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Cont

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1 Overviewofbenefits 5

Examplesofwhateachbenefitcovers 6

RiskandSavingsbenefits 8

Someimportantwords 9

About healthcare providers 9

About medicines and payment for medicines 9

About limits to what we pay 9

About treatment and payment for treatment 9

360 Care: Let the healing begin (with your GP) 10

PrescribedMinimumBenefits(basiclevelofcoverforadefinedsetofconditions) 10

2 Emergencies 11

Youarecoveredforemergencymedicalexpenses 11

Emergencymedicalservices:call0860333432 11

You must contact us within two working days if it was an emergency 11

Contact us within two working days if you needed trauma treatment 12

3 Hospitalvisitsandtreatmentpaidfromthe

CoreBenefitBundle 13

Aboutlimitsandco-paymentsforhospitalstays 13

No overall yearly limit 13

Therearelimitsandrestrictionsforspecifictreatmentsandconditions 13

Differentcoverfordifferenttypesofhospitaltreatments 13

Hospitalcostswecoverinfull 13

Medicineyoureceiveinhospital 13

Doctorvisitswhileyou’reinhospital 14

Bloodandpathologyserviceswhileyou’reinhospital 15

Maternitybenefit 15

Spinalsurgery 15

Oncology(cancer) 16

Full cover for services through ICON 16

IfyouhavereachedyourlimitfortheOncologybenefit 16

Limitsforspecifictreatments 16

Oncology Disease Management Programme (ODM) 16

Specialised radiology (for example, MRI or CT scans) 16

Othertreatmentsorproceduresthatyoureceiveinhospital 17

Sometreatmentandproceduresdoneoutofhospital 18

Services like physical rehab and treatment in sub-acute facilities 18

Nursing instead of hospitalisation 18

Procedures performed in day wards, day clinics and doctor’s rooms 18

Doctor appointments with network GPs 18

Female contraception 18

Sometreatmentafterahospitalvisit 19

Medicine you get while in hospital to take at home 19

Treatmentinthe30daysafteryourhospitalvisit(post-hospitalisationbenefit) 19

Prosthesisbenefittable 19

External prosthesis 19

Internal prosthesis 19

ImprovedClinicalPathwayServices(ICPS)andJointCarefornon-PMBhip

andkneereplacements 20

4 TohavehospitalorothertreatmentcoveredbytheCoreBenefitBundle 21

Youmusthaveauthorisation 21

Contact us at least 48 hours before the hospital stay or the procedure 21

When you contact us, have this information ready 21

flexiFED4GRIDnetworkhospitals 22

flexiFED4GRIDnetworkdayclinics 24

flexiFED4Electnetworkhospitals 26

5 Screeningandimmunisationbenefits 27

Screeningbenefit 27

ActiveDiseaseRiskManagementprogrammes 28

Immunisationbenefitforchildren 28

6 Chronicmedicine(coveredbyChronicDiseaseBenefit) 29

Whatischronicmedicine? 29

Limits 29

Toclaimunderthisbenefit 29

List of chronic conditions 29

List 1: Conditions that are on the CDL 29

If your condition is on List 1 (CDL) 30

List 2: Additional chronic conditions covered on your option 30

If your condition is on List 2 (Additional Chronic Conditions) 30

CoverfortreatmentforHIV/Aids 33

HowtoapplyfortheChronicDiseaseBenefit 33

Step 1: Collect the information needed to apply 33

Step 2: Apply 33

Step 3: We will give you a response right away 33

Step 4: You get your medicine access card 33

Wewillgiveyoutreatmentguidelines 34

Ifthereisaco-paymentonyourmedicine 34

Cont

ents

03 04Pleasenote:AllFedhealthbenefitsaresubjecttoregisteredSchemeRules,andassuch,thisdocumentonlyaimstoprovideasummaryofsuchbenefits.ForthefullSchemeRules,pleasevisitfedhealth.co.zaorcontacttheFedhealthCustomerContactCentreon0860002153toobtainacopy.

