Ultima Range Ultima 200 RISK S Major Medical Benefit Chronic Disease Benefit Savings How the scheme works Major Medical Benefit All costs for hospitalisation are covered from this benefit and must be preauthorised. Chronic Disease Benefit Medication for approved chronic diseases is covered from this benefit. DAY-TO-DAY S Day-to-Day Benefit Day-to-day expenses are covered from Savings. FEDHEALTH membership means REAL Medical Aid, REAL Service and REAL Benefits. Introducing Ultima 200. Ultima 200 provides unlimited private hospitalisation at a hospital of the member s choice, and full cover at cost with all Fedhealth Network specialists. It also provides cover for 65 chronic conditions, and includes a Savings account that offers a small amount of Day-to- Day cover. contributions Rand amounts paid monthly to the Scheme for cover received as well as annual benefit values Annual Savings M 324 M + AD 600 M + AD + CD 684 Risk Savings TOTAL Member 2 366 27 2 393 Adult Dependant 2 006 23 2 029 Child Dependant 705 7 712 healthcare spending Examples of healthcare spend available for various family structures, as well as annual Threshold levels and self-payment gaps * Up to a maximum of three children M - member AD - adult dependant CD - child dependant
[ 1 major medical benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised major medical benefit (continued) Overall annual limit (OAL) Healthcare Professional Tariff (HPT) ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Unlimited Oncology ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED R373 000. Subject to Enhanced Protocols. DSP-ICON above limit (See HPT above) - Fedhealth Network GPs and Specialists - Non-Fedhealth Network GPs - Non-Fedhealth Network Specialists - Other Healthcare Professionals Covered at cost Covered at 100% of FR 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 co-payment table on page 2 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 (dietetics, occupational therapy and speech therapy) and physical therapy (physiotherapy and biokinetics) Maxillo-facial surgery Including surgical extraction of impacted wisdom teeth Emergency treatment in a casualty ward Female health benefit: contraceptives Immune deficiency related to HIV infection Unlimited at negotiated tariff Unlimited with Europ Assistance Unlimited at cost Unlimited (See HPT above) Unlimited, subject to approval (See HPT above) Co-payment applies to surgical extraction of impacted wisdom teeth Unlimited at FR Unlimited at MPL Unlimited (See HPT above) - Specialised medication (also see below) Organ transplant including immunosuppression medication - Corneal graft Pathology, radiology (general) Post-hospitalisation benefit Post-natal midwifery benefit Prostheses - Internal - External Psychiatric services R148 000 R373 000 (See HPT above) R17 800 per beneficiary Unlimited at FR Up to 30 days after discharge at FR 4 consultations per pregnancy at FR Various sub-limits apply (See page 2) R14 800 R25 100 (see HPT above) Renal Dialysis (chronic) - Haemodialysis and peritoneal dialysis R373 000 at FR Specialised medication benefit (eg. biologicals) - oncology & non-oncology R148 000 Specialised radiology Unlimited at FR Take-out medicines Terminal care benefit 7 days medication per hospital event at MPL R26 500 at FR FR - Fedhealth Rate ICON - Independent Clinical Oncology Network HPT - Healthcare Professional Tariff DSP - Designated Service Provider MPL - Medicine Price List
PROCEDURE co-payments CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL / FACILITY BILL ONLY Surgical extraction of impacted wisdom teeth R3 360 Rhizotomies and facet pain block (limited to 1 of either procedures per beneficiary per year) R3 600 Balloon Sinuplasty R5 930 Arthroscopic procedures Ankle, Hip, Knee, Shoulder, Wrist R2 010 Laparoscopic procedures Appendectomy, Diagnostic, Hernia repairs (other than inguinal hernia repair), Nissen/ Toupey R2 010 All arthroscopic and laparoscopic procedures not listed above Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered 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. Prosthess paid at cost subject to limits ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED Detachable platinum coils R45 308 Cardiac stents R42 728 Cardiac valves R38 018 Cardiac pacemakers R50 354 Carotid stents R18 280 Aorta stent grafts R50 354 Peripheral arterial stent grafts R34 205 Embolic protection devices R45 308 Shoulder replacement R40 373 Elbow replacement R40 373 Hip replacement R40 373 Knee replacement R40 373 Bone lengthening devices R40 373 Spinal plates and screws R40 373 Other approved spinal implantable devices R40 373 Intraocular lenses (per lens) R2 804 Combined benefit limit for all unlisted internal prosthesis R31 289 [ 2
