member guide maxima plus

Transcription

1 2014 member guide maxima plus

2 how does your scheme work? contents B E N E F I T S R I S K Major Medical Benefit Chronic Disease Benefit Safety Net Benefit Savings OHEB B E N E FI T S D A Y - T O D A Y - T O B E N E FI - D A Y - D A Y How does your scheme work? 2 Major Medical Benefit 3 Prescribed Minimum Benefits 6 Chronic Disease Benefit 9 Day-to-Day Benefit 15 Contributions 20 Unique Benefits 21 Important user tips 25 Medscheme Client Service 28 Centres Contact numbers 29 Major Medical Benefit All costs for hospitalisation are covered from this benefit. Chronic Disease Benefit Your medication for approved chronic diseases is covered from this benefit. Safety Net Benefit The Safety Net Benefit pays for certain day-to-day expenses once your OHEB and Savings have been depleted and your claims have accumulated to the required level. Day-to-Day Benefit Day-to-day expenses are covered from the Out-of-Hospital Expenses Benefit (OHEB) and Savings. 1 ] [ 2

3 BENEFIT major medical benefit All costs for hospitalisation are covered from this benefit and must be pre-authorised ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED BENEFIT major medical benefit (continued) Psychiatric services ALL LIMITS ARE PER FAMILY PER YEAR UNLESS OTHERWISE SPECIFIED R (See HPT) Overall annual limit (OAL) Healthcare Professional Tariff (HPT) Specialists tariff - Fedhealth Specialist Partners - Non-Fedhealth Specialist Partners Other Healthcare Professionals including GPs Prescribed Minimum Benefits (PMBs) Unlimited Covered at cost Covered at 200% of FR Covered at 300% of FR Unlimited in state hospitals Renal Dialysis (chronic) - Haemodialysis and peritoneal dialysis Unlimited at FR Specialised medication benefit (eg. biologicals) - oncology & non-oncology Specialised radiology Take-out medicines HPT - Healthcare Professional Tariff *PMB - Prescribed Minimum Benefits *MPL - Medicine Price List R Unlimited at FR 7 days medication per hospital event at MPL* FR - Fedhealth Rate Hospitalisation costs Unlimited at negotiated tariff Co-payments See details on page 4 Alternatives to hospitalisation co-payments CO-PAYMENTS (PER EVENT) APPLICABLE ON THE HOSPITAL/ FACILITY BILL ONLY 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) Unlimited at negotiated tariff Unlimited with Europ Assistance Unlimited at cost Unlimited at cost Colonoscopy, Upper GI endoscopy R1 900 Extraction of wisdom teeth R3 170 Hiatus hernia surgery Rhizotomies and facet pain block (limited to 1 of either procedures per beneficiary per year) R3 400 Balloon Sinuplasty R5 600 Spinal surgery Joint replacements Maxillo-facial surgery Incl surgical extraction of impacted wisdom teeth Unlimited, subject to approval (See HPT) Co-payment applies to surgical extraction of impacted wisdom teeth Arthroscopic procedures Ankle, Knee, Shoulder Hip, Wrist Emergency treatment in a casualty ward Unlimited at FR Laparoscopic procedures Female health benefit: contraceptives Terminal care benefit Immune deficiency related to HIV infection Unlimited at MPL* R at FR Unlimited (See Healthcare Professional Tariff) Appendectomy, Hernia repairs (other than inguinal hernia repair) Diagnostic, Nissen/ Toupey Nephrectomy Oncology Unlimited. Subject to Enhanced Protocols (See HPT) All arthroscopic and laparoscopic procedures not listed above Only the costs for hospital/ facility, theatre fees, anaesthetist & surgeon will be covered - Specialised medication (also see page 4) R Organ transplant including immunosuppression medication - Corneal graft Unlimited (See HPT) R per beneficiary Pathology 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 Various sub-limits apply (See page 7) - External R ] [ 4

