sustainable and will not run outofmoney.

**Savings AccountThe part of your contribution that is paid to the Savings Account is not pooled with other members’ contributions.ThemoneyintheSavingsAccountis your money and it gives you a level of control on yourspending.Themoneythatisnotusedinoneyear is carried over to the following year and this is calledcarry-overSavings.Thismaybeusedafteryournewyear’sday-to-daybenefitshavebeendepleted.Anysavingsbalancenotusedwillbepaidoutifyouleavethescheme.

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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 FPs (when your Out-of-HospitalExpensesBenefithasrunout)Oncology 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 MinimumBenefitchronicconditionsaswellasanadditional40 conditionsThe 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.Out-of-HospitalExpensesBenefit3.Carry-overSavingsorself-payment4.ThresholdBenefit

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

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OVERVIEWOFBENEFITS

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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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 prevents unsafecombinationsoftreatmentsincludingmedicines.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.Ifreferralisnotobtainedtherewillbea10%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)inorderforamembertobeentitledtofundinginfull.Schemesmayalsoapplyformularies–alistofmedicineswhichshould be used to treat PMBs, and managed care protocols – based on evidence-based medicine and cost-effectiveness principlestomanagethisbenefit.

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.Ifreferralisnotobtainedtherewillbea10%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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EMERGENCIES

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.

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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Contact us within two working days if you needed trauma treatment

Ifyouvisitcasualtyfortraumatreatment,youmustgetanauthorisationnumberfromuswithintwoworkingdaysofthetreatment.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.

The cost of all emergency treatment is covered in full from scheme benefits,aslongasKatecontactstheschemewithintwoworkingdaysoftheemergencytreatment.

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HOSPITALVISITSANDTREATMENTPAIDFROMTHEMAJORMEDICALBENEFIT

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) We pay the full cost, up to a limit of R331 100 per family per year subjecttomanagedcareprotocols

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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 Wepay300%oftheFedhealthRateforprofessionalfees.Youmustpay the rest direct to the specialist

FamilypractitionerswhoareintheFedhealthnetwork We pay professional fees in full

FamilypractitionerswhoarenotintheFedhealthnetwork

Wepay100%oftheFedhealthRateforprofessionalfees.Youmustpay the rest direct to the healthcare professional

Otherhealthcareprofessionals,e.g.physiotherapiststhattreatyouinhospital

Wepay300%oftheFedhealthRateforprofessionalfees.Youmustpay the rest direct to the healthcare professional

Dietetics,occupationaltherapy,speechtherapyandphysicaltherapy(physiotherapyandbiokinetics)

Wepay300%oftheFedhealthRateforprofessionalfees.Youmustpaytherestdirecttothehealthcareprofessional.Subjecttomedicalpractitioner referral

Beforeyougotohospital,youshouldtrytomakesurethatyourdoctorandspecialistareintheFedhealthnetwork.

Goingtohospitalforanoperation:

AN EXAMPLE

Whatthememberdoes Howtheexpenseisfunded

Alice’ssonneedstohavehistonsilsout.Alicemadesurethat the surgeon and the anaesthetist are in the Fedhealth network.Shegatherstherequiredinformationfromherdoctor and then phones Fedhealth to get an authorisation number.

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,Alicewouldpaythedifferencebetween300%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,theywillbecoveredupto300%oftheFedhealth Rate

FundingforDoula(laboursupportduringnaturalchildbirth)

R1 270 per delivery

Afterdelivery:Post-natalmidwiferybenefit

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

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

Spinal surgery

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.

Pleasenote:Shouldyoudeclinetoparticipateintheprogrammepriortosurgery,therewillbeNObenefitforspinal

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surgery.Inotherwords,theSchemewillnotpayforthehospital,surgeon,prosthesisoranythingrelatedtotheprocedure.Thisdoesnotapplytoemergencytreatment/PMBs.