Wewillapproveachroniccondition,notindividualchronicmedications 34

Chronicmedicationdeliveredtoyourdoor 34

7 Payingforday-to-dayexpenses(Day-to-DayBenefits) 35

Thebasicsofthetwobenefitsforday-to-daymedicalexpenses 35

The Savings Account 35

The MediVault and Wallet 35

How do you activate your MediVault and transfer funds into your Wallet? 35

MediVault transfers to Wallet 35

When will funds be available in my Wallet? 35

How is the instalment paid back? 36

What will happen if there is membership movement? 36

My MediVault 36

TheThresholdBenefit 36

You must pay while you are in the self-payment gap 36

Examples of expenses that will increase the self-payment gap 37

WhentheThresholdBenefitkicksin,existinglimitsapply 37

Coverfordoctors,specialistsandmedicines 37

GPs in the Fedhealth network 37

GPs not in the Fedhealth network 37

Specialists in the Fedhealth network 37

Specialists not in the Fedhealth network 38

Prescribed medicine 38

Dispensing fees for prescribed medicine 38

Over-the-counter medicine 38

Female contraception 38

Pregnancy 38

Specialised radiology (for example, MRI or CT scans) 38

Allcoverinday-to-daybenefits 41

8 Howtoclaim 45

If the healthcare professional or the hospital claims on your behalf 45

If you need a refund because you paid the medical expense 45

You must claim within four months of the date of the treatment 45

Sendyourclaimsto 45

Ifyouhavebeeninacaraccident 45

9 Aboutyourschemeandmembership 47

Members 47

Dependants 47

Who can be registered as a dependant 47

Criteria for children 47

Adding a newborn baby 47

You must give us these documents for registering dependants 47

Membershipcards 48

Removingadependantfromyourmembership 48

Howwecommunicatewithyou 48

We email and SMS your claim status 48

Make sure we have your correct email address and cell number 48

Youcanfindyourclaimandbenefitinformationonourwebsite 48

You can message Fedhealth free of charge with the FedChat Mobile App 48

Fedhealth Family Room 48

Microsite 48

flexiFED4contributionstable 50

Optionchanges 50

You can upgrade to a higher option 50

Payingforyourmedicalaid 50

You must pay by the third of each month 50

Our bank details 50

Leavingthescheme 50

Three months of notice to leave 50

Last contribution 50

Amount in Savings Account – if you spent less than you paid in 51

Amount in Savings Account – if you spent more than you paid in 51

Whistle-blowingonfraud 51

10Extraservices 51

24-hour Nurse Line on 0860 333 432 51

MediTaxi 51

SOS call me 52

Fedhealth Baby 52

Paed-IQ 52

11 Servicecentresandcontactdetails 53

Medscheme Client Service Centres 53

Contact us 53

The ideal plans for mature families looking for all-encompassing cover

As part of our new flexiFED option range that gives members more control over how their cover is structured, the flexiFED 4, flexiFED 4GRID and flexiFED 4Elect options are perfect for more mature families who want cover that leaves nothing to chance.

Their core benefi t bundles – or the basic cover that you enjoy on these options – provide you with sound in-hospital benefi ts, chronic benefi ts, screening benefi ts, and day-to-day benefi ts, that include additional benefi ts like unlimited network GP consultations always paid from Risk and never from Savings.

These options have a Threshold Benefi t, which means you can submit claims to accumulate to a predetermined threshold level after which they will be paid from the Threshold Benefi t. You will have a 20% co-payment on all claims.

On flexiFED 4GRID, you save 11% on your monthly contribution by committing to use Fedhealth’s network of 100 top-class hospitals only for planned procedures. In the case of an emergency for stabilising treatment, you can still use any private hospital and will be covered without any co-payment. On flexiFED 4Elect, you pay a fi xed excess of R11 500 on all hospital admissions, except for emergencies, and by doing so, you’re saving 25% on your monthly contribution. This excess applies to the hospital bill only; you could still have co-payments on out-of-network specialists, a procedure co-payment or shortfalls because benefi t limits have been exceeded.

On these options you also have access to a MediVault and Wallet facility, a predetermined amount available for your day-to-day medical expenses, which you only start paying back over a 12-month period once you start using it.