4 major medical benefit All authorised costs for hospitalisation are covered from this benefit at the Healthcare Professional Tariff. Please remember to familiarise yourself with the network provisions on this option. Hospital costs will be covered unlimited, from this benefit. Certain benefits are subject to and limited by case management and managed care protocols. These protocols have been introduced to ensure best quality treatment at best rates. Consult the Major Medical Benefit table for detail on these interventions and their limits. Fedhealth Specialist Partners: the Scheme has partnered with specialists across all disciplines in order to ensure that members have no co-payments when visiting these specialists. Making use of a Fedhealth Specialist Partner in hospital will ensure no co-payments, as fixed rates have been negotiated with these partners. Voluntary use of a non- Fedhealth Specialist Partner will result in lower reimbursement rates of your in-hospital specialist account. Please note that certain procedures performed by a specialist may still attract a co-payment whether a network specialist is used or not. Selected procedures performed in a day ward, day clinic and the doctor s rooms are also covered from this benefit and not from your day-to-day benefits. For a list of these procedures and pre-authorisation, please phone the Fedhealth Customer Contact Centre on or visit the Fedhealth website on Specialised Radiology, for example MRI and CT scans, is also covered from the Major Medical Benefit whether the procedure is performed in hospital or not. Specialised Radiology will therefore be paid by the Scheme and will not be deducted from OHEB or Savings. Treatment received in a casualty ward for trauma as well as any other treatment in a casualty ward that is immediately followed by a hospital admission, is covered from the Major Medical Benefit. Trauma is defined as a physical injury to the body by an external force that requires immediate attention, for example stitches. Certain treatment arising from a hospital event, for example physiotherapy, x-rays and blood tests are covered for 30 days from date of discharge from hospital from the Major Medical Benefit. For a list of these treatments and pre-authorisation, please phone the Fedhealth Customer Contact Centre on or visit the Fedhealth website on Oncology benefit: The Scheme has contracted with Independent Clinical Oncology Network (ICON) for the provision of oncology treatment. ICON is a network of oncologists that includes 75% of all practicing oncologists in South Africa. Details of the ICON network are available on their website at or with a call to your Oncology Case Manager on Oncology Limit* Specialised Drug Sub-limit oncology Brachytherapy materials Applicable Protocols DSP / Preferred Provider Status Unlimited R R Enhanced ICON* - Preferred Provider * Once benefit limits are exhausted, only PMBs will be covered. *ICON - Independent Clinical Oncology Network A Preferred Provider means that Fedhealth would prefer you to use the ICON network as their treatment protocols are aligned with the Scheme. However, you may still use a service provider of your choice. Please note that should you use an oncologist outside of the ICON network your treatment will only be reimbursed at 100% of the Fedhealth Rate regardless of whether care takes place in or out of hospital. Treatment at ICON oncologists will be reimbursed in full at the ICON rate. All costs covered from the Major Medical Benefit need to be pre-authorised by the Authorisation Centre on prescribed minimum benefits (PMBs) All medical schemes are required by law to cover 270 hospital based conditions, 25 chronic conditions in full without co-payment or deductibles, as well as any emergency treatment and certain out of hospital treatment. This means that all schemes must provide PMB level of care at cost for these conditions. The Medical Schemes Act 131 of 1998 allows schemes to require members to make use of Designated Service Providers (DSPs) in order for a member to be entitled to funding in full. Schemes may also apply Formularies a list of medicines which should be used to treat PMBs, and managed care protocols based on evidence-based medicine and cost-effectiveness principles to manage this benefit. Fedhealth has designated their Specialist Partners, Network GPs and a designated pharmacy network, the Medi-Rite group of pharmacies, as the Designated Service Providers for the provision of PMBs (as well as the State). This means that a member must make use of a Fedhealth Specialist Partner, a Network GP or the designated pharmacy network, in order for the cost to be funded in full. Should the member not use these DSPs for the treatment of a PMB condition, the Scheme will reimburse treatment at the non-fedhealth Partner Rate applicable to your option. Co-payments are applicable to the voluntary use of non-dsps. It is important to note that qualification as a PMB is not based solely on the diagnosis (condition) but also on the treatment provided (level of care). This means that although your condition may be a PMB condition, the Scheme would only be obliged to fund it in full if the treatment provided was deemed to be PMB level of care. 5 ] [ 6

5 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. Prostheses paid at cost subject to limits BENEFIT ALL LIMITS ARE PER FAMILY PER YEAR UN- LESS OTHERWISE SPECIFIED Detachable platinum coils R Cardiac stents R Cardiac valves R Cardiac pacemakers R Aorta stent grafts R Intraocular lenses (per lens) R2 645 Shoulder replacement R Elbow replacement R Hip replacement R Knee replacement R Total ankle replacement Bone lengthening devices Spinal plates and screws Carotid stents Peripheral arterial stent grafts Embolic protection devices Other approved spinal implantable devices See combined benefit limit for all unlisted internal prosthesis* Combined benefit for all unlisted internal prosthesis *R screening benefit This benefit provides access to a number of screening and preventative programmes aimed at improving members health BENEFIT CRITERIA LIMIT PER BENEFICIARY AGE OF CHILD At Birth immunisation benefit VACCINE Tuberculosis (Bacilles Calmette Guerin) OPV (0) Oral Polio Vaccine 6 Weeks OPV (1) Oral Polio Vaccine RV (1) Rotavirus Vaccine DTaP-IPV//Hib (1), Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilus influenzae type b Combined Hep B (1) Hepatitis B Vaccine PCV 7 (1) Pneumococcal Conjugated Vaccine 10 Weeks DTaP-IPV//Hib (2), Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilus influenzae type b Combined Hep B (2) Hepatitis B Vaccine 14 Weeks RV (2) Rotavirus Vaccine (should not be administered after 24 weeks) DTaP-IPV//Hib (3), Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilus influenzae type b Combined Hep B (3) Hepatitis B Vaccine PCV 7 (2) Pneumococcal Conjugated Vaccine 9 Months Measles Vaccine (1) PCV 7 (3) Pneumococcal Conjugated Vaccine 18 Months DTaP-IPV//Hib (4), Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilus influenzae type b Combined Measles Vaccine (2) 6 Years Td Vaccine Tetanus and reduced strength of diphtheria Vaccine 12 Years Td Vaccine Tetanus and reduced strength of diphtheria Vaccine 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 Children s Health Immunisation Programme (as per State EPI) Cardiac Health Cholesterol screening (full lipogram) Geriatric Health Pneumococcal vaccination Bone densitometry Colorectal cancer screening (faecal occult blood test) Women; 50 to 70 Women; 21 to 65 Various (see list) All lives; aged 20 years and older All lives; older than 65 Women; older than 65 All lives; ages 50 to 75 1 every 3 years 1 every 3 years Various 1 every 5 years 1 per lifetime 1 per lifetime 1 every 2 years General Flu vaccination All lives 1 every year EPI - Expanded Programme on Immunisation 7 ] [ 8