[ 3 screening benefit This benefit provides access to a number of screening and preventative programmes aimed at improving members health CRITERIA ALL LIMITS ARE PER BENEFICIARY Women s Health Breast cancer screening with mammography Cervical 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 74 Women; ages 21 to 65 1 every 3 years 1 every 3 years Children s Health Immunisation Programme As per State EPI As per State EPI Cardiac Health Cholesterol screening (full lipogram) Geriatric Health Pneumococcal vaccination Bone densitometry Colorectal cancer screening (faecal occult blood test) All lives; aged 20 years and older All lives; older than 65 Women; older than 65 All lives; ages 50 to 75 1 every 5 years 1 per lifetime 1 per lifetime 1 every 2 years General Flu vaccination All lives 1 every year Limit chronic disease benefit Medication for approved chronic diseases is covered from this benefit COVER R4 020 per beneficiary, subject to an overall limit of R7 230 per family per year IN- (Lists 1 and 2 below) Conditions covered 65 conditions See lists 1 & 2 below Formulary Comprehensive formulary Designated Service Provider (DSP) Service provider of choice OUT-OF- (List 1 below only) Formulary Restrictive formulary Designated Service Provider (DSP) Medi-Rite Pharmacy HIV/ AIDS MEDICINE INCLUDING TREATMENT FOR MOTHER-TO-CHILD TRANSMISSION, RAPE & POST-EXPOSURE PROPHYLAXIS Limit Unlimited In-benefit means that you have not exhausted your Chronic Disease Benefit. Out-of-benefit means that you have exhausted your Chronic Disease Benefit limit. Non-compliance with DSP and/ or formulary requirements 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: 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: Alzheimer s Disease, Angina, Ankylosing Spondylitis, Anorexia Nervosa, Attention Deficit Disorder (in children only), Barrett s Oesophagus, Benign Prostatic Hyperplasia, Bulimia Nervosa, Conn s Syndrome, Cushing s Syndrome, Cystic Fibrosis, Deep Vein Thrombosis, Depression, Dermatomyositis, Gastro-Oesophageal Reflux Disease, Generalised Anxiety Disorder, Gout, Hypoparathyroidism, Menopause, Motor Neuron Disease, Muscular Dystrophy, Myaesthenia Gravis, Narcolepsy, Obsessive Compulsive Disorder, Osteoporosis, Paget s Disease, Pancreatic Disease, Panic Disorder, Paraplegia/Quadriplegia (associated medicine), Pemphigus, Polyarteritis Nodosa, Post-Traumatic Stress Syndrome, Pulmonary Interstitial Fibrosis, Scleroderma, Stroke, Thromboangitis Obliterans, Thrombocytopaenic Purpura, Tourette s Syndrome, Valvular Heart Disease, Zollinger Ellison Syndrome
[ 4 day-to-day benefit Day-to-Day expenses are covered from available funds in the Savings Account, Out-of-Hospital Expenses Benefit (OHEB) and carry over Savings on Ultimax and from Savings only on Ultima 200. On Ultimax, limits may apply when calculating certain claims for accumulation to Threshold as well as for refunds from OHEB and Threshold. Ultima 200 does not have an Out-of-Hospital Expenses Benefit (OHEB) or a Threshold Benefit Appliances, external accessories and orthotics Alternative healthcare LIMIT PER FAMILY PER YEAR Maternity Over-the-counter medication Prescribed medication Radiology (Specialised) Specialists excluding psychiatrists day-to-day benefit (continued) LIMIT PER FAMILY PER YEAR Paid from the Major Medical Benefit if pre-authorised Accupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including prescribed medication) Additional medical services - Fedhealth Network Specialists - Non-Fedhealth Network Specialists Audiology, dietetics, occupational therapy, orthoptics, podiatry, psychologists, social workers and speech therapy FR - Fedhealth Rate OHEB - Out-of-Hospital Expenses Benefit Dentistry (Advanced) Including oral surgery, osseo-integrated implants, orthognathic surgery and orthodontic treatment Optometry Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, readers and optometric examinations Biokinetics, Chiropractics, Dentistry (Basic), Radiology (General), Pathology and Physiotherapy General Practitioners - Fedhealth Network GPs - Non-Fedhealth Network GPs
the benefits that set us apart Benefits unique to Fedhealth: Unlimited Network GP visits paid from Risk and never from Savings on all comprehensive options Child rates for financially dependent children up to 27 years of age 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. *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 is paid directly from Risk, so as not to deplete members day-to-day benefits 7 days of paid for take-home medication after discharge from hospital paid from Risk Specialised radiology like MRI and CT scans - paid from Risk and never from Savings - whether performed in or out-ofhospital Trauma treatment at a casualty ward - whether admitted or not, emergency treatment is always paid from Risk Cover for female contraception *must be prescribed by a GP or gynaecologist and not applicable to pills prescribed for acne The Screening Benefit - health screenings for women and children, cardiac screenings as well as an annual flu vaccine funded from Risk. Top comprehensive options also include screening programmes for older members. 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) ~ AsthmaCare ~ DiabeticCare ~ CardioCare ~ Oncology Disease Management. And then members still get: Professional and extreme sports cover - injuries sustained during sporting activities are covered In-hospital dentistry for children under 8 - hospital and anaesthetist costs covered from the In-Hospital Benefit, while the dentist s account comes from day-to-day benefits. *The Authorisation Centre must be contacted at least 48 hours before the procedure Easy membership for former child dependants - meaning no underwriting required for former child dependants. Scheme rules & conditions apply. 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.