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)

FullcoverforservicesthroughICONTheschemehascontractedwithIndependentClinicalOncologyNetwork(ICON)foroncologytreatment.IfyouuseanICONserviceprovider,theMajorMedicalBenefitwillcoveryourtreatmentforthefollowinginfullaccordingtothescheme’slevel3protocols:

• 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.

IfyoudonotuseanICONoncologist,thenwecoveryourtreatmentonlyupto100%oftheFedhealthRate.

LimitsforspecifictreatmentsAlthoughthereisnooveralllimitforoncology,therearesomelimitsforspecifictreatments.

Specialisedmedicine(eg,biologicals) Limit of R331 100 per family per year (Note that the use of specialised medicine, including biologicals, cannot total more than this limit for both oncology and for other use)

Brachytherapymaterials Limit of R52 900

OncologyDiseaseManagementProgramme(ODM)Ondiagnosisofcancer,itisimportantthatyouregisterontheOncologyDiseaseManagementProgramme(ODM).Youoryourtreating doctor can call them on 0860100572andregister.Theprogrammeaimstohelpyourdoctortoensurebesttreatmentandsupport.

ChangesinyouroncologymedicineneedtobegiventoODMassoonaspossible.Pleasefaxthechangedtreatmentplanto0214662303 or email [email protected]

Specialisedradiology(forexample,MRIorCTscans)Wecoverspecialisedradiology(forexample,MRIorCTscans)infullatcost,whetheryouhaveitin-orout-of-hospital.However,youmustgetseparateauthorisationforaspecialisedradiologicalprocedure,whetherittakesplacein-orout-of-hospital.

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Other treatments or procedures that you receive in hospital

All limits in this section are per family per year, unless otherwise explained

Appliances,externalaccessories,(e.g.compressionstockingsforDVT)

Unlimitedcover.Wecoverthefullcost

Arthroscopicprocedures Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)

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

Jointreplacements Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)

Non-PMBhipandkneereplacementswithDSP

Unlimited cover if you use one of the scheme’s DSPs, ICPS or JointCare,fornon-PMBhipandkneejointreplacements.Seepage18

Voluntarynon-useofDSPfornon-PMBhipandkneereplacements

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

Allopenherniarepairs Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)

HIV:ImmunedeficiencyrelatedtoHIVinfection

Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)

Organtransplantincludingimmunosuppressionmedication


Orthotics Unlimitedcover.Wecoverthefullcost

Rhizotomiesandfacetpainblocks Limitedtooneofeitherprocedureforeachbeneficiaryeveryyear.(See page 12 for cover for doctors and specialists)

Balloonsinuplasty Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)

Laparoscopicprocedures Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)

Maxillo-facialsurgery Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)

Post-hospitalisationbenefit Wepayforupto30daysafterdischargeat100%oftheFedhealthRate.Seepage17.

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

WepayuptoalimitofR40600.(Seepage12forcoverfordoctorsand specialists)

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

Unlimitedat100%oftheFedhealthRate

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

Unlimitedat100%oftheFedhealthRate(aslongasyougetseparateauthorisation)


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Spinalsurgery Unlimitedcover.(Seepage12forcoverfordoctorsandspecialists)NobenefitunlessConservativeBackandNeckRehabilitationProgrammehasbeencompleted.Subjecttointernalprosthesisbenefitlimit.Seepage18

Terminalcare WepayuptoalimitofR299500at100%oftheFedhealthRate

Wisdomteeth(surgicalremovalofimpactedwisdomteeth)


Some treatment and procedures done out of hospital

TosaveyourDay-to-DayBenefit,wepayforvarioustreatmentsthatarenotdoneinhospitalfromtheMajorMedicalBenefit.ThishelpsmembersbecauseitmeansthatyourDay-to-DayBenefitwilllastlongereachyear.

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

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.

DoctorappointmentswithnetworkFPswhenyourOut-of-HospitalExpensesBenefithasrunoutIfyouuseanFPintheFedhealthnetworkandyourOut-of-HospitalExpensesBenefithasrunout,theappointmentispaidoutoftheMajorMedicalBenefit.