6 Limit chronic disease benefit Medication for approved chronic diseases is covered from this benefit Conditions covered Formulary Designated Service Provider (DSP) Formulary Designated Service Provider (DSP) COVER R per beneficiary, subject to an overall limit of R per family per year IN-BENEFIT (Lists 1 and 2 below) OUT-OF-BENEFIT (List 1 below only) 51 conditions See lists 1 & 2 below No formulary restrictions Service provider of choice Comprehensive formulary Service provider of choice HIV/ AIDS MEDICINE BENEFIT 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 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: 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. Additional chronic conditions covered on Maxima Plus: Angina, Ankylosing Spondylitis, Anorexia Nervosa, Attention Deficit Disorder (in children only), Barrett s Oesophagus, Bulimia Nervosa, Conn s Syndrome, Cushing s Syndrome, Deep Vein Thrombosis, Depression, Dermatomyositis, Gastro-Oesophageal Reflux Disease, Generalised Anxiety Disorder, Narcolepsy, Polyarteritis Nodosa, Pulmonary Interstitial Fibrosis, Obsessive Compulsive Disorder, Panic Disorder, Paraplegia/Quadriplegia (associated medicine), Post-Traumatic Stress Syndrome, Scleroderma, Thromboangitis Obliterans, Thrombocytopaenic Purpura, Tourette s Syndrome, Valvular Heart Disease, Zollinger-Ellison Syndrome *PMB - Prescribed Minimum Benefits 9 ] [ 10

7 chronic disease benefit The Chronic Disease Benefit covers 51 chronic conditions on Maxima Plus. Consult the Chronic Disease Benefit table on page 9 for a list of these conditions and your applicable limits. Formularies and DSP: The Scheme makes use of formularies and a Designated Service Provider (DSP) to manage the cost and ensure accessibility and appropriate level of care for all our members. - Formularies: A formulary is an approved list of medication for each of the chronic conditions covered by the Scheme. These formularies should in no way compromise the quality of healthcare that you, the member receives. Formularies are also subject to the Medicine Price List (MPL). On your option there are no formulary restrictions in benefit. However, once out of benefit (when your chronic disease benefit limits have been exhausted), cover for the 25 PMB conditions will be subject to the Comprehensive Formulary. - DSP: There are no DSP restrictions on your option. This means you may use a provider of choice in and out of benefit. Co-payments: Your option is subject to Fedhealth s Comprehensive Formulary once out of benefit. If you choose to use out-of-formulary medication, please note that this will attract a 40% co-payment on the cost of the medication. The co-payment is not refundable from savings. Medicine Price List (MPL): Your medication will be covered at the Medicine Price List (MPL) rates up to the limits as specified in your option. MPL is a reference price list that benchmarks each product against generically similar products. It does not restrict member s choice, but limits the amount that the Scheme will refund for each product. The MPL reference price is set at a level to ensure that a number of medicines will be available without any co-payment. Treatment Guidelines: The Scheme has established treatment guidelines for the 25 PMB chronic conditions to ensure that you have access to appropriate treatment for your condition. You will receive details of the treatment guidelines applicable to you once you register for one of these conditions and the Scheme has received your first claim relating to this condition. How to apply for the Chronic Medicine Benefit: On diagnosis of a listed chronic condition you will need to apply for chronic medication telephonically or online via the Medscheme website. Telephonically: You can call Chronic Medicine Management (CMM) between 08h30 and 17h00, Monday to Thursday, and 09h00 17h00 on Friday, on Online: You may also apply for chronic medication 24 hours a day by logging onto the Fedhealth website ( If you have not completed an online application before, you will be prompted to register as a first time user since a login username and password will be requested. Once you have registered and your profile is open, click on my authorisations and then select my chronic application. Select the beneficiary for whom you would like to apply and then click on the Chronic authorisation button at the bottom of the page. Then select New Chronic Application. For both telephonic and online applications, we will require the following information: Membership number Dependant code ICD10 code Drug Name, strength and quantity Prescribing Doctor s practice number Diagnostic test results, e.g. Total Cholesterol, LDL, HDL, glucose tests, thyroid (depending on your condition). Once you have completed the registration process, you will receive an immediate response. Where more clinical information is required, members of the clinical team will review the information supplied and correspond with you and your doctor. Once your application has been approved: CMM will provide you with your medicine access card, which will list the approved medicines to be covered from this benefit. Once you have received your medicine access card, your doctor will need to provide you with a repeat prescription for the approved medicines for a maximum of six months (your doctor is legally not allowed to give you a repeat for more than six months). What to do if your authorised chronic medication changes: If your doctor decides to change your medication, or dosage, CMM needs to be advised. The quickest and simplest way would be for your doctor to inform CMM telephonically on Within 24 hours, a temporary medicine access card will be sent to your pharmacy enabling them to dispense your medicine without delay. Alternatively, you can also apply for the change in medication online at Your new medicine access card will be mailed to you. Make sure your doctor provides you with an updated repeat prescription to match the approved medicines on your medicine access card. 11 ] [ 12

