maxima core Mid 20-something. Smart and settling down. In good health. More responsible and can afford more cover. Give me

Transcription

1 r a t e s & b e n e f i t s t a b l e s

2 maxima basis maxima entryzone maxima core Mid 20-something. Smart and settling down. In good health. More responsible and can afford more cover. Give me Young, responsible, can afford more. In a relationship and thinking of starting a family, my needs have changed. Give me great cover with hospital and day-to-day benefits. Young, independent 20-something. Healthy, the best hospital plan with unlimited fit and single. Do my own thing, handle my private hospital cover. bills. Just started out, but want the peace of mind to know I m safe because accidents happen. Give me basic, solid hospital cover I can afford on a budget. 100% of Fedhealth Rate R1 million overall annual limit PMB chronic conditions from MEDI-Rite pharmacies and subject to a restrictive No day-to-day benefit, Hospital Plan M - Member A - Adult dependant C - Child dependant Member 875 Adult dependant 630 Child dependant 250 Member Adult dependant 945 Child dependant 390 PMB chronic conditions from MEDI-Rite pharmacies and subject to a restrictive Benefit once level has been reached PMB chronic conditions from MEDI-Rite pharmacies and subject to a restrictive Expenses Benefit (OHEB) as well as a Benefit M: = A: = C: = 225 M = M + A = M + A + C = M + A + 2C = M + A + 3C = M + C = Member Adult dependant Child dependant 435

3 maxima standard Older, I want it all. Married with a family. Taking care of my family s health is essential, I can afford to. I want medical expenses taken care of. maxima exec I m at the top of my game. My medical aid also needs to be. Give me all the benefits of Real Medical Aid. maxima plus Mature, professional and responsible. Health is a priority. Can afford to protect my family and myself. I want everything covered and expect it to be. Give me all the benefits of Real Medical Aid and more. 300% of Fedhealth Rate 39 chronic conditions Annual limit: R3 870 per beneficiary R7 740 per family 51 chronic conditions Annual limit: R4 900 per beneficiary R9 200 per family 51 chronic conditions Annual limit: R per beneficiary R per family Expenses Benefit (OHEB) + Savings (x12) as well as a Benefit M: = A: = C: = 886 M = M + A = M + A + C = M + A + 2C = M + A + 3C = M + C = M A C Risk Savings TOTAL Expenses Benefit (OHEB) + Savings (x12) as well as a Benefit M: = A: = C: = M = M + A = M + A + C = M + A + 2C = M + A + 3C = M + C = M A C Risk Savings TOTAL Expenses Benefit (OHEB) + Savings (x12) as well as a Benefit M: = A: = C: = M = M + A = M + A + C = Member Adult Child* M + A + 2C = M + A + 3C = M + C = M A C Risk Savings TOTAL

4 unique benefits WE PAY MORE FROM RISK THAN ANY OTHER SCHEME: private hospitalisation on most options Post-hospitalisation treatment for up to 30 days after discharge from hospital Seven days of take home medication Specialised radiology like MRI and CT scans Trauma treatment at a casualty ward whether admitted to hospital or not More than 60 procedures performed in day wards, day clinics or doctors rooms Monthly prescriptions for oral contraceptives (excluding Maxima EntryZone and Maxima Core) diabetes programme available with no impact on Chronic Disease Benefit (Maxima Plus and Maxima Exec ) WE ADD MORE VALUE EVERY DAY: Child rates for financially dependent children up to 27 years of age Upgrade to a higher option any time of the year on diagnosis of a dread disease or in the case of a life changing event A Fedhealth Baby programme that offers education, support, great giveaways and now also the support of a Doula during labour Disease management programmes for people living with HIV/ AIDS, diabetes, cancer and cardiac disease 24 hour Fedhealth Nurseline Free trauma counselling for practical and emotional support Accidental injury cover for cats and dogs through Petsure Evacuation benefit for contract workers in Africa.