Please see the following pages for more details on the flexiFED 4, flexiFED 4GRID and flexiFED 4Elect core benefi t bundles and what they offer you.

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CORE BENEFIT BUNDLE

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flexiFED 4 / flexiFED 4GRID / flexiFED 4Elect

Basicbenefitbundlewiththresholdformaturefamilies

IN-HOSPITAL BENEFIT

Hospitalisation Unlimited at hospital of choice*

Maternity Unlimited at cost with network specialists and GPs

Network GPs and Specialists Unlimited cover at cost

Non-network GPs, Specialists and all other healthcare professionals Up to 100% of Fedhealth Rate

Oncology R444 700

Organ Transplant R444 700

Renal Dialysis R444700atDesignatedServiceProvider.40%co-paymentonnon-useofDSP

Childhood illness specialised drug benefi t Childrenuptotheageof18yearssubjecttomanagedcareprotocols

CHRONIC DISEASE BENEFIT

Chronic conditions as covered under flexiFED 4 Cover is provided for the conditions on the Chronic Disease List (CDL) plus 14 additional conditions, as well as medicine for allergic rhinitis for children up to the age of 18 where the child is registered with Chronic Medicine Managementforasthma,medicineforeczemaforchildrenuptotheageof18andmedicineforacneuptotheageof21atproviderofchoice.SubjecttoalimitofR5680pbandR11350perfamily.ThereafterunlimitedcoverforconditionsontheCDL.SubjecttointermediateformularyandMPL

SCREENING BENEFIT

Women’s health Cervicalcancerscreening(Papsmear) Women;ages21to65.1everythreeyears

Children’s health ImmunisationProgramme(asperstateEPI)

Birth to 12 years

Cardiac health Cholesterolscreening(fulllipogram) Alllives;aged20andolder.1everyfive years

General Fluvaccination All lives; 1 every year

HIVfingerpricktest All lives; 1 every year

Breastcancerscreeningwithmammography

Alllives;aged45andolder.1everythreeyears

Pneumococcalvaccination Alllives;aged65andolder.1perlifetime

Colorectalcancerscreening(faecaloccultbloodtest)

Alllives;aged50to75.1everyyear

Men’s health ProstateSpecificAntigen(PSA) Men;ages45to69.1everyyear

Health risk assessments

Wellnessscreening(BMI,bloodpressure,fingerprickcholesterol

&glucosetests)All lives; 1 every year

Preventativescreeningbycontractedwellnessnetworkprovider

(waist-to-hipratio,bodyfat%,flexibility,posture&fitness)

All lives; 1 every year

*Members on flexiFED 4Elect and flexiFED 4GRID shouldnote:Networkhospitalsonly,oraco-paymentofR11500willapply.05 06

Risk and Savings bene�tsYourschemeworksbytakingyourcontributionanddividingitintotwoparts.The one part goes towards RiskBenefits, the other goes to a Savings Account.

Risk bene�ts Savings AccountForriskbenefits,theschemepoolstogethermembers’contributions and uses the money to fund a set of benefits,includingtheIn-HospitalBenefit,ChronicDiseaseBenefit,ScreeningBenefit,Day-to-dayBenefits,value-addedadditionalbenefitsandThresholdBenefitknownastheCoreBenefitBundle.

Theschemehasrulesforwheneachoftheriskbenefitsisallowedtopayout.Theseschemerulesgivelimitsforwhatthebenefitcanpayoutforparticularconditions,treatmentsandmedicines.Becausetheschemeappliesitsrulesconsistently,wecanbeconfidentthat:

• We treat all members fairly and do not discriminate against any members

• The medical scheme is sustainable and will not run outofmoney.

The part of your contribution that is paid to the Savings Accountisnotpooledwithothermembers’contributions.The money in the Savings Account is your money and it givesyoualevelofcontrolonyourspending.Themoneythat is not used in one year is carried over to the following yearandthisiscalledCarry-overSavings.Thismaybeusedafteryournewyear’sday-to-daybenefitshavebeendepleted.Anysavingsbalancenotusedwillbepaidoutifyouleavethescheme.

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flexiFED 4 / flexiFED 4GRID / flexiFED 4Elect

THRESHOLDDay-to-dayclaimsaccumulateattheFedhealthRatetotheThresholdLevel.

Limits apply to certain expenses

Annual Threshold LevelMM+1M+2M+2+

R13 650R24 150R27 660R31 500

Limits LimitsmayapplywhencalculatingcertainclaimsforaccumulationtoThreshold. These limits will also apply for refunds from Threshold

Additional medical services Inandout-of-hospital:SubjecttoSavings/Walletorself-funded.DoesnotaccumulatetoThreshold. Paid from Threshold up to R11 600 per family per year

Advanced dentistry Limit of R7 400 per person per year, up to an overall limit of R22 100 per family per year

Antenatal scans Two 2D antenatal scans per person per year

Appliances, external accessories and orthotics

Inandout-of-hospital.SubjecttoSavings/Walletorself-funded.DoesnotaccumulatetoThreshold. Paid from Threshold up to R11 600 per family per year with a sub-limit of R4 340 for foot orthotics

Optometry Limit of R3 340 per person per year, up to an overall limit of R10 190 per family per year

Prescribed medication Limit of R5 680 per person per year, up to an overall limit of R11 400 per family per year

flexiFED 4 / flexiFED 4GRID / flexiFED 4Elect

DAY-TO-DAY BENEFIT

Unlimited network GP visits Unlimited at network GPs; flexiFED 4GRID and flexiFED 4ElectmembersmustnominateaGP.

Maternity Nobenefit

Fedhealth Baby Maternity Programme All pregnant members and dependants

Fedhealth Toddler Programme Access to sound advice for parents with toddlers up to the age of 24 months

Doula benefit Up to R1 300 per delivery

Postnatal midwifery benefit 4 consultations per pregnancy with a midwife in- and out-of-hospital

Infant hearing screening benefit 1 test from birth up to the age of 8 weeks with an audiologist up to the Fedhealth Rate

Paed-IQ Telephonic support for paediatric related illness

Paediatrician consultations Nobenefit

Optometry Nobenefit

Post-hospitalisation treatment Forupto30daysafterdischargefromhospitallikephysiotherapy,x-raysorpathologyi.e.follow-up treatment for a full 30-day period is covered

Take-home medicine 7-days of paid for take home medication after discharge from hospital - provided the medicationisdispensedbythehospitalandreflectsontheoriginalhospitalaccount.

Specialised radiology MRI/CTscansarepaidwhethertheyareperformedin-orout-of-hospital. FirstR2200fornon-PMBMRI/CTscansisforthemember’saccount

Trauma treatment at casualty ward Whetheradmittedtohospitalornot,emergencytreatment,likestitches,iscovered. Authorisation must be obtained and a co-payment of R570 per visit for non-PMBs applies

Female contraception Includesoral,patches,contraceptiverings,certaininjectablesaswellasIUDs (includes Mirena device)

Additional benefits Upgrades within 30 days of a life-changing event; 24-hour Fedhealth Nurse Line; emotionalwellbeingprogramme;emergencytransport/response;MediTaxi;SOSCallMe;

managed care programmes

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Some important wordsHere are explanations of some important words used in this booklet:

About healthcare providersFedhealthnetwork: The Fedhealth network includes doctors, specialists, pharmacies and facilities that Fedhealth has an agreementwith.Itisalwaysinyourbestinteresttouseahealthcareproviderinthenetworkaswehaveagreedrateswiththem.PleaseusethenetworklocatoronourwebsiteorcontactusifyouwanttofindahealthcareproviderintheFedhealthnetwork.

flexiFED 4GRIDandflexiFED 4Electhospitalnetworks: The flexiFED 4GRID and flexiFED 4Elect hospital networks are a prescribedlistoffacilitiesthatFedhealthhasanagreementwithforyouroption.Itisalwaysinyourbestinteresttouseafacilityinthenetworkaswehaveagreedrateswiththem.Ifyouuseanyotherhospital,youmustpayR11500ofthecostofthehospitalaccount.Pleaseseepage22foralistofflexiFED 4GRID and flexiFED 4Electprescribedhospitals.

DesignatedServiceProvider: This is a healthcare provider (for example, a doctor, pharmacy or hospital) that members mustuseinorderforthemnottoincuraco-paymentontheirtreatment.

About medicines and payment for medicinesMedicinePriceList: For every originator medicine which has one or more generic alternatives, the scheme has determinedaceilingprice(themaximumwewillpay)forthatgroupofgenericmedication.Thisceilingpricewillbehighenoughtopayinfullforatleastoneofthegenericmedicinesforthatparticulargroupofmedicine.

Genericmedicines: Generic medicines are medicines that are brought to market after patents have expired on originator medicines.Theycontaintheexactsameactiveingredients,strengthandformulationastheoriginatorproduct.However,theyareusuallymuchcheaperthantheoriginatorproduct.Choosingmedicinethattheschemecoversinfullensuresthatyouwillhavenooutofpocketco-payments.Forexample,ifanoriginatorproducthassevengenerics,theMedicinePriceListpricewillbeset–notatthecheapest–butatthecostofoneofthesegenerics.Whenanewgenericisintroducedfortheoriginatorproduct,theMedicinePriceListamountmayberecalculated.

Originator: Originator medicines are medicines that have been newly developed and subsequently patented by a pharmaceuticalcompany.

Formulary: Thisisanapprovedlistofmedicineforeachofthechronicconditionscoveredbythescheme.Ifaformularyapplies,weonlycovermedicinethatislistedontheformulary.TheMedicinePriceList(MPL)alsoappliestomedicinesinaformulary.

About limits to what we payFedhealthRate: These are the rates that the scheme sets every year for each and every medical service, procedure, treatmentetc.Theseratesareadjustedannuallybyinflationandareusedasthebasisforalltariffnegotiations.

Healthcareprofessionaltariff: This is the reimbursement rate that has been negotiated or set for the payment of professionalservicesandwillusuallybeamultipleoftheFedhealthRate.

Co-payment: Thisisanamountthatyoumustpayfromyourownpocketforaparticulartreatmentorservice.

About treatment and payment for treatment

Treatmentprotocol: Aplanforacourseoftreatment.

360 Care: Let the healing begin (with your GP)Do you recall there was a time when the family doctor treated Mom, Dad, the kids and Granny as well? He or she got to know the familyinsideandout,andwasawareofalltheirailmentsandallergies.Thismeantthateveryoneknewwheretoturnwhentheyfeltpoorly–asinglemedicalprofessionaltheycouldtrustforexpertmedicaladvice.

This is the inspiration behind our 360 Care initiative, in which your General Practitioner or GP becomes the coordinator of your care, workingdirectlywithyou,themember,toensurethatyourhealthneedsaremetsafely,timeouslyandcosteffectively.Inanutshell,this means that your GP, who will have the best understanding of your health status and treatment history, will refer you to the appropriatespecialiststodelivertherightcareattherighttime.

We believe that 360 Care improves the quality of healthcare by facilitating access to the appropriate specialist care, and that itpreventsunsafecombinationsoftreatmentsincludingmedicines.Italsopreventsunnecessaryduplicationofcostlyclinical testsandtreatments–whichcontributetorisinghealthcarecostsandincreasesinmembers’contributions.Finally,wehaveintroduced electronic health records which allow the healthcare providers treating you to easily access and exchange your medicalinformation.

In addition, your GP will refer you and should be able to make an appointment for you with a specialist much quicker than you mightbeabletodoyourself.So,simplyvisityourNetworkGP(anunlimitedbenefitonyouroption)forareferraltotherelevantspecialist.Non-networkGPsmayalsobeconsulted,butthesevisitswillbepaidfromyourSavingsandmayresultinaco-paymentfromyou.

Under 360 Care, you will require a GP referral to visit any one of the following specialists: cardiologists, dermatologists, gastroenterologists, gynaecologists, neurologists, neurosurgeons, orthopaedic surgeons, otorhinolaryngologists (ENT), paediatric cardiologists, paediatricians, physicians, plastic and reconstructive surgeons, psychiatrists, pulmonologists, rheumatologists, surgeonsandurologists.AGPreferralisnotnecessaryfor:childrenundertheageoftwovisitingapaediatrician,femalemembersvisiting a gynaecologist for their annual check-up, visits to oncologists, ophthalmologists, radiologists (general or specialised) or pathologyservices.ReferralmustbeobtainedfromaGPifspecialistconsultationispayablefromtheriskbenefit.Ifreferralisnotobtainedtherewillbea20%co-paymentonspecialistclaimspaidfromtheriskbenefit.

Trusting your GP to coordinate your specialist care means having a healthcare practitioner with the information at hand to give you andyourlovedonesthebestpossiblecare.Justwhatyourpreciousfamilydeserves.

Prescribed Minimum Benefits (basic level of cover for a defined set of conditions)All medical schemes are required by law to cover the treatment of 270 hospital based conditions and 25 chronic conditions, the Chronic Disease List (CDL), in full without co-payment or deductibles, as well as any emergency treatment and certain out of hospitaltreatment.ThismeansthatallschemesmustprovidePMBlevelofcareatcostfortheseconditions.

The Medical Schemes Act 131 of 1998 allows schemes to require members to make use of Designated Service Providers (DSPs) inorderforamembertobeentitledtofundinginfull.Schemesmayalsoapplyformularies–alistofmedicineswhichshouldbeused to treat PMBs, and managed care protocols – based on evidence-based medicine and cost-effectiveness principles to manage thisbenefit.

Fedhealth has appointed their network specialists, network GPs and four preferred provider pharmacies, Clicks, Dis-Chem, MediRite andPharmacyDirectfortheprovisionofPMBs.Thesepharmaciescanguaranteepricecertaintyalthoughmembersarewelcometouseanypharmacyoftheirchoicewithoutpenalty.MembersmustmakeuseofaFedhealthnetworkspecialistandanetworkGPinorderforthecosttoberefundedinfull.ShouldthemembernotusetheseDSPsforthetreatmentofaPMBcondition,theschemewillreimbursetreatmentatthenon-Fedhealthnetworkrate.Co-paymentsareapplicabletothevoluntaryuseofnon-DSPs.ReferralmustbeobtainedfromaGPforconsultationswithFedhealthNetworkSpecialists.Ifreferralisnotobtainedtherewillbea20%co-paymentonspecialistclaimspaidfromtheriskbenefit.ItisimportanttonotethatqualificationforreimbursementasaPMBisnotbasedsolelyonthediagnosis(condition)butalsoonthetreatmentprovided(levelofcare).

This means that although your condition may be a PMB condition, the scheme would only be obliged to fund it in full if the treatmentprovidedwasdeemedtobePMBlevelofcare.

09 10

Contact us within two working days if you needed trauma treatment

If you visit casualty for trauma treatment, you must get an authorisation number from us withintwoworkingdaysofthetreatment.Ifyoudonot,theclaimwillbepaidfromtheDay-to-DayBenefit.

Goingtohospitalinanemergency:

AN EXAMPLE

Whatthememberdoes Howtheexpenseisfunded

Kateisinvolvedinacaraccident.Abystandercallsthe number that they see on the Fedhealth sticker onKate’scar.

An ambulance is sent by Europ Assistance to transporthertohospital.Shereceivesemergencymedical care in casualty and is discharged the sameday.

KatewillhavetopaythefirstR570oftheaccount.TheSchemewillpaythebalancefromtheCoreBenefitBundle,aslongasKatecontactstheschemewithintwoworkingdaysoftheemergencytreatment.

You are covered for emergency medical expensesThistableshowsthatthecostofmedicalcareinemergencieswillbepaidfromtheCoreBenefitBundle.

Toqualifyasanemergency,theconditionmustbeunexpectedandneedimmediatetreatment.(Thismeansthatif there is no immediate treatment, the condition might result in lasting damage to organs, limbs or other body parts, or evenindeath).

AmbulanceServices:call0860333432

UnlimitedcoverwithEuropAssistance

Treatmentincasualty ClaimswillbepaidfromtheCoreBenefitBundleonlyif...A member visits the trauma unit of a clinic or hospital and is admitted into hospital immediately for further treatmentA member visits the trauma unit of a clinic or hospital for emergency treatment for afracture,forexample.

ClaimswillbepaidfromtheDay-to-DayBenefitif…A member visits the trauma unit of a clinic or hospital for a non-emergency and is not immediately admitted into hospitalPlease note that if a member visits their GP for an emergency treatment such as stitches and the procedure takes place in the doctor’s consulting rooms, this will be paidfromday-to-daybenefitsandnotfromtheCoreBenefitBundle.

A R570 co-payment will apply to all visits to the trauma unit of a clinic or hospital if thememberisnotadmittedtohospitaldirectly.

EmotionalWellbeingProgramme

Fedhealth’s Emotional Wellbeing Programme, available to all Fedhealth membersandbeneficiariesthroughtheFedhealthFamilyRoom,offersapsychosocial wellbeing service for members that equips them to make the necessarychangestoimprovetheirqualityoflife.Call0873658664

Emergencymedicalservices:call0860333432

You can contact Europ Assistance for a range of emergency services on 0860333432. These services include:Emergency road or air responseMedical advice in any emergency situationDelivery of medication and bloodPatient monitoringCare for stranded minors or frail companions24-hourFedhealthNurseLine.

You must contact us within two working days if it was an emergency

Inanemergencyyoumustgetanauthorisationnumberfromuswithintwoworkingdaysaftergoingtohospital.If you do not, you will have topayapenaltyofR1000.

If you cannot contact the Authorisation Centre yourself, then your doctor or a family member or the hospital can contact usonyourbehalf.

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e About limits and co-payments for hospital staysNooverallyearlylimitThereisnooverallyearlylimitfortheCoreBenefitBundle.

TherearelimitsandrestrictionsforspecifictreatmentsandconditionsHospitalcostsarecoveredunlimitedfromtheCoreBenefitBundle.Casemanagementandmanagedcareprotocolsapplytocertainbenefits.Theseprotocolshavebeenintroducedtoensurebestqualitytreatmentatbestrates.ConsulttheCoreBenefitBundletablesinthissectionfordetailontheseprotocolsandlimits.

Forsometreatmentsandprocedures,youmustpayanamountoutofyourownpocket.Thisiscalledaco-payment. Co-paymentsapplytothehospitalbillandareusuallypaidupfronttothehospital.

Different cover for different types of hospital treatments

Whenyougotohospital,therearedifferentaccountsfromdifferentproviders.Wecovertheseaccountsdifferently. Hereisasummary.Pleasereadthefullsectionfordetails.

• Theaccountforhospitalcosts.Examplesofwhatthiswouldincludeare:wardfees,theatrefees,supplies,and medicinethatwasdispensedbythehospital.Inmostcases,hospitalcostswillbecoveredinfullbytheCoreBenefitBundle.However,forsometreatments:

- You might have to pay an amount out of your own pocket, referred to as a co-payment -Theremightbelimitstotheamountwecover.Forexampleprosthesis.• Theaccountsfromdoctorsorspecialists.Forexample,ifyouhadanappendectomy,youwouldreceiveaseparateaccountfromthespecialistwhoperformedtheprocedure.IfthedoctororspecialistisintheFedhealthnetwork, wewillcoverthisinfull.

• Theseparateaccountsfromothervariousproviders,forexample,physiotherapists,X-raydepartments.Wecovertheseatdifferentrates.Seepage14.

Hospital costs we cover in full

We have agreed rates with hospitals and we will therefore pay the full hospital bill for:• Accommodation in a general ward (you pay the difference if you go to a private ward)• High care ward and intensive care unit• Theatrefees.

Medicine you receive in hospital

Medicinethatyouusewhileyouareinhospital Nolimit,wepaythefullcost,subjecttomanagedcareprotocols

Medicinesthatareprescribedinhospitalforyoutousewhenyougohome(take-outmedicines)

Sevendaysofmedicineforeachhospitalevent. We pay the full cost

Childhood illness specialised drug benefit Childhoodillnessspecialiseddrugbenefitforchildrenuptotheageof18subjecttomanagedcareprotocols

Doctor visits while you’re in hospital

While you are in hospital, you are under the care of specialists (such as paediatricians or cardiologists) and other doctors (suchasGeneralPractitioners).Thesearecovereddifferentlytodoctorappointmentsoutofhospital.Youmustremember thatthereimbursementratesbelowarefortheprofessionalfeesonly.

SpecialistswhoareintheFedhealthnetwork We pay professional fees in full

SpecialistswhoarenotintheFedhealthnetwork Wepay100%oftheFedhealthRateforprofessionalfees. You must pay the rest direct to the specialist

GeneralPractitionerswhoareintheFedhealthnetwork We pay professional fees in full

GeneralPractitionerswhoarenotintheFedhealthnetwork

Wepay100%oftheFedhealthRateforprofessionalfees. You must pay the rest direct to the healthcare professional

Dietetics,occupationaltherapyandspeechtherapy PaidfromtheDay-to-DayBenefit.Doesnotaccumulate tothreshold.PaidfromthresholduptoR11600perfamilyper year

Physicaltherapy(physiotherapy) Wepay100%oftheFedhealthRateforprofessionalfees.Youmustpaytherestdirecttothehealthcareprofessional.Subjecttoreferralbyamedicalpractitioner.Mustbe pre-authorisedandsubjecttotreatmentprotocols

Beforeyougotohospital,youshouldtrytomakesurethatyourdoctorandspecialistareintheFedhealthnetwork.

Goingtohospitalforanoperation:

AN EXAMPLE

Whatthememberdoes Howtheexpenseisfunded

Alice’ssonneedstohavehistonsilsout.AlicemadesurethatthesurgeonandtheanaesthetistareintheFedhealthnetwork.She gathers the required information from her doctor and then phonesFedhealthtogetanauthorisationnumber.

The child has the operation and leaves the hospital on the sameday.

Alice receives two invoices by email:- An invoice from the anaesthetist- An invoice from the ear-nose-and-throat (ENT) specialist

Shesendstheaccountstotheschemeforpayment.

ThehospitalsendsitsaccountdirecttoFedhealth.

The scheme covers the cost of the anaesthetist and the specialistinfullbecausetheyareintheFedhealthnetwork.

Theschemecoversthehospitalaccountinfull.Benefits,limitsandmanagedcareprotocolsapply.

Note: if the surgeon and the anaesthetist were not in the Fedhealth network, Alice would pay the difference between 100% of the Fedhealth Rate and the cost directly to the healthcareserviceprovider.

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eBlood and pathology services while you’re in hospital

Blood,bloodequivalentsandbloodproducts We cover the full cost

Pathology(bloodtests) Wepay100%oftheFedhealthRateforprofessionalfees.You must pay the rest direct to the healthcare professional

Maternity benefit

Medicalexpensesduringpregnancy SeeDay-to-Daybenefitsonpage38

Medicalexpensesrelatedtothedelivery PaidfromCoreBenefitBundle

Expensesforward,medicines,materialsetc.Includesdeliveryinhospital,aregisteredbirthingunitorathomeIncludesthehireofawaterbath

We cover the full cost

Gynaecologistandpaediatrician WillbecoveredinfullifintheFedhealthnetwork.Iftheyarenotin the Fedhealth network, they will be covered up to 100% of the Fedhealth Rate

FundingforDoula(laboursupportduringnaturalchildbirth)

R1 300 per delivery

Afterdelivery:Post-natalmidwiferybenefit

Four consultations in- or out-of-hospital per pregnancy at 100% of the Fedhealth Rate

Infanthearingscreeningbenefit Hearing test done with an audiologist until the age of eight weeks

Spinal surgery

ThereisaR4200co-paymentonthehospitalbill.ThereisnobenefitiftheConservativeBackandNeckRehabilitationProgrammehasnotbeencompleted.

ConservativeBackandNeckRehabilitationProgrammeFollowingheadaches,backandneckpainisthemostcommoncauseofillhealthandincapacityamongsthumanbeings.Itoftenhassignificantfinancialandsocialimplications,andