maxima plus exec standard standard net basis core entryzone

Transcription

1 maxima plus exec standard standard net basis core entryzone

2 contents who we really are How does it work? 2 Hospital plans Maxima Core & Maxima EntryZone 4 Comprehensive plans Maxima Plus, Exec, Standard, Standard Net and Basis 10 As a long-standing medical scheme founded in 1936, our name and branding may have changed, but we have established a depth of experience and knowledge that challenges most other schemes in the country. Healthy Finances We are one of the largest and oldest open schemes in South Africa with an annual turnover of over R2 billion. Our scheme is financially sound with reserves well over 25% and we have had a consistently high Global Credit Rating of AA- for the last six years. Our large membership base gives us a substantial, stable pool from which we can project future claims experience and plan for our future financial obligations. Highest Service Levels Medscheme, a level 3 BBBEE administration company and one of the largest in the industry, provides excellent administration and managed care services to Fedhealth. Our commitment to high service levels is shown through: An average claim turnaround time of 5 days from receipt of claim to settlement An efficient, friendly and highly rated ISO9001 compliant Customer Contact Centre Average waiting time is 8 seconds State-of-the-art electronic communication systems are in place for members to receive claim and benefit updates electronically, via SMS and An informative monthly newsletter, HouseCall!, delivered electronically and in hardcopy, keeps members in the know on all related Fedhealth news A quarterly Fedhealthy lifestyle magazine. PAGE 1

3 B E N E F I T S MAJOR MEDICAL BENEFIT SAFETY NET BENEFIT SAVINGS D A Y - T O - D A Y R I S K CHRONIC DISEASE BENEFIT OHEB B E N E FI T S Major Medical Benefit All costs for hospitalisation are covered from this benefit. Chronic Disease Benefit Medication for approved chronic diseases is covered from this benefit. Day-to-Day Benefit Day-to-day expenses are covered from the Out-of- Hospital Expenses Benefit (OHEB) and Savings up to cost. Safety Net Benefit The Safety Net Benefit pays for certain day-to-day expenses once OHEB and Savings have been depleted and claims have accumulated to the required level. PAGE 2

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5 hospital plans Maxima Core & Maxima EntryZone BENEFIT major medical benefit All costs for hospitalisation are covered from this benefit maxima core maxima entryzone ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Overall annual limit (OAL) Unlimited Unlimited at network hospitals only. R4 500 co-payment on voluntary use of non-network hospital Healthcare Professional Tariff (HPT) Specialists tariff - Fedhealth Specialist Partners - Non-Fedhealth Specialist Partners Other Healthcare Professionals including GPs Prescribed Minimum Benefits (PMB) Covered at cost Covered at 100% of Fedhealth Rate Covered at 200% of Fedhealth Rate Covered at cost Covered at 100% of Fedhealth Rate Covered at 100% of Fedhealth Rate Unlimited in state hospitals Hospitalisation costs Unlimited at negotiated tariff Unlimited at negotiated tariff at network hospitals only. R4 500 co-payment on voluntary use of non-network hospital Co-payments See details on page 5 Alternatives to hospitalisation Sub-acute facilities, physical rehabilitation facilities, nursing services, private nurse practitioners & nursing agencies Ambulance services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Additional medical services (occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Dentistry: Maxillo-facial surgery Emergency treatment in a casualty ward Female health benefit: contraceptives Hospice care Immune deficiency related to HIV infection Oncology - Specialised medication Organ transplant including immunosuppression medication - Corneal graft Pathology Post-hospitalisation benefit Post-natal midwifery benefit Prostheses - Internal - External Unlimited. Subject to approval (See Healthcare Professional Tariff) Unlimited at negotiated tariff PMB level of care only Unlimited with Europ Assistance Unlimited at cost Unlimited (See Healthcare Professional Tariff) Unlimited at Fedhealth Rate R at Fedhealth Rate Unlimited (See Healthcare Professional Tariff) R at ICON*. PMBs only at ICON* Subject to Standard Protocols (See Healthcare Professional Tariff) R (See Healthcare Professional Tariff) PMBs only in state facilities Unlimited at Fedhealth Rate Up to 30 days after discharge at Fedhealth Rate 4 days at Fedhealth Rate Various sub-limits apply (see page 6) R8 900 at cost PMBs only PMBs only *ICON - Independent Clinical Oncology Network