8 chronic disease benefit continued Fedhealth offers Disease Management Programmes that support specific diseases. These programmes are offered at no additional cost. Aid for AIDS (AfA) AfA is a comprehensive HIV disease management programme with access to anti-retrovirals and related medicines as well as post-exposure preventative medication. Ongoing patient and provider support as well as regular monitoring of disease progression and response to therapy is provided. To join AfA call them in confidence on Your doctor may also call AfA on your behalf. AsthmaCare Most people with asthma should be able to enjoy a normal lifestyle, including getting a good night s sleep and being able to participate in sport and other normal daily activities. AsthmaCare enables you to achieve this by focusing on the appropriate use of medicine. The programme also provides education and counselling on issues that will help you to clearly understand and manage the disease. Phone or [email protected] for more detail or to register. CardioCare Anyone who has had angina or a heart attack is well aware of how important good medicine management is and how critical it is to tackle any lifestyle risks you may have. CardioCare focuses on members who have coronary heart disease, with the aim of preventing heart attacks. The programme promotes healthy lifestyle and the appropriate monitoring and treatment of risk factors. Phone or [email protected] for more detail or to register. Oncology Disease Management Programme (ODM) On diagnosis of cancer, it is important that you register on the Oncology Disease Management Programme (ODM). You or your treating doctor can call them on and register. The programme aims to assist your doctor to ensure best treatment and support. Your oncology benefit covers the following expenses: chemotherapy, radiotherapy, approved medication, related consultations, pathology and general radiology. Specialised radiology, for example MRI and CT scans, will be covered from the unlimited Major Medical Benefit and will not affect your oncology benefit limit. A specialised medication benefit of R is included in the oncology benefit. Remember that Fedhealth allows option upgrades any time of the year within 30 days of diagnosis of a dread disease like cancer. Changes in your oncology medication need to be communicated to ODM as soon as possible by faxing the amended treatment plan to or ing [email protected]. DiabeticCare This programme helps you to control your blood sugar. It also addresses the importance of screening tests and the necessity of lifestyle adjustments, which can vastly improve the well-being of diabetic patients. The programme also educates you on correct medicine management and monitoring. Phone or [email protected] for more detail or to register. 13 ] [ 14

9 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 Co-payments in Safety Net Appliances, external accessories and orthotics Alternative healthcare LIMIT PER FAMILY PER YEAR R per family per year before and after Safety Net. (R3 500 sub-limit for foot orthotics) Subject to OHEB*, Savings and Safety Net BENEFIT day-to-day benefit (continued) Over-the-counter medication Prescribed medication Radiology (Specialised) Specialists excluding psychiatrists LIMIT PER FAMILY PER YEAR Subject to Savings only. Does not accumulate to or pay from Safety Net R8 040 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 preauthorised Accupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including prescribed medication) Subject to OHEB* and Savings. Does not accumulate to or pay from Safety Net - Fedhealth Specialist Partners Subject to OHEB*, Savings and accumulation at cost to Safety Net. Unlimited at cost once Safety Net is reached 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 - Non-Fedhealth Specialist Partners Subject to OHEB*, Savings and Safety Net. Accumulation to Safety Net at Fedhealth Rate only. Unlimited at Fedhealth Rate once Safety Net is reached Dentistry (Advanced) Including oral surgery, osseo-integrated implants, orthognathic surgery and orthodontic treatment Biokinetics, Chiropractics, Dentistry (Basic), Radiology (General), Pathology and Physiotherapy General Practitioners R6 030 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 Specialists: Psychiatrists - Fedhealth Psychiatrist Partners Subject to Additional Medical Services limit of R per family per year before and after Safety Net. Subject to OHEB*, Savings and Safety Net. Accumulation to and refund from Safety Net at cost. - Fedhealth GP Partners - Non-Fedhealth GP Partners Maternity Optometry Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, readers and optometric examinations 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 700 per beneficiary per year, R8 210 per family per year before and after Safety Net. Subject to OHEB*, Savings and Safety Net - Non-Fedhealth Psychiatrist Partners *MPL - Medicine Price List FR - Fedhealth Rate Subject to Additional Medical Services limit of R per family per year 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 * OHEB - Out-of-Hospital Expenses 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 unless otherwise specified. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from Safety Net. 15 ] [ 16