5 All costs for hospitalisation are covered from this benefit maxima plus maxima exec maxima standard maxima basis maxima core maxima entryzone BENEFIT LIMIT PER FAMILY PER YEAR Overall annual limit (OAL) R1 million. for emergencies/ accidents/ trauma Healthcare professional tariff in hospital Up to 300% of FR Up to 200% of FR* Up to 200% of FR* Up to 200% of FR* Up to 200% of FR* Up to 100% of FR Prescribed Minimum Benefits (PMB) Hospitalisation costs at negotiated tariff at negotiated tariff at negotiated tariff at negotiated tariff at negotiated tariff R1 million. for emergencies/ accidents/ trauma Co-payments (per event) applicable on the hospital / facility bill Hernia surgery: Joint replacements: R5 300 Hernia surgery: Joint replacements: R5 300 Back surgery: R5 300 Hernia surgery: Joint replacements: R5 300 Back surgery: R5 300 Varicose vein procedures: Hysterectomy: (unless for cancer) R3 000 co-payment on the following procedures/ admissions: Back & neck pain, back surgery, bunion procedures, gastritis/ dyspepsia/ heartburn, all hernia procedures, nasal procedures, scopes (upper GI endoscopy, colonoscopy, cystoscopy), laparoscopic procedures, arthroscopic procedures, skin biopsy/ excision, hysterectomy (unless for cancer), tonsil/ adenoid procedures, varicose vein procedures, elective caesarean sections, cataract surgery Alternatives to hospitalisation Subject to OAL Ambulance services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Consultations and visits (GPs and specialists), auxiliary services (occupational therapy), maternity, pathology, physical therapy (physiotherapy and biokinetics), radiology, surgical and non-surgical procedures and tests at cost at cost at cost at cost at cost Subject to OAL Subject to OAL Dentistry: Maxillo-facial surgery, subject to approval, subject to approval, subject to approval, subject to approval, subject to approval Emergency treatment in a casualty ward Subject to OAL Female health benefit: oral contraceptives at MPL at MPL at MPL at MPL Hospice care R R R R R R Immune deficiency related to HIV infection Subject to OAL Oncology Specialised medication sub-limit R R (with a 20% co-payment) R R Basic Oncology Programme R Basic Oncology Programme PMBs in state facilities Organ transplant including immunosuppression medication R R R R PMBs in state facilities Post-hospitalisation benefit Post-natal midwifery benefit 4 days 4 days 4 days 4 days 4 days Prostheses: Internal External R at cost R at cost R at cost R at cost R at cost R8 000 at cost R at cost R8 000 at cost R at cost R8 000 at cost PMBs PMBs Psychiatric services R R R R R PMBs Renal Dialysis (chronic): Haemodialysis and peritoneal dialysis R R R R PMBs in state facilities Specialised medication (eg. biologicals) benefit (non-oncology) R R (with a 20% co-payment) Specialised radiology Subject to OAL Take-out medicines * Certain procedures required as a result of accident or injury as well as natural maternity deliveries covered up to 300% of FR FR - Fedhealth Rate PMB - Prescribed Minimum Benefits

6 Day-to-day expenses are covered from available funds in your Out-of-Hospital Expenses Benefit (OHEB) and Savings Account. Limits may apply when calculating certain claims for accumulation to. These limits will also apply for refunds from OHEB and. maxima plus maxima exec maxima standard maxima basis maxima core maxima entryzone BENEFIT LIMIT PER FAMILY PER YEAR Tariff Up to 100% of FR Up to 100% of FR Up to 100% of FR Up to 100% of FR Up to 100% of FR Co-payments in No co-payment 10% co-payment 20% co-payment 20% co-payment 20% co-payment Appliances, external accessories and orthotics Savings and. R per family per Savings and. R per family per Savings and.. Subject to. Alternative healthcare: Accupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including prescribed medication) Auxiliary services: Audiology, biokinetics, chiropractics, dietetics, occupational therapy, orthoptics, physiotherapy, podiatry, psychologists, social workers and speech therapy, etc Dentistry (Advanced): including oral surgery, osseo-integrated implants, orthognathic surgery and orthodontic treatment Dentistry (Basic), Radiology (General), Pathology, Specialists General Practitioners In-network Out-of-network Health Risk Assessment at preferred pharmacy network Maternity Optometry: Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, Readers and optometric examinations Over-the-counter medication Savings. Does not accumulate to or pay from Savings and. R per family per Savings and. and after Savings and. (Payable from OHEB*, Savings then unlimited) Savings and. Savings and. 2 assessments per beneficiary per year before and after Savings and. Savings and. R2 300 per beneficiary per year, R6 950 per family per Subject to Savings. Does not accumulate to or pay from Savings. Does not accumulate to or pay from Savings and. R per family per Savings and. and after Savings and. (Payable from OHEB*, Savings then unlimited) Savings and. Savings and. 2 assessments per beneficiary per year before and after Savings and. Savings and. R2 300 per beneficiary per year, R6 950 per family per Subject to Savings. Does not accumulate to or pay from Savings. Does not accumulate to or pay from Savings and. Savings and. and after Savings and. (Payable from OHEB*, Savings then unlimited) Savings and. Savings and. 2 assessments per beneficiary per year before and after Savings and. Savings and. R2 300 per beneficiary per year, R6 950 per family per Subject to Savings. Does not accumulate to or pay from Subject to OHEB*. Does not accumulate to or pay from.. R5 100 per R per family per. (Payable from OHEB* then unlimited). once is reached Subject to OHEB* and. 2 assessments per beneficiary per year before and after. 2 antenatal scans per year before and after. R2 300 per R6 950 per family per. R365 per R730 per family per. Included in prescribed medication limits Subject to. Subject to. and after Subject to. Subject to. Subject to. 2 assessments per beneficiary per year before and after Safety Net Subject to. Subject to. R2 300 per beneficiary per year, R6 950 per and after HOSPITAL PLAN ONLY Prescribed medication Savings and. and after Savings and. and after Savings and. and after. R6 800 per R per family per Subject to. and after Radiology (Specialised) * OHEB Out-of-Hospital Expenses Benefit MPL - Medicine Price List FR - Fedhealth Rate

7 (continued) SAFETY NET BENEFIT The Benefit pays for certain day-to-day expenses once OHEB and Savings have been depleted and your claims have accumulated up to the required level. Your level is reached through the accumulation of your claims paid from OHEB, Savings and your own pocket through the year at the Fedhealth Rate. Where limits apply, expenses will accumulate up to this limit and this limit will also apply to refunds from. A 20% co-payment will apply to all claims paid from the Benefit on Maxima Standard, Basis and Core and a 10% co-payment will apply to all claims paid from the Benefit on Maxima Exec. No co-payment will apply to GP consultations in-network. Maxima EntryZone does not have a benefit. Limit Your medication for approved chronic diseases is covered from this benefit maxima plus maxima exec maxima standard maxima basis maxima core maxima entryzone R per beneficiary, subject to an overall limit of R per family per year R4 900 per beneficiary, subject to an overall limit of R9 200 per family per year COVER R3 870 per beneficiary, subject to an overall limit of R7 740 per family per year Prescribed Minimum Benefits Prescribed Minimum Benefits Prescribed Minimum Benefits Conditions covered In-benefit Out-of-benefit (List 1 below ) In-benefit Out-of-benefit (List 1 below ) 51 conditions See lists 1, 2 & 3 below No restrictions 51 conditions See lists 1, 2 & 3 below 39 conditions See lists 1 & 2 below FORMULARY See list 1 below See list 1 below See list 1 below DESIGNATED SERVICE PROVIDER (DSP) HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS Limit In-benefit means that you have not exhausted your limit. Out-of-benefit means that you have exhausted your limit. Non-compliance with DSP and/ or requirements, as per your specific option will attract a co-payment of 40%. If this is in respect of a PMB condition, then the co-payment is not refundable from Savings. All medicine claims are subject to the Medicine Price List (MPL), a generic reference price, and the maximum negotiated dispensing fee. Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply. CHRONIC CONDITIONS LISTS LIST 1. PMB Conditions (all options): 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 LIST 2. (Maxima Plus, Exec and Standard): Ankylosing Spondylitis, Anorexia Nervosa, Attention Deficit Disorder, Bulimia Nervosa, Depression, Dermatomyositis, Generalised Anxiety Disorder, Narcolepsy, Obsessive Compulsive Disorder, Panic Disorder, Paraplegia/Quadriplegia (associated medicine), Post-Traumatic Stress Syndrome, Scleroderma, Tourette s Syndrome LIST 3. (Maxima Plus and Exec): Angina, Barrett s Oesophagus, Conn s Syndrome, Cushing s Syndrome, Deep Vein Thrombosis, Gastro-Oesophageal Reflux Disease, Polyarteritis Nodosa, Pulmonary Interstitial Fibrosis, Thromboangitis Obliterans, Thrombocytopaenic Purpura, Valvular Heart Disease, Zollinger-Ellison Syndrome