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.

OthercostsforcontraceptionwillusuallybecoveredbytheDay-to-DayBenefits.

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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(SavingsAccountandOut-of-HospitalExpensesBenefit)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

ExternalprosthesisWepayforexternalprosthesesuptoalimitofR20700perfamilyperyearatcost.ThisispaidoutoftheMajorMedicalBenefit.

InternalprosthesisThereisaseparatebenefitforinternalprosthesis.Thebenefitdoesnotincludeosseo-integratedimplantsforreplacingteeth.Hipandkneebilateralreplacementswillbeallowedforuptodoubletheamountforasinglehipandkneereplacement.

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Internalprosthesisexpense Cover Limitsperfamily

Aortastentgrafts 100%ofcost R56 200

Detachableplatinumcoils 100%ofcost R50 600

Cardiacstents 100%ofcost R47 700

Cardiacvalves 100%ofcost R42 400

Cardiacpacemakers 100%ofcost R56 200

Intraocularlenses(perlens) 100%ofcost R3 100

Shoulderreplacement 100%ofcost R45 100

Elbowreplacement 100%ofcost R45 100

Hipreplacement(SeeICPSandJointCarebelow) 100%ofcost R45 100

Kneereplacement(SeeICPSandJointCarebelow) 100%ofcost R45 100

Totalanklereplacement 100%ofcostSeecombinedbenefitlimitforallunlisted internal prostheses*

Bonelengtheningdevices 100%ofcost R45 100

Spinalplatesandscrews 100%ofcost R45 100

Carotidstents 100%ofcost R20 400

Peripheralarterialstentgrafts 100%ofcost R38 200

Embolicprotectiondevices 100%ofcost R50 600

Otherapprovedspinalimplantabledevices 100%ofcost R45 100

*Combinedbenefitlimitforallunlistedinternalprostheses 100%ofcost R34900

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.

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TOHAVEHOSPITALOROTHERTREATMENTCOVEREDBYTHEMAJORMEDICALBENEFIT

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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SCREENINGANDIMMUNISATIONBENEFITS

Screening benefit

Thisbenefitcoversvariousscreeningandpreventativeprogrammesthataimtoimproveyourhealth.

Screeningtest Peopleregisteredontheschemewhoqualifyforthebenefit

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

Over50s

Pneumococcalvaccination Everyone older than 65 1 per lifetime

Bonedensitometry Women older than 65 1 per lifetime

Colorectalcancerscreening (faecaloccultbloodtest)

Everyone; 50 to 75 years old 1 every year

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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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

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CHRONICMEDICINE(COVEREDBYCHRONICDISEASEBENEFIT)

What is chronic medicine?TheChronicDiseaseBenefitcoverschronicmedicine.Chronicmedicineismedicinethatistakenforapersistentorotherwiselong-lastingcondition.Examplesofconditionsthatrequireongoingmedicinearehypertension,diabetesandasthma.Thisoptioncoverschronicmedicinefor65chronicconditions.

LimitsTheoveralllimitisR26800peryearperbeneficiary,uptoalimitofR44700peryearforeachfamily.

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

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

ListofchronicconditionsThisbenefitcoversmedicineandtreatmentforasetof65chronicconditionsaswellasHIV/Aids.ThesearegiveninList1belowandList2onpage24.

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

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

EpilepsyGlaucomaHaemophiliaHyperlipidaemiaHypertensionHypothyroidismMultiple SclerosisParkinson’s DiseaseRheumatoid ArthritisSchizophreniaSystemic Lupus ErythematosusUlcerative Colitis

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IfyourconditionisonList1(PrescribedMinimumBenefits)

IfyouhavenotreachedyourlimitfortheChronicDiseaseBenefit:

Medicinesthatwecover(formulary)

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

Serviceprovidersyoushoulduse Iftheconditionqualifiesforthebenefit,youcanuseanyserviceprovider.