6 hospital plans Maxima Core & Maxima EntryZone BENEFIT major medical benefit (continued) maxima core maxima entryzone ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Psychiatric services R (See Healthcare Professional Tariff) PMBs only Renal Dialysis (chronic) - Haemodialysis and peritoneal dialysis R at Fedhealth Rate PMBs only in state facilities Specialised medication (eg. biologicals) benefit (oncology & nononcology) Specialised radiology Take-out medicines Unlimited at Fedhealth Rate 7 days medication per hospital event at MPL* *MPL - Medicine Price List co-payments maxima core CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY maxima entryzone Colonoscopy, Upper GI endoscopy R1 800 Extraction of wisdom teeth, Hiatus hernia surgery, Hysterectomy (unless for cancer), Inguinal hernia surgery, Varicose vein procedures R3 000 Back surgery, Joint replacements R6 000 R3 350 co-payment on the following procedures/ admissions All hernia procedures, Back & neck pain, Back surgery Bunion procedures, Cataract surgery, Elective caesarean sections, Gastritis/ dyspepsia/ heartburn, Hysterectomy (unless for cancer), Nasal procedures Scopes (upper GI endoscopy, colonoscopy, cystoscopy), Skin biopsy/ excision, Tonsil/ adenoid procedures, Varicose vein procedures Arthroscopic procedures Ankle, Knee, Shoulder R1 800 R3 350 Laparoscopic procedures Diagnostic, Nissen/ Toupey R1 800 R3 350 ADDITIONAL ARTHROSCOPIC AND LAPAROSCOPIC PROCEDURES WHERE THE SCHEME WILL NOT FUND LAPAROSCOPIC EQUIPMENT AND DISPOSABLES Appendectomy, Hernia repairs (other than inguinal repair), Hip, Hysterectomy, Nephrectomy, Pyeloplasty, Radical Prostatectomy, Splenectomy, Unilateral Inguinal Hernias, Wrist Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered maxima entryzone network hospitals 5 HOSPITAL PROVINCE SUBURB Life Beacon Bay Hospital Eastern Cape East London Mercantile Private Hospital Eastern Cape Korsten St Georges Hospital Eastern Cape Centrahill St James Hospital Eastern Cape Southernwood St Mary's Private Hospital Eastern Cape Umtata Bloemfontein Eye Centre Free State Bloemfontein HOSPITAL PROVINCE SUBURB Pasteur Hospital Free State Bloemfontein Rosepark Hospital Free State Bloemfontein Bougainville Private Hospital Gauteng Hercules Brenthurst Clinic Gauteng Johannesburg Carstenhof Clinic Gauteng Midrand Cormed Clinic Gauteng Vanderbijlpark

7 maxima entryzone network hospitals (continued) HOSPITAL PROVINCE SUBURB Dalview Clinic Gauteng Brakpan Flora Clinic Gauteng Roodepoort Fourways Hospital Gauteng Fourways Gardens Glynnwood Hospital Gauteng Benoni Louis Pasteur Hospital Gauteng Pretoria Central Midvaal Private Hospital (Pty) Ltd Gauteng Three Rivers Robinson Hospital Gauteng Randfontein Roseacres Clinic Gauteng Primrose Chatsmed Garden Hospital Kwa-Zulu Natal Chatsworth Durdoc Clinic Kwa-Zulu Natal Durban Central Entabeni Private Hospital Kwa-Zulu Natal Durban Maxwell Clinic Kwa-Zulu Natal Qualbert Mount Edgecombe (Phoenix) Hospital Kwa-Zulu Natal Mount Edgecombe Westville Hospital Kwa-Zulu Natal Westville HOSPITAL PROVINCE SUBURB Cosmos Hospital Mpumalanga Witbank Peglerae Private Hospital North West Rustenburg Mediclinic Kimberley Northern Cape Kimberley Bay View Private Hospital Western Cape Mossel Bay Blaauwberg Hospital Western Cape Bloubergrant Mediclinic Cape Gate Western Cape Cape Gate Mediclinic Cape Town Western Cape Mill Street Ceres Private Hospital Western Cape Ceres Claremont Hospital Western Cape Claremont Kingsbury Hospital Western Cape Claremont Mediclinic Geneva Western Cape George Mediclinic George Western Cape George Mitchells Plain Medical Centre Western Cape Cape Town West Coast Private Hospital Western Cape Vredenburg Zoutpansberg Private Hospital Limpopo Polokwane internal prosthesis benefit table This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth maxima core maxima entryzone BENEFIT COVER LIMIT PER FAMILY PER YEAR Detachable platinum coils 100% of cost R Cardiac stents 100% of cost PMBs only Cardiac valves 100% of cost PMBs only Cardiac pacemakers 100% of cost PMBs only Carotid stents 100% of cost See combined benefit limit for all unlisted internal prosthesis* Aorta stent grafts 100% of cost R Peripheral arterial stent grafts 100% of cost See combined benefit limit for all unlisted internal prosthesis* Embolic protection devices 100% of cost See combined benefit limit for all unlisted internal prosthesis* Shoulder replacement 100% of cost See combined benefit limit for all unlisted internal prosthesis* Elbow replacement 100% of cost See combined benefit limit for all unlisted internal prosthesis* Hip replacement 100% of cost See combined benefit limit for all unlisted internal prosthesis* Knee replacement 100% of cost See combined benefit limit for all unlisted internal prosthesis* PMBs only Bone lengthening devices 100% of cost See combined benefit limit for all unlisted internal prosthesis* Spinal plates and screws 100% of cost See combined benefit limit for all unlisted internal prosthesis* Other approved spinal implantable devices 100% of cost See combined benefit limit for all unlisted internal prosthesis* Intraocular lenses (per lens) 100% of cost R2 500 *Combined benefit limit for all unlisted internal prosthesis 100% of cost *R

8 hospital plans Maxima Core & Maxima EntryZone screening benefit This 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 Health Breast cancer screening with mammography Cervical cancer screening Women; ages 50 to 70 Women; ages 21 to 65 1 every 3 years 1 every 3 years Children s Health Immunisation Programme (as per State EPI) Various Various Cardiac Health Cholesterol screening (full lipogram) All lives; older than 20 1 every 5 years General General practitioner consultation (in network only) Flu vaccination All lives All lives 1 every year 1 every year maxima entryzone Limit chronic disease benefit Medication for approved chronic diseases is covered from this benefit maxima core COVER Prescribed Minimum Benefits only maxima entryzone Conditions covered See list below Formulary Restrictive formulary Designated Service Provider (DSP) MEDI-Rite pharmacy HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS Limit Unlimited Non-compliance with DSP and/ or formulary requirements will attract a co-payment of 40%. All medicine claims are subject to the Medicine Price List (MPL), a generic reference price list, and the maximum negotiated dispensing fee. Where the dispensing fee has not been negotiated, a maximum dispensing fee of 26% / R26 will apply. 25 PRESCRIBED CHRONIC CONDITIONS Addison s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac Failure, Cardiomyopathy, COPD/ Emphysema/ Chronic Bronchitis, Chronic Renal Disease, Coronary Artery Disease, Crohn s Disease, Diabetes Insipidus, Diabetes Mellitus type 1 & 2, Dysrhythmias, Epilepsy, Glaucoma, Haemophilia, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis, Parkinson s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus Erythematosus, Ulcerative Colitis PAGE 7

9 day-to-day benefit PMB level of care at Specialist Network Partners, GP Network Partners and designated Pharmacy provider only PAGE 8

10 hospital plans Maxima Core & Maxima EntryZone benefits unique to fedhealth Because life is not always predictable, we are there with benefits that are about our members. We are talking about benefits that are practical and usable, ensuring that our members always get value for their money. These benefits form the core of our philosophy of being Real. If you want to measure us for living up to our promise, then our unique benefits are the place to look. It s what makes us stand out from the rest because they are mostly designed around one simple premise: ALLOWING MEMBERS TO SAVE MONEY. We pay more from risk: Unlimited private hospitalisation. (Network hospitals only on Maxima EntryZone) Post-hospitalisation treatment for up to 30 days after discharge from hospital 7 days of take-home medication All specialised radiology like MRI and CT Scans Trauma treatment at a casualty ward whether admitted to hospital or not Contracted fixed rates at partner providers. We add more value to 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 Emergency medical transport anywhere in SA through Europ Assistance A Fedhealth Baby Programme that offers education, support, great give-aways and the support of a Doula during labour 24-Hour Fedhealth Nurseline Free trauma counselling for practical and emotional support Comprehensive HIV/AIDS and other disease management programmes. contributions maxima core Member Adult Dependant Child Dependant 440 maxima entryzone Member 883 Adult Dependant 660 Child Dependant 297 PAGE 9

11 comprehensive plans Maxima Plus, Exec, Standard, Standard Net & Basis BENEFIT major medical benefit All costs for hospitalisation are covered from this benefit maxima plus maxima exec maxima standard maxima standard net maxima basis ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Overall annual limit (OAL) Unlimited Unlimited at network hospitals only. R4 500 co-payment on voluntary use of nonnetwork hospitals Healthcare Professional Tariff in hospital (HPT) Specialists tariff - Fedhealth Specialist Partners - Non-Fedhealth Specialist Partners Other Healthcare Professionals including GPs Prescribed Minimum Benefits (PMB) Covered at cost Covered at 200% of FR Covered at 300% of FR Covered at cost Covered at 200% of FR Covered at 200% of FR Unlimited in state hospitals Covered at cost Covered at 100% of FR Covered at 200% of FR Unlimited Hospitalisation costs Unlimited at negotiated tariff Unlimited at negotiated tariff at network hospitals only. R4 500 co-payment on voluntary use of nonnetwork hospitals Unlimited at negotiated tariff Co-payments See details on page 11 Alternatives to hospitalisation Sub-acute facilities, physical rehabilitation facilities, nursing services, private nurse practitioners & nursing agencies Unlimited at negotiated tariff Unlimited at negotiated tariff. PMB level of care only Ambulance services Appliances, external accessories, orthotics, blood, blood equivalents and blood products Additional medical services (occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Unlimited with Europ Assistance Unlimited at cost Unlimited (See Healthcare Professional Tariff) Dentistry: Maxillo-facial surgery Unlimited, subject to approval (See Healthcare Professional Tariff) Emergency treatment in a casualty ward Female health benefit: contraceptives Hospice care Immune deficiency related to HIV infection Oncology - Specialised medication (also see page 11) Organ transplant including immunosuppression medication - Corneal graft Unlimited. Subject to Enhanced Protocols (See HPT) R at cost Unlimited (See HPT) R per beneficiary Unlimited. Subject to Enhanced Protocols (See HPT) R at cost R (See HPT) R per beneficiary Unlimited at Fedhealth Rate Unlimited at MPL* R at Fedhealth Rate Unlimited (See Healthcare Professional Tariff) R Subject to Standard Protocols. DSP- ICON* above limit (See HPT) R (See HPT) R per beneficiary R at ICON*. Subject to Standard Protocols (See HPT) R (See HPT) FR - Fedhealth Rate *ICON - Independent Clinical Oncology Network *MPL - Medicine Price List PAGE 10

12 BENEFIT Pathology Post-hospitalisation benefit Post-natal midwifery benefit Prostheses - Internal - External major medical benefit (continued) maxima plus maxima exec maxima standard maxima standard net maxima basis Various sub-limits apply (See page 13) R at cost ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Various sub-limits apply (See page 13) R at cost Unlimited at Fedhealth Rate Up to 30 days after discharge at Fedhealth Rate 4 days at Fedhealth Rate Various sub-limits apply (See page 13) R8 900 at cost Psychiatric services R (See HPT) R (See HPT) R (see HPT) Renal Dialysis (chronic) - Haemodialysis and peritoneal dialysis Unlimited at FR R at FR R at FR R at FR Specialised medication (eg. biologicals) benefit (oncology & non-oncology) R at cost R at cost Specialised radiology Take-out medicines Unlimited at Fedhealth Rate 7 days medication per hospital event at MPL* HPT - Healthcare Professional Tariff FR - Fedhealth Rate *MPL - Medicine Price List co-payments maxima plus maxima exec maxima standard maxima standard net maxima basis CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY Colonoscopy, Upper GI endoscopy R1 800 Extraction of wisdom teeth R3 000 Hiatus hernia surgery No co-payment R3 000 Rhizotomies and facet pain block (limited to 1 of either procedures per beneficiary per year) R3 200 Balloon Sinuplasty R5 300 Back surgery No co-payment R6 000 Joint replacements No co-payment R6 000 Arthroscopic procedures Ankle, Knee, Shoulder No co-payment R1 800 Hip, Wrist No co-payment R1 800 Included in additional list below Laparoscopic procedures Appendectomy, Hernia repairs (other than inguinal hernia repair) No co-payment R1 800 Included in additional list below Diagnostic, Nissen/ Toupey No co-payment R1 800 Nephrectomy No co-payment Included in additional list below ADDITIONAL ARTHROSCOPIC AND LAPAROSCOPIC PROCEDURES WHERE THE SCHEME WILL NOT FUND LAPAROSCOPIC EQUIPMENT AND DISPOSABLES Hysterectomy, Pyeloplasty, Radical Prostatectomy, Splenectomy, Unilateral Inguinal Hernias Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered 11

13 screening benefit This benefit provides access to a number of screening and preventative programmes aimed at improving members health maxima plus maxima exec maxima standard maxima standard net maxima basis BENEFIT CRITERIA ALL LIMITS ARE PER BENEFICIARY Women s Health Breast cancer screening with mammography Cervical cancer screening Women; ages 50 to 70 Women; ages 21 to 65 1 every 3 years 1 every 3 years Children s Health Immunisation Programme (as per State EPI) Various Various Cardiac Health Cholesterol screening (full lipogram) All lives; older than 20 1 every 5 years Geriatric Health Pneumococcal vaccination Bone densitometry Colorectal cancer screening (faecal occult blood test) All lives; older than 65 Women; older than 65 All lives; ages 50 to 75 1 per lifetime 1 per lifetime 1 every 2 years General Flu vaccination All lives 1 every year N/A N/A N/A maxima standard net network hospitals HOSPITAL PROVINCE SUBURB HOSPITAL PROVINCE SUBURB Life Beacon Bay Hospital Eastern Cape East London Robinson Hospital Gauteng Randfontein Mercantile Private Hospital Eastern Cape Korsten St Georges Hospital Eastern Cape Centrahill St James Hospital Eastern Cape Southernwood Bloemfontein Eye Centre Free State Bloemfontein Pasteur Hospital Free State Bloemfontein Rosepark Hospital Free State Bloemfontein Bougainville Private Hospital Gauteng Hercules Brenthurst Clinic Gauteng Johannesburg Cormed Clinic Gauteng Vanderbijlpark Dalview Clinic Gauteng Brakpan Flora Clinic Gauteng Roodepoort Fourways Hospital Gauteng Fourways Gardens Glynnwood Hospital Gauteng Benoni Louis Pasteur Hospital Gauteng Pretoria Central Roseacres Clinic Gauteng Primrose Chatsmed Garden Hospital Kwa-Zulu Natal Chatsworth Durdoc Clinic Kwa-Zulu Natal Durban Central Entabeni Private Hospital Kwa-Zulu Natal Durban Maxwell Clinic Kwa-Zulu Natal Qualbert Mount Edgecombe (Phoenix) Hospital Kwa-Zulu Natal Mount Edgecombe Westville Hospital Kwa-Zulu Natal Westville Blaauwberg Hospital Western Cape Bloubergrant Cape Gate Mediclinic Western Cape Cape Gate Cape Town Mediclinic Western Cape Mill Street Ceres Private Hospital Western Cape Ceres Claremont Hospital Western Cape Claremont Kingsbury Hospital Western Cape Claremont West Coast Private Hospital Western Cape Vredenburg Midvaal Private Hospital (Pty) Ltd Gauteng Three Rivers PAGE 12

