Maxima Core

FEDHEALTH membership means REAL Medical Aid, REAL Service and REAL Benefi ts.

Introducing Maxima Core, a Hospital Plan.

Maxima Core provides mid-20somethings with unlimited hospitalisation at all private hospitals, together with the peace of mind of a Chronic Disease Benefi t that covers 25 chronic conditions at 100% of the Medicine Price List. It also offers freedom on important major medical expenses, like a signifi cant amount for oncology treatment and various reduced co-payments. Treatment by Fedhealth Network specialists is covered at cost for in-hospital procedures. And includes essential value-adds, like the Screening Benefi t, that offers a free annual fl u vaccine for the whole family and 1 free Network GP visit per benefi ciary per year.

How the scheme worksMajor Medical Benefi t

All costs for hospitalisation are covered from this benefi t and must be pre-authorised.

Chronic Disease Benefi tMedication for approved chronic diseases is covered from this benefi t.

Day-to-Day Benefi tPMB level of care applies at the Designated Pharmacy Provider, GP Network and

Specialist Network only.

Max

ima

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maxima coreMember 1 529

Adult Dependant 1 295

Child Dependant 534

contributions

RISK

BE

NE

FITS

RISK B

EN

EFITS

Major Medical Benefit

Chronic Disease Benefit

hospital plans Maxima Core

FR - Fedhealth Rate ICON - Independent Clinical Oncology Network HPT - Healthcare Professional Tariff

[ 1

major medical benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised

maxima core

BENEFIT ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHER-WISE SPECIFIED

Overall annual limit (OAL) Unlimited

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 200% of FR

Prescribed Minimum Benefits (PMBs) Unlimited in state hospitals

Hospitalisation costs Unlimited at negotiated tariff

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, blood, blood equivalents and blood products

Unlimited at cost

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

Emergency treatment in a casualty ward Unlimited at FR

Female health benefit: contraceptives No benefit

Immune deficiency related to HIV infection Unlimited (See HPT above)

Oncology

- Specialised medication

R213 000 at ICON. Subject to Standard Protocols (See HPT above)

No benefit

major medical benefit (continued)

maxima core

BENEFIT ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHER-WISE SPECIFIED

Organ transplant including immunosuppression medication

- Corneal graft

R213 000 (See HPT above)

No benefit

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

Various sub-limits apply (see page 4)

R9 970 at cost

Psychiatric services R21 500 (See HPT above)

Renal Dialysis (chronic)

- Haemodialysis and peritoneal dialysis R213 000 at FR

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

MPL - Medicine Price List

hospital plans Maxima Core[ 2

co-paymentsmaxima core

PROCEDURE CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPI-TAL/ FACILITY BILL ONLY

Colonoscopy, Upper GI endoscopy R2 500

Open hiatus hernia surgery, Hysterectomy (unless for cancer), Inguinal hernia surgery, Varicose vein procedures

R 3 360

Spinal surgery, Joint replacements R6 720

Surgical extraction of impacted wisdom teeth R3 360

Arthroscopic procedures

Ankle, Knee, Shoulder R2 500

Laparoscopic procedures

Diagnostic, Nissen/ Toupey R2 500

All arthroscopic and laparoscopic procedures not listed above Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered

internal prosthesis benefit tableThis benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth

maxima core

BENEFIT LIMIT PER FAMILY PER YEAR

Detachable platinum coils R43 289

Cardiac stents PMBs only

Cardiac valves PMBs only

Cardiac pacemakers PMBs only

Aorta stent grafts R49 906

Intraocular lenses (per lens) R2 804

Carotid stents

See combined benefit limit for all unlisted internal prosthesis*

Peripheral arterial stent grafts

Embolic protection devices

Shoulder replacement

Elbow replacement

Hip replacement

Knee replacement

Bone lengthening devices

Spinal plates and screws

Other approved spinal implantable devices

Combined benefit limit for all unlisted internal prosthesis *R21 308

hospital plans Maxima Core[ 3

screening benefitThis benefit provides access to a number of screening and preventative programmes aimed at improving members’ health

maxima core

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

GeneralGeneral practitioner consultation (in network only)Flu vaccination

All livesAll lives

1 every year1 every year

EPI - Expanded Programme on Immunisation

chronic disease benefitMedication for approved chronic diseases is covered from this benefit

maxima core

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 dis-pensing fee. Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply.

25 CHRONIC CONDITIONS

day-to-day benefitPMB level of care at Specialist Network, GP Network and Designated Pharmacy provider only

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

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.

Benefits unique to Fedhealth:• 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

• 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 - 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

• The Screening Benefit - health screenings for women and children, cardiac screenings as well as an annual flu vaccine funded from Risk.

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. The dentist’s account will need to be paid by the member. *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.

• 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.

Disclaimer: This document is a summary for information purposes only and does not supersede the rules of the Scheme. In the event of any discrepancy between this summary and the Rules, the Rules will prevail. A copy of the Rules is available on request.