10 day-to-day benefit Out-of-Hospital Expenses Benefit (OHEB) and Savings Day-to-day expenses such as optometry and dentistry are covered from available funds in your Out-of-Hospital Expenses Benefit (OHEB) and Savings. To calculate your annual benefit, refer to the rate table on page 20. Should you join after 1 January, your annual benefit will be subject to proration. Your day-to-day benefit is the total of OHEB and Savings available plus amounts payable from the Safety Net Benefit when reached. Sublimits will apply for claims refunded from OHEB and for accumulation to and refund from Safety Net. Day-to-day expenses will be refunded from OHEB first at the Fedhealth Rate and MPL rate, and when it is depleted, from your Savings Account up to cost. Should claims refunded from OHEB be in excess of the allowed tariffs, the balance will be refunded from Savings. Year-end Savings Account balances will be carried over to the new year. Should you resign from the Scheme, any Savings Account balances will be transferred to your new scheme. Amounts owing to Fedhealth are payable to the Scheme on resignation. For prescribed medication, Fedhealth have capped the reimbursable dispensing fee on medicine at 26% with a maximum dispensing fee of R26 for products that have a cost (Single Exit Price) that exceeds R100. Fedhealth has negotiated dispensing fees with a number of pharmacies in order to ensure that members will have no co-payments. It is in the interests of members to make use of these pharmacies, not only to avoid co-payments, but also to ensure more effective management of day-to-day benefits. A list of pharmacies who have agreed to a preferential dispensing fee is available on on the Fedhealth Network Locator or with a call to the Fedhealth Customer Contact Centre on Please note that this is not applicable to the Chronic Disease Benefit. Over-the-counter medication: schedules 0, 1 and 2 medicine. Medicines with a schedule of 0, 1 or 2 can be purchased from the pharmacy without a prescription from your doctor. Simply speak to the pharmacist regarding your symptoms and if there is an appropriate schedule 0, 1 or 2 medication available, this medication can be paid from your available Savings. The pharmacist can either submit the claim directly to the Scheme or you can ask for a script and submit this to the Scheme for a refund. This medication does not accumulate to your Safety Net level. Over-the-counter medication (schedule 0, 1 and 2) will not be refunded from OHEB, but will be refunded from Savings. Fedhealth GP Partners: Making use of a Fedhealth GP Partner means that your consultation will be funded from your OHEB and once depleted, your visits to a Fedhealth GP Partner will be covered in full from Risk, unlimited. This benefit covers the consultation and minor procedures only and not medication. To locate a GP on this network you can either call the Fedhealth Customer Contact Centre on or visit and access the Fedhealth Network Locator. Fedhealth Specialist Partners: Making use of a Fedhealth Specialist Partner for your out-of-hospital consultations means that you will never have a co-payment on the consultation fee. If you have day-to-day benefits available, the consultation will be deducted from these benefits at the negotiated tariff and will also accumulate in full towards your Safety Net Level. However, if your day-to-day benefits have been depleted you will have to pay for the consultation from your own pocket but also only at the negotiated tariff. To locate a Fedhealth Specialist Partner, call the Fedhealth Customer Contact Centre on or visit and access the Fedhealth Network Locator. 17 ] [ 18

11 Self-Payment Gap It may happen that your OHEB and Savings have been depleted before the required Safety Net Level has been reached. This is referred to as a self-payment gap. You will now continue to pay for day-to-day expenses from your own pocket. In order to close this self-payment gap, you need to continue to submit these claims to Fedhealth. These claims will not be refunded, but will accumulate towards your Safety Net Level. GP visits: During the self-payment gap Fedhealth will however continue to cover GP visits including minor procedures, (but excluding medication) unlimited, provided you use a Fedhealth GP Partner. To locate a GP on this network you can either call the Fedhealth Customer Contact Centre on or visit and access the Fedhealth Network Locator. Safety Net Benefit The Safety Net Benefit pays for day-to-day expenses once OHEB and Savings have been depleted and your claims have accumulated up to the required Safety Net Level. To calculate your Safety Net Level, refer to the table opposite. Your Safety Net Level is reached through the accumulation of your claims paid from OHEB and Savings and your own pocket throughout 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. Further claims will however be paid if you have Savings available. Consult the day-to-day benefit table on pages 15 & 16 for detail on these accumulation limits. Once you have reached the required Safety Net Level, your day-to-day expenses will now be refunded from the Safety Net Benefit. Many of your day-to-day expenses will be covered unlimited except for advanced dentistry, optometry, prescribed medication, appliances and all additional medical services which includes psychologists and psychiatrists for which only the remainder of the annual limit will apply. For example, if a family spends R9 000 on optometry, a maximum of R8 210 (set sub-limit) will accumulate to their Safety Net Level. Once this family is in Safety Net, they will have no further optometry benefit from the Safety Net Benefit. Consultations at a Fedhealth GP Partner are unlimited. Consultations at a Fedhealth Specialist Partner are unlimited (except Psychiatrists - see page 16) at the negotiated tariff. contributions contributions Rand amounts paid monthly to the Scheme for cover received as well as annual benefit values * Up to a maximum of three children maxima plus (including OHEB and Savings) Risk + Savings = TOTAL Annual Safety Net* Annual OHEB Member Adult Dependant Child Dependant healthcare spending Examples of healthcare spend available for various family structures, as well as annual safety net levels and self-payment gaps Annual Savings Annual + OHEB = Annual Day-to- Day Annual Safety Net Level Annual Self-Payment Gap M M + AD M + AD + CD M - member AD - adult dependant CD - child dependant 19 ] [ 20

12 What sets us apart as a scheme is that together with our first-rate medical aid options, we offer unique value-added benefits. With many of these tangible benefits we pay more from Risk than other schemes to ensure that your day-today medical spending not only goes further, but also works harder for you. benefits unique to us: Unlimited GP visits to Network GPs paid from Risk and never from Savings on all comprehensive options. Child rates for financially dependent children up to 27 years of age yes, student dependants pay rates applicable to children, provided they re unmarried and not earning more than the maximum social pension. Upgrade 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 you re never locked into an option, and can upgrade should something dramatic happen that changes your 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 which means most follow-up treatment for a full 30 day period is paid directly from Risk not to deplete your day-to-day benefit. This benefit is designed to: Minimise the stay in hospital Ensure the completion of treatment for a particular condition Protect day-to-day benefits. This benefit covers: Treatment at 100% of the Fedhealth Rate Post-hospital treatment up to 30 days from date of discharge from hospital. It includes complications that might arise from hospitalisation, physiotherapy, occupational therapy, speech therapy, x-rays, ultrasounds and pathology tests. The following conditions apply to the 30 day post-hospitalisation benefit: You must pre-authorise treatment prior to the treatment date Only treatment as a result of a hospital event will be covered, i.e. related to the original diagnosis If you do not pre-authorise treatment, the claim will be paid from your day-to-day benefits (OHEB and Savings). 7 days of take-home medication after discharge from hospital. If you or one of your dependants has been admitted to hospital, your doctor may want to give you medication at the time of your discharge. This is referred to as Take-out medicine. Fedhealth covers this medication from the Major Medical Benefit, which is a Risk benefit, and not from your day-to-day benefits. The Take-out medicine benefit covers a maximum of seven days of medication. The medication must both be dispensed by the hospital and reflect on the original hospital account. If you are given a prescription for Take-out medicine and you take this prescription to a regular pharmacy for dispensing, the claim will be paid from your day-to-day benefits (OHEB and Savings) and not from Risk. Specialised radiology like MRI and CT scans is paid from from the Major Medical Benefit, no matter what option you re on and irrespective of whether the procedure is performed in or out of hospital, provided pre-authorisation has been obtained from the Authorisation Centre. If you are in hospital, you will require an additional authorisation for a specialised radiological procedure. Trauma treatment at a casualty ward - whether admitted to hospital or not, emergency treatment, like stitches, is always paid from Risk and never from your Savings (meaning we don t deplete your day-to-day benefits). Other schemes cover these costs directly from your day-to-day benefit, or will only provide cover from Risk should you be admitted to hospital immediately after treatment in the emergency ward is received. According to the rules of the Scheme, trauma or emergency treatment is defined as a physical injury caused to the body by an external force, which requires immediate attention. The Scheme also considers life threatening conditions, that require immediate hospitalisation after treatment in the casualty ward, as trauma or emergency treatment. Claims will be paid from Risk if... You visit the trauma unit of a clinic or hospital for emergency treatment, like stitches You visit the clinic or hospital with a life threatening condition and are admitted immediately for further treatment. Claims will NOT be paid from Risk if... You visit your GP for an emergency treatment, like stitches, and the procedure takes place in the doctor s consulting rooms You visit the trauma unit of a clinic or hospital with an ailment other than a life threatening condition and are not admitted immediately into hospital. Should these claims not be authorised, they will also be paid from your day-to-day benefits (OHEB and Savings). This authorisation must be obtained within 2 working days of treatment. 21 ] [ 22

13 Procedures performed in doctors rooms - a number of procedures that can safely be performed in the doctor s rooms are also covered from the Major Medical Benefit and not from day-today benefits, for example excision of a nailbed. (These procedures will be funded according to Fedhealth s Network Provider arrangements). Cover for female contraception - oral contraceptives, contraceptive patches and certain contraceptive injections as well as IUDs, including Mirena are covered from Risk on your option. When you obtain your script from the pharmacy it will automatically be funded from your Major Medical Benefit. Please remember that your oral contraception prescription will only be funded from Risk if it is prescribed for the purpose of contraception and not for the purpose of treating a skin condition. The following contraceptives are usually prescribed for the treatment of a skin condition and will therefore not be covered from Risk: Cyprene-35 ED, Diane 35, Tricilest, Ginette, Minerva, Adco-Fem 35, Claro and Diva. IUDs including Mirena : device is paid from Risk but excludes consultation and cost of procedure which will be paid from your day-to-day benefits (OHEB and Savings). Please check on your monthly member statement that your prescription was indeed deducted from Risk and not from your Savings. Phone the Fedhealth Customer Contact Centre on immediately should there be any discrepancy. How we add REAL value: The Fedhealth Baby Programme The Fedhealth Baby programme has been put together by experts with you and baby in mind. From great give-aways, discounts, education and just plain fun, you ll find that the Fedhealth Baby programme is there to make your experience all the more special. We offer the following benefits: A Fedhealth Baby Bag packed to the brim with quality products; from all the baby care products you ll ever need, to nappies, a Having your baby handbook and more! All especially chosen to take good care of your little one Discounts for the best baby brands including Huggies, Chelinos, Living & Loving, Preggie Bellies and a whole lot more On-going communication and education in the form of weekly s to mum and bi-monthly s to dad Health profiling for each trimester 24 hour Medical Advice Line Funding for Doula (labour support) assistance during natural birth New birth card Immunisation s to keep Fedhealth parents up to date. In addition, a Fedhealth Baby representative will maintain contact over each trimester to make sure mom and baby are making healthy progress. Any Fedhealth member or dependant who is pregnant can register on the Fedhealth Baby programme at no additional cost by calling them on Hour Fedhealth Nurseline - the 24-hour Fedhealth Nurseline is available for assessing day-to-day symptoms, emergency medical advice, health knowledge (e.g. explanation of medical terms, procedures and test results), drug database (e.g. complete information on medication, contra-indications, etc), stress management, poisoning and teenage support. Call them on FREE trauma counselling after a traumatic experience, for example falling victim to crime or a motor vehicle accident, Fedhealth provides emotional and practical support through ICAS. Call them on Emergency transport/ response As a Fedhealth member, you can contact Europ Assistance for a range of emergency services on These services include: Emergency road or air response Medical advice in any emergency situation Delivery of medication and blood Patient monitoring Care for stranded minors or frail companions 24-hour personal health adviser. 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 you still get: Professional and extreme sports cover - injuries sustained during professional, adventurous and even extreme sporting activities, like scuba diving, skydiving, bungee jumping, hunting and mountaineering, 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 while the dentist s account comes from day-to-day benefits (OHEB and Savings). *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 former child dependants. 23 ] [ 24

14 important user tips Pre-authorisation You need authorisation for any benefit payable from the Major Medical Benefit, for example, a planned or emergency hospital admission, specialised radiology, selected procedures, 30 day post-hospitalisation benefit and casualty ward treatment. The Authorisation Centre needs to be contacted at least 48 hours before admission for a non-emergency or planned procedure to obtain an authorisation number. In an emergency, or if you need to be admitted sooner than planned, you must obtain an authorisation number from the Authorisation Centre within two working days after admission. If you are unable to contact the Authorisation Centre yourself, then your doctor or a family member or the hospital can contact us on your behalf. Failure to obtain pre-authorisation for a planned event at least 48 hours before admission or within two working days after an emergency event will mean that you are liable for a penalty of R1 000 or your treatment may not be covered. We need the following information to authorise your treatment: ~ Membership number ~ Member or beneficiary date of birth ~ Reason for admission, ICD10 code/ s and applicable tariff codes for the proposed treatment ~ Date of admission and the proposed date of operation ~ The referring doctor s name, his/ her telephone and practice numbers, if available ~ Name of the hospital with telephone and practice numbers if available ~ For a CT scan, MRI procedure, etc., the name of the radiological practice is also required. Contact number: (Monday to Thursday 08h30 17h00 and Friday 09h00 17h00) [email protected] How to claim In most cases your healthcare professional will submit your claim on your behalf directly to Fedhealth via Electronic Data Interchange (EDI). In this case, please do not also submit this claim. If the healthcare professional does not submit a claim on your behalf, or if you have settled the account yourself, all you need to do is submit the proof of payment together with the claim and make sure the account reflects your membership number. Forward this to Fedhealth either by mail, fax or for fast and effective processing. Postal address: Private Bag X3045, Randburg, 2125 Fax number: (011) [email protected] Should your healthcare professional inform you that the claim has not been paid, you can contact the Fedhealth Customer Contact Centre to enquire on the status of the claim on or you can check your claims status on the website. See Electronic Communications Services. If you have paid the healthcare professional, Fedhealth will refund you directly into your bank account. ICD10 coding: It s important to remember that all claims to a medical scheme must contain an ICD10 code. Claims without an ICD10 code will be rejected. Please ensure that the Scheme is in possession of your updated banking details for refund purposes. To update your banking details, please phone the Fedhealth Customer Contact Centre on Only claims received within four months of treatment will be processed. Any claims received after this time will be considered stale. These claims will be processed for tax certificate purposes only. Claims against the Road Accident Fund If you have been involved in a car accident, you may have a claim against the Road Accident Fund. Certain procedures will apply before claims will be paid by the Scheme. Please contact the MVA/ Third Party department at Fedhealth for further details. Telephone number: (012) / 86 Fax number: (012) Postal address: P O Box 11793, Hatfield, 0028 Who can be registered as a dependant? Your spouse, partner, children or other family members who rely on you for financial care and support may be registered as your dependants. Fedhealth will charge the child rate for your child dependants until they turn 27. However, the child needs to be a full-time student, either living at home or in a residential situation at a tertiary education institution. If your child is not a student, Fedhealth needs confirmation that they are living at home, unmarried, and not in receipt of a regular income greater than the maximum social pension. Adding a newborn baby to your membership As a Fedhealth member you are given 30 days to register a newborn baby or individual underwriting may apply. You are therefore required to complete a Newborn Registration form. A copy of the baby s birth certificate or notification of birth from the hospital must be attached when submitting the form to the Scheme. If you belong to an employer group, the salary department also needs to be updated with a new dependant s contribution due for the next month as Fedhealth does not charge for the month in which a baby is born. ID numbers are required to be submitted to the Scheme as soon as the baby is registered. New membership cards will automatically be generated and posted to you. Adding a dependant to your membership Please check your company subsidy with regards to additional dependants if you belong to an employer group. A Member Record Amendment Form needs to be completed. New membership cards will automatically be generated and posted to you. Should you wish to add a dependant that falls into one of the following categories, please take note of the additional information required in order to proceed with applying for their membership: Your biological or adopted child over the age of 21 years Proof of registration from a full time tertiary institution for the current year if a full time student, or an affidavit for the dependant confirming residency, employment, income and marital status Your adopted child under the age of 21 years Proof of legal adoption Your foster child Legal documents pertaining to the foster child A parent or grandparent of the principal member An affidavit confirming residency, employment, income and marital status. 25 ] [ 26

15 A sibling, grandchild, nephew or niece An affidavit confirming residency, employment, income and marital status of child and both parents A divorced spouse A copy of the divorce decree confirming that the principal member is responsible for the medical aid contribution payments. Removing a dependant from your membership In order to remove a dependant you are required to complete a Member Record Amendment Form. This form must be processed and stamped by the HR Department and forwarded to the Scheme if you belong to an employer group. Electronic communication services Managing your medical aid fast and effectively with: Real-time electronic communication The Scheme will and SMS a claim status to you showing claims that have been received and processed. Please ensure we have your correct cell phone number and address by calling the Fedhealth Customer Contact Centre on medscheme client service centres The Fedhealth website You can also view a full update of your benefit and claim status by registering on the Fedhealth website. On the site you ll have immediate access to all your personal information, visit the site at Mobile apps Available free to Apple and Android users, both the Fedhealth Member App and the Fedhealthy Magazine App allow for unique online experiences. The Member App enables direct access to your medical aid, while the Magazine App allows you to browse the publication in exciting e-format. For personal assistance, visit one of the following Medscheme Client Service Centres These branches are open Monday to Friday 08h30 16h00 Credit control Bloemfontein Shop C7, 1st Floor Middestad Centre, c/o Charles and West Burger Street Fedhealth s banking details Cape Town 15th Floor, Atterbury House, 9 Riebeek Street Contributions to Fedhealth are paid monthly in arrears and should be received by the Scheme by the 3rd of the following month. Account name: Bank: Branch code: Account number: Fedhealth Medical Scheme Nedbank Leaving the Scheme Should you wish to resign from Fedhealth, we require three month s written notice Please note that as Fedhealth is an arrears billing scheme, your last contribution will be deducted by the 3rd of the month following your last day of membership. Fraud management You can help combat fraud by anonymously contacting our fraud hotline if you become aware of any healthcare professional or member abusing the system. Fraud Hotline: ] Durban 3rd Floor, 67 Old Fort Road Port Elizabeth 1st Floor, Block 6, Greenacres Office Park, 2nd Avenue, Newton Park Pretoria Ground Floor, Benstra Building, 473B Church Street, Arcadia Roodepoort 37 Conrad Street, Florida North Vereeniging 2nd Floor, 36 Merriman Avenue [ 28

16 contact us Fedhealth Customer Contact Centre Monday to Thursday 08h30 17h00 Friday 09h00 17h00 Tel: Web: Postal address: Private Bag X3045, Randburg 2125 Hospital Authorisation Centre Monday to Thursday 08h30 17h00 Friday 09h00 17h00 Tel: Web: Ambulance Services Europ Assistance Tel: Aid for AIDS Monday to Friday 08h00 17h00 Tel: Fax: Web: SMS (call me): Chronic Medicine Management Monday to Thursday 08h30 17h00 Friday 09h00 17h00 Tel: Fax: / 80 Web: Postal address: P O Box 38632, Pinelands, 7430 Fedhealth Baby Monday to Friday 08h00 17h00 Tel: [email protected] Web: Fraud Hotline Tel: Trauma Counselling ICAS Tel: MVA Third Party Recovery Department Monday to Friday 07h00 15h00 Tel: (012) / 86 Fax: (012) Postal address: MVA Third Party Recovery Department P O Box 11793, Hatfield, 0028 Oncology Disease Management Monday to Friday 08h30 17h00 Tel: Fax: (021) [email protected] Web: Postal address: P O Box 38632, Pinelands, 7430 Disease Management Monday to Friday 08h30 17h00 Tel: [email protected] Web: 29 ] [ 30

17 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.