14 comprehensive plans Maxima Plus, Exec, Standard, Standard Net & Basis internal prosthesis benefit table This benefit does not include osseo-integrated implants for the purpose of replacing a missing tooth or teeth. Hip and knee bilateral replacements will be allowed for up to double the amount for a single hip and knee replacement, whichever is the lower maxima plus maxima exec maxima standard maxima standard net maxima basis BENEFIT COVER ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Detachable platinum coils 100% of cost R Cardiac stents 100% of cost R R PMBs only Cardiac valves 100% of cost R R PMBs only Cardiac pacemakers 100% of cost R R R PMBs only Carotid stents 100% of cost See combined benefit limit for all unlisted internal prosthesis* Aorta stent grafts 100% of cost R Peripheral arterial stent grafts 100% of cost See combined benefit limit for all unlisted internal prosthesis* Embolic protection devices 100% of cost See combined benefit limit for all unlisted internal prosthesis* Shoulder replacement 100% of cost R R R Elbow replacement 100% of cost R R R Hip replacement 100% of cost R R R Knee replacement 100% of cost R R R See combined benefit limit for all unlisted internal prosthesis* See combined benefit limit for all unlisted internal prosthesis* See combined benefit limit for all unlisted internal prosthesis* See combined benefit limit for all unlisted internal prosthesis* Bone lengthening devices 100% of cost See combined benefit limit for all unlisted internal prosthesis* Spinal plates and screws 100% of cost See combined benefit limit for all unlisted internal prosthesis* Other approved spinal implantable devices 100% of cost See combined benefit limit for all unlisted internal prosthesis* Intraocular lenses (per lens) 100% of cost R2 500 *Combined benefit for all unlisted internal prosthesis 100% of cost *R *R *R PAGE 13

15 Limit chronic disease benefit Medication for approved chronic diseases is covered from this benefit maxima plus maxima exec maxima standard maxima standard net maxima basis R per beneficiary, subject to an overall limit of R per family per year R5 450 per beneficiary, subject to an overall limit of R per family per year COVER R4 340 per beneficiary, subject to an overall limit of R8 630 per family per year Prescribed Minimum Benefits only Conditions covered IN-BENEFIT (Lists 1, 2 and 3 below) IN-BENEFIT (List 1) 51 conditions See lists 1, 2 & 3 below 39 conditions See lists 1 & 2 below See list 1 below Formulary No formulary restrictions Comprehensive formulary Restrictive formulary Designated Service Provider Service provider of choice MEDI-Rite pharmacy OUT-OF-BENEFIT (List 1 below only) Formulary Comprehensive formulary Restrictive formulary Designated Service Provider Service provider of choice MEDI-Rite pharmacy Limit HIV/ AIDS MEDICINE BENEFIT INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS Unlimited Out-of-benefit does not apply In-benefit means that you have not exhausted your Chronic Disease Benefit limit. Out-of-benefit means that you have exhausted your Chronic Disease Benefit limit. Non-compliance with DSP and/ or formulary requirements, as per the 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 list, 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 (in children only), 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 PAGE 14

16 comprehensive plans Maxima Plus, Exec, Standard, Standard Net & Basis day-to-day benefit Day-to-day expenses are covered from available funds in the Out-of-Hospital Expenses Benefit (OHEB) and Savings Account. Limits may apply when calculating certain claims for accumulation to Safety Net. These limits will also apply for refunds from OHEB and Safety Net BENEFIT Tariff maxima plus maxima exec maxima standard maxima standard net maxima basis LIMIT PER FAMILY PER YEAR Up to 100% of Fedhealth Rate Co-payments in Safety Net No co-payment 10% co-payment 20% co-payment Appliances, external accessories and orthotics Alternative healthcare R per family per year before and after Safety Net. Subject to OHEB*, Savings and Safety Net R8 940 per family per year before and after Safety Net. Subject to OHEB*, Savings and Safety Net R8 940 per family per year before and after Safety Net. Safety Net Accupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including prescribed medication) Savings. Does not accumulate to or pay from Safety Net Subject to OHEB*. Does not accumulate to or pay from Safety Net Additional medical services Audiology, dietetics, occupational therapy, orthoptics, podiatry, psychologists, social workers and speech therapy, etc R per family per year before and after Safety Net. Subject to OHEB*, Savings and Safety Net R8 940 per family per year before and after Safety Net. Subject to OHEB*, Savings and Safety Net R8 940 per family per year before and after Safety Net Safety Net Dentistry (Advanced) including oral surgery, osseointegrated implants, orthognathic surgery and orthodontic treatment Biokinetics, Chiropractics, Dentistry (Basic), Radiology (General), Pathology and Physiotherapy General Practitioners - Fedhealth GP Partners - Non-Fedhealth GP Partners Antenatal Scans Optometry Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, readers and optometric examinations R5 700 per beneficiary per year, R per family per year before and after Safety Net. Subject to OHEB*, Savings and Safety Net Subject to OHEB*, Savings and Safety Net. Unlimited once Safety Net is reached Subject to OHEB* then unlimited from Risk Subject to OHEB*, Savings and Safety Net. Unlimited once Safety Net is reached 2 x 2D antenatal scans per year before and after Safety Net Subject to OHEB*, Savings and Safety Net R2 560 per beneficiary per year, R7 760 per family per year before and after Safety Net. Subject to OHEB*, Savings and Safety Net R5 700 per beneficiary per year, R per family per year before and after Safety Net. Safety Net Safety Net. Unlimited once Safety Net is reached Subject to OHEB* then unlimited from Risk Safety Net. Unlimited once Safety Net is reached 2 x 2D antenatal scans per year before and after Safety Net. Safety Net R2 560 per beneficiary per year, R7 760 per family per year before and after Safety Net Safety Net PAGE 15 * OHEB - Out-of-Hospital Expenses Benefit

17 day-to-day benefit (continued) maxima plus maxima exec maxima standard maxima standard net maxima basis BENEFIT Over-the-counter medication Prescribed medication Radiology (Specialised) Specialists excluding psychiatrists - Fedhealth Specialist Partners - Non-Fedhealth Specialist Partners Specialists: Psychiatrists LIMIT PER FAMILY PER YEAR Subject to Savings only. Does not accumulate to or pay from Safety Net R7 600 per beneficiary per year, R per family per year before and after Safety Net. Subject to OHEB*, Savings and Safety Net. Paid from the Major Medical Benefit if pre-authorised Subject to OHEB*, Savings and accumulation at cost to Safety Net. Unlimited at cost once Safety Net is reached Subject to OHEB*, Savings and Safety Net. Accumulation to Safety Net at Fedhealth Rate only. Unlimited at Fedhealth Rate once Safety Net is reached R405 per beneficiary per year, R815 per family per year before and after Safety Net. Included in Prescribed Medication limits. Subject to OHEB* and refund from Safety Net. Does not accumulate to Safety Net R7 600 per beneficiary per year, R per family per year before and after Safety Net. Safety Net accumulation at cost to Safety Net. Unlimited at cost once Safety Net is reached Safety Net. Accumulation to Safety Net at FR only. Unlimited at FR once Safety Net is reached - Fedhealth Psychiatrist Partners Subject to Additional Medical Services limit of R per family before and after Safety Net. Subject to OHEB*, Savings and accumulation at cost to Safety Net Subject to Additional Medical Services limit of R8 940 per family before and after Safety Net. Subject to OHEB*, Savings and accumulation at cost to Safety Net Subject to Additional Medical Services limit of R8 940 per family before and after Safety Net. accumulation at cost to Safety Net Subject to Additional Medical Services limit of R8 940 per family before and after Safety Net. Subject to OHEB* and Safety Net. Accumulation to and refund from Safety Net at FR only - Non-Fedhealth Psychiatrist Partners Subject to Additional Medical Services limit of R per family before and after Safety Net. Subject to OHEB*, Savings and Safety Net. Accumulation to and refund from Safety Net at Fedhealth Rate only Subject to Additional Medical Services limit of R8 940 per family before and after Safety Net. Subject to OHEB*, Savings and Safety Net. Accumulation to and refund from Safety Net at Fedhealth Rate only SAFETY NET BENEFIT The Safety Net Benefit pays for certain day-to-day expenses once OHEB and Savings have been depleted and claims have accumulated up to the required level. The Safety Net level is reached through the accumulation of claims paid from OHEB, Savings and the member s own pocket through the year at the Fedhealth Rate. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from Safety Net. A 20% co-payment will apply to all claims paid from the Safety Net Benefit on Maxima Standard and Basis and a 10% co-payment will apply to all claims paid from the Safety Net Benefit on Maxima Exec. No co-payment will apply to GP or specialist consultations in-network. * OHEB - Out-of-Hospital Expenses Benefit PAGE 16

18 comprehensive plans Maxima Plus, Exec, Standard, Standard Net & Basis benefits unique to fedhealth Because life is not always predictable, we are there with benefits that are about our members. We are talking about benefits that are practical and usable, ensuring that our members always get value for their money. These benefits form the core of our philosophy of being Real. If you want to measure us for living up to our promise, then our unique benefits are the place to look. It s what makes us stand out from the rest because they are mostly designed around one simple premise: ALLOWING MEMBERS TO SAVE MONEY. We pay more from risk: Unlimited private hospitalisation. (Network hospitals only on Maxima Standard Net ) Post-hospitalisation treatment for up to 30 days after discharge from hospital 7 days of take-home medication All specialised radiology like MRI and CT Scans Trauma treatment at a casualty ward whether admitted to hospital or not Monthly prescription for female contraceptives: oral, patch and IUDs including Mirena Contracted fixed rates at partner providers. We add more value to 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 Emergency medical transport anywhere in SA through Europ Assistance A Fedhealth Baby Programme that offers education, support, great give-aways and the support of a Doula during labour 24-Hour Fedhealth Nurseline Free trauma counselling for practical and emotional support Comprehensive HIV/AIDS and other disease management programmes. PAGE 17

19 contributions maxima plus (including OHEB and Savings) Risk Savings TOTAL Safety Net* OHEB Savings OHEB Dayto-Day Safety Net Level Self Payment Gap Member M Adult Dependant M + AD Child Dependant M + AD + CD maxima exec (including OHEB and Savings) Risk Savings TOTAL Safety Net* OHEB Savings OHEB Dayto-Day Safety Net Level Self Payment Gap Member M Adult Dependant M + AD Child Dependant M + AD + CD maxima standard (including OHEB and Savings) Risk Savings TOTAL Safety Net* OHEB Savings OHEB Dayto-Day Safety Net Level Self Payment Gap Member M Adult Dependant M + AD Child Dependant M + AD + CD maxima standard net (including OHEB and Savings) Risk Savings TOTAL Safety Net* OHEB Savings OHEB Dayto-Day Safety Net Level Self Payment Gap Member M Adult Dependant M + AD Child Dependant M + AD + CD maxima basis (including OHEB) Risk Savings TOTAL Safety Net* OHEB Savings OHEB Dayto-Day Safety Net Level Self Payment Gap Member M Adult Dependant M + AD Child Dependant M + AD + CD * Up to a maximum of three children PAGE 18

20 Private Bag X3045 Randburg 2125, 37 Conrad Street Florida North Fedhealth Customer Contact Centre 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.