IfyouhavereachedyourlimitfortheChronicDiseaseBenefit:


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


List2:Additionalchronicconditionscoveredonyouroption

Alzheimer’sDiseaseAnginaAnkylosing SpondylitisAnorexia NervosaAttentionDeficitDisorder(inchildrenonly)Barrett’s OesophagusBenign Prostatic HyperplasiaBulimia NervosaConn’s SyndromeCushing’s SyndromeCystic FibrosisDeep Vein ThrombosisDepressionDermatomyositisGastro-OesophagealRefluxDiseaseGeneralised Anxiety DisorderGoutHypoparathyroidismMenopauseMotor Neuron Disease

Muscular DystrophyMyaesthenia GravisNarcolepsyObsessive Compulsive DisorderOsteoporosisPaget’s DiseasePancreatic DiseasePanic DisorderParaplegia/Quadriplegia(associatedmedicine)PemphigusPolyarteritis NodosaPost-Traumatic Stress SyndromePulmonary Interstitial FibrosisSclerodermaStrokeThromboangitis ObliteransThrombocytopaenic PurpuraTourette’s SyndromeValvular Heart DiseaseZollinger Ellison Syndrome

IfyourconditionisonList2(AdditionalChronicConditions)

IfyouhavenotyetreachedyourlimitfortheChronicDiseaseBenefit


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


Thereisnobenefitatallfortheadditionalchronicconditionsonceyourchronicbenefitisusedup.

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Havingachroniccondition:

AN EXAMPLEWhatthememberdoes Howtheexpenseisfunded

Lilyhasasthmaand her doctor prescribes medicine thatshemusttakeregularly.

She decides to apply online on www.fedhealth.co.zaratherthanonthephone.Her doctor gives her the details that the online applicationasksfor.

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 as well as by email and takes it to the pharmacy togetherwithherscripttobuythemedicine.ThepharmacyisintheFedhealthnetwork.

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(Out-of-HospitalExpensesBenefitandthescheme).

LilyhasnotreachedthelimitfortheChronicDiseaseBenefit, so the cost of the medicine is covered in full, as long as the prescribed medicine is on the comprehensive formulary and the costs fall within the ceiling price given on theMedicinePriceList.IfLilyusesmedicinethatisnotonthecomprehensiveformulary,thenLilywouldhavetopay40%ofthecostfromherownpocket.

IfLilyhadreachedthelimitfortheChronicDiseaseBenefit, becauseasthmaisaPrescribedMinimumBenefitcondition,we would cover medicines that are on the comprehensive formulary.Thismeansthattheremightbesomemedicinesthatwedonotcoveratall.IfLilyusesmedicinesthatarenotonthecomprehensiveformulary,thenLilywouldhavetopay40%ofthecostfromherownpocket.

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

IfLilyhadaconditionthatisnotaPrescribedMinimumBenefit,therewouldbenocoveraftertheChronicDiseaseBenefithasreachedthelimit.

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Cover for treatment for HIV/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 towww.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-paymentbecauseitisnotintheformularythenyoushoulddiscussapossiblealternativewithyourprescribingdoctor.

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.RemembertoincludeyourFedhealthmembershipnumberonallcommunication.

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

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-dayexpensesmaybepaidoutofthreedifferentbenefitsundertheoverallDay-to-DayBenefit.Thewaythebenefitsworkwillaffectthelimitsthataregiveninthetableonpage34,somakesureyoureadthiswholesection.

Thebasicsofthethreebenefitsforday-to-daymedicalexpensesThelimitsofallthebenefitsbelowdependonthesizeofyourfamily.Pleaserefertotheratestableonpage44.

TheSavingsAccountpaysforday-to-dayexpensesfirst(fromthebeginningoftheyear)andpaysexpensesuptotheactualcost.Insomecases,ifyouhavemoneyavailableinyourSavingsAccount,youcanusethistopayco-payments.However,aco-paymentforaPrescribedMinimumBenefitcannotbepaidfromyourSavingsAccount.OncetheSavingsAccountisempty,thenday-to-dayexpensesarepaidfromtheOut-of-HospitalExpensesBenefit.

TheSavingsAccountworksdifferentlytootherbenefitsinthatyoucarryanyremainingamountovertothenextyear.Therearealsoimplicationsifyouleavethescheme–seepage45.

Out-of-HospitalExpensesBenefit:After the Savings Account has run out of funds, then day-to-day expenses are paid fromtheOut-of-HospitalExpensesBenefituptotheFedhealthRateuntilthebenefitlimitisreached.Therearemaximumamountsforspecifictreatmentsandconditions.

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

Youmustpaywhileyouareintheself-paymentgapTheremightbeagapbetweenwhentheSavingsAccountandOut-of-HospitalExpensesBenefitrunoutandtheThresholdBenefitkicksin.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:

• Using alternative healthcare (eg, homeopathy) or having medicines prescribed from alternative healthcare providers• 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• UsingpharmaciesthatarenotintheFedhealthnetwork.

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WhentheThresholdBenefitkicksin,existinglimitsapplyOnceyouhavereachedtherequiredthresholdlevel,yourday-to-dayexpenseswillbepaidfromtheThresholdBenefit.Manyofyourday-to-dayexpenseswillbecoveredunlimited,butanyexistinglimitswillstillapply.Forexample,ifafamilyspendsR14000on advanced dentistry and optometry, a maximum of R13 800 will add up towards their threshold level because the combined limit foroptometryandadvanceddentistryisR13800perfamily.OncethisfamilyisintheThresholdBenefit,theywillhavenomorecoverforoptometryandadvanceddentistryfromtheThresholdBenefitastheirlimitwillhavebeenreached.

AlsotheThresholdBenefitpaysonlyuptotheFedhealthRate.Youhavetopayanydifferencefromyourownpocket.

Cover for doctors, specialists and medicines

FPsintheFedhealthnetworkIfyouuseaFP(familypractitioner)intheFedhealthnetwork,yourconsultationispaidoutoftheOut-of-HospitalExpensesBenefitonlyandneverfromyourSavings.WhenyourOut-of-HospitalExpensesBenefitrunsout,FPconsultationsarepaidoutoftheMajorMedicalBenefit.Thiscoverstheconsultationonly.TofindaFPintheFedhealthnetwork,gotoourwebsite,theFedhealthMemberApp or call 0860002153.

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

ThismeansthatyoualwayshaveunlimitedcoverforFPs,aslongasyouuseaFPintheFedhealthnetwork.

FPsnotintheFedhealthnetworkIf you do not use a FP in the Fedhealth network, the consultation will be paid from Savings and the Out-of-Hospital Expenses Benefitandwilladduptothethresholdlevelat100%oftheFedhealthRate.WhenintheThresholdBenefit,theseconsultationsarepaidat100%oftheFedhealthRate.

SpecialistsintheFedhealthnetworkSpecialistsintheFedhealthnetworkhaveagreedtoasetrateforconsultations.Ifyouhaveday-to-daybenefitsavailable,theconsultationwillbepaidoutofthesebenefitsatthisrate.Itwillalsoadduptowardsthethresholdlevelatthisrate.Ifyouareintheself-paymentgap,youwillhavetopayfortheconsultationfromyourownpocketbutalsoonlyatthesetrate.WhenyoureachthethresholdlevelandtheThresholdBenefitkicksin,wecovervisitstospecialistsintheFedhealthnetworkinfull.Beforeyouconsultaspecialist,pleaseseeyourFPtoobtainareferral.Ifreferralisnotobtainedtherewillbea10%co-paymentonspecialistclaimspaidfromtheRiskbenefit.

SpecialistsnotintheFedhealthnetworkIf you do not use a specialist in the Fedhealth network, the consultation will be paid from your Savings Account up to cost and from theOut-of-HospitalExpensesBenefitattheFedhealthRate.Youmustpaythedifferenceoutofyourownpocket.

TheexpensewilladduptothethresholdlevelattheFedhealthRate.WhenintheThresholdBenefit,theconsultationsarealsopaidattheFedhealthRate.Beforeyouconsultaspecialist,pleaseseeyourFPtoobtainareferral.Ifreferralisnotobtainedtherewillbea10%co-paymentonspecialistclaimspaidfromtheRiskbenefit.

PrescribedmedicineThereisalimitforprescribedmedicine.Forexample,theindividuallimitisR9500.IfyouhavealreadyspentR5000accordingtothe ceiling prices given in the Medicine Price List when you reach the threshold level, then you will only have R4 500 available to spendfromtheThresholdBenefitforprescribedmedicine.WhenyouareintheThresholdBenefit,yougetcoverforprescribedmedicineonlyattheceilingpriceoftheMedicinePriceList.Youareresponsibleforpayingthedifference.

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DispensingfeesforprescribedmedicinePharmacieschargeadispensingfeeforeachprescribedmedicinethattheysell.TheschemehasagreedspecialratesfordispensingfeeswithpharmaciesintheFedhealthnetwork.IfyouuseapharmacyintheFedhealthnetwork,wewillcovertheagreeddispensingfeeinfullfromyourday-to-daybenefits.

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.ThecostwillbepaidoutofyourSavingsAccountonly,(theOut-of-HospitalExpensesBenefitdoesnotpayforover-the-countermedicine)andtheamountwillnotadduptowardsyourthresholdlevel.

TheThresholdBenefitdoesnotcoverover-the-countermedicine.

FemalecontraceptionInmostcases,femalecontraceptioniscoveredbytheMajorMedicalBenefit–seepage16.However,contraceptivepillsarepaidfromyourSavingsAccountandtheOut-of-HospitalExpensesBenefitiftheyareprescribedforreasonsotherthancontraception(forexample,forskinproblems).ExamplesofcontraceptivepillsthatwedonotcoverundertheMajorMedicalBenefitincludeCyprene-35ED,Diane–35,Tricilest,GinetteandMinerva.

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

PregnancyPregnancy costs are covered from the Savings Account and the Out-of-Hospital ExpensesBenefit.YoushouldselectagynaecologistintheFedhealthnetwork.Consultations will be covered in full at the set rate and will add up to the threshold levelinfull.Ifthespecialistisnotinthenetwork,thenonlytheFedhealthRatewilladduptothethresholdlevel.UsingagynaecologistintheFedhealthnetworkwillensure that in-hospital claims are covered in full and you will not have to pay any co-payments.

Atotaloftwo2Dultrasoundscansperpregnancywilladduptothethresholdlevel.

Specialisedradiology(forexample,MRIorCTscans)We cover specialised radiology (for example, MRI or CT scans) in full at cost, whetheryouhaveitin-orout-of-hospital.However,youmustgetseparateauthorisation for a specialised radiological procedure, whether it takes place in- or

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out-of-hospital.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:

If Mary has funds available in the Out-of-Hospital Expenses Benefit,thisbenefitwillfundtheconsultationinfull.

IfMary’sOut-of-HospitalExpensesBenefitisusedup,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 there is no money left in the Savings Account, the Out-of-HospitalExpensesBenefitcoverstheprescribedmedicineinfullandthefullamountaddsuptothethresholdlevel.(IfMaryhad chosen a medicine that cost more than the ceiling price on the Medicine Price List, the difference would not add up to the thresholdlevel).

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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.

If David has no money left in his Savings Account, the consultation is paid out from theOut-of-HospitalExpensesBenefituptotheFedhealthRate.Davidmustpaythedifferenceoutofhisownpocket.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.

IfthereisnomoneyleftintheSavingsAccount,theOut-of-HospitalExpensesBenefitcovers the prescribed medicine in full and the full amount adds up to the threshold level.(IfDavidhadchosenamedicinethatcostmorethantheceilingpriceontheMedicinePriceList,thedifferencewouldnotadduptothethresholdlevel).

Goingtoseeaspecialist:


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

IfthespecialistisintheFedhealthnetworkThis is how the consultation will be funded:

IfJohnhasmoneyavailableinhisSavingsAccount,theconsultationiscoveredinfullatthesetrateandaddupstothethresholdlevelinfull.

IfJohnhasnomoneyleftinhisSavingsAccount,theconsultationispaidoutfromtheOut-of-HospitalExpensesBenefitandtheexpenseaddsuptothethresholdlevelinfull.

IfthespecialistisnotintheFedhealthnetworkThis is how the consultation will be funded:

IfJohnhasmoneyavailableinhisSavingsAccount,theconsultationiscoveredinfull.However,onlytheFedhealthRateaddsuptothethresholdlevel.

IfJohnhasnomoneyleftinhisSavingsAccount,theconsultationispaidoutfromtheOut-of-HospitalExpensesBenefituptotheFedhealthRate.Johnhastopayforthedifferenceoutofhisownpocket.OnlytheFedhealthRateaddsuptothethresholdlevel.

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All cover in day-to-day benefits

Inthetablebelow,certainexpensesaresubjecttolimits.TheselimitsapplytotheaccumulationofclaimstothethresholdlevelaswellastherefundofclaimsfromtheThresholdBenefit.Forexample,ifafamilyspendsR14000onoptometryandadvanceddentistry, a maximum of R13 800 will add up towards their threshold level because the combined limit for optometry and advanced dentistryisR13800perfamily.OncethisfamilyisintheThresholdBenefit,theywillhavenomorecoverforoptometryandadvanceddentistryfromtheThresholdBenefitastheirlimitwillhavebeenreached.AlsotheThresholdBenefitpaysonlyuptotheFedhealthRate.Youhavetopayanydifferencefromyourownpocket.

ThesesamelimitsalsoapplytorefundsfromtheOut-of-HospitalExpensesBenefit.

Day-to-daymedicalexpense Limits HowtheSavingsAccountcoverstheexpense

HowtheOut-of-HospitalExpensesBenefitcoverstheexpense

Howtheexpenseaddsuptowardsthethresholdlevel

HowtheThresholdBenefitcoverstheexpense

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

Limit of R16 600 per family per year for the total of all additional medical services

At cost Up to the Fedhealth Rate untilthebenefitlimitisreached.Amounts spent above limit may be paid out of carry-over Savings if there are funds available

Adds up at Fedhealth Rate to the maximum of the limit

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 Up to the Fedhealth Rate Does not add up to threshold level

Not covered

Antenatalscans Two 2D antenatal scans per person per year




Appliances,externalaccessoriesandorthotics: Hearing aids, wheelchairs etc

Limit of R14 800 per familyperyear.Sub-limitof R4 130 per person for foot orthotics




*PrivatenursingthatfallsoutsidetheAlternativestoHospitalisationBenefit

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Biokinetics,chiropractics No limit At cost Up to the Fedhealth Rate

Adds up at Fedhealth Rate

Covered at Fedhealth Rate

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 R6 900 per person per year, up to an overall limit of R13 800 per family per year (combined advanced dentistry and optometry limit)




Dentistry(Basic) No limit At cost Up to the Fedhealth Rate



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

FamilyPractitioners:*Pleasenoteonlytwomentalhealthconsultationsperbeneficiarywillbepaidfromthemajormedicalbenefit

FedhealthNetworkFPs No limit – you are always covered even in the self-payment gap.(Thisisbecausewhen the Out-of-Hospital Expenses Benefitisusedup,the expenses will be coveredbytheMajorMedicalBenefit)

Never paid from savings

At cost (set rate) Adds up at set rate if refunded from OHEB

Covered from MajorMedicalBenefit

Non-FedhealthNetworkFPs No limit At cost Up to the 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 R6 900 per person per year, up to an overall limit of R13 800 per family peryear.(R1500sub-limit per frame)(combined advanced dentistry and optometry limit)




Over-the-countermedication Paid out only from Savings (not from Out-of-Hospital ExpensesBenefitorThresholdBenefit)

At cost Not covered Does not add up to threshold level

Not covered

Pathology No limit At cost Up to the Fedhealth Rate



Physiotherapy No limit At cost Up to the Fedhealth Rate



Prescribedmedication Limit of R9 500 per person per year, up to an overall limit of R18 800 per family per year

At cost Up to the MPL untilthebenefitlimitisreached.Amounts spent above limit may be paid out of carry-over Savings if there are funds available

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 Up to the Fedhealth Rate



Radiology(Specialised) PaidfromtheMajorMedicalBenefitifpre-authorised

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SpecialistsexcludingPsychiatrists

FedhealthNetwork SpecialistsFP referral required for consultations to be paid from Riskbenefit

No limit Up to set rate

At cost (set rate) Adds up at set rate

Covered at set rate (Fedhealth network specialists will only charge thesetrate).10%co-payment if FP referral not obtained

Non-FedhealthNetworkSpecialistsFP referral required for consultations to be paid from Riskbenefit

No limit At cost Up to the Fedhealth Rate


Covered at Fedhealth Rate.10%co-payment if FP referral not obtained

Specialists:Psychiatrists

FedhealthNetwork PsychiatristsFP referral required for consultations to be paid from Riskbenefit

The Additional Medical Services limit of R16 600 per family per year applies(combined limit)

Up to set rate

At cost (set rate) untilthebenefitlimitisreached.Amounts spent above limit may be paid out of carry-over Savings if there are funds available

Adds up at set rate to the maximum of the limit

Covered at set rate up to the limit (Fedhealth network specialists will only charge thesetrate).10%co-payment if FP referral not obtained

Non-FedhealthNetworkPsychiatristsFP referral required for consultations to be paid from Riskbenefit

The Additional Medical Services limit of R16 600 per family per year applies(combined limit)

At cost Up to the Fedhealth Rateuntilthebenefitlimitisreached.Amounts spent above limit may be paid out of carry-over Savings if there are funds available


Covered at Fedhealth Rate up to the limit.10%co-payment if FP referral not obtained

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HOWTOCLAIM

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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ABOUTYOURSCHEMEANDMEMBERSHIP

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09About 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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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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09 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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Ultimax contributions table

CONTRIBUTIONSRand amounts paid monthly to the Scheme for cover

receivedaswellasannualbenefitvalues

Risk Savings TOTALAnnual

Threshold*Annual OHEB

Member 9 770 536 10 306 14 575 2 700

Adult Dependant 8 306 455 8 761 11 089 4 240(Family)Child Dependant* 2 986 164 3 150 3 696*

HEALTHCARE SPENDINGExamples of healthcare spend available for various family structures,

as well as annual threshold levels and self-payment gaps

Annual Savings

Annual OHEB

Annual Day-to-Day

Annual Threshold Level

Annual Self-Payment

Gap

M 6 432 2 700 9 132 14 575 5 443

M + AD 11 892 4 240 16 132 25 664 9 532

M + AD + CD 13 860 4 240 18 100 29 360 11 260

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

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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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EXTRASERVICES

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),healthprofilingforeachtrimester,fundingforDoula 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 followuponthebirthwithinaweekoftheduedate.

• 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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SERVICECENTRESANDCONTACTDETAILS

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11Medscheme 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: 0866 114 000/ 1/ 2/ 3/ 4email:[email protected]:www.pharmacydirect.co.zaSMS (call me): 083 690 8934

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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 Ultimax 2018 · COMPREHENSIVE OPTION RANGE. Ultimax. 2018. 1. 1 Overview of benefits 5 Risk and Savings benefits 5 Examples of what each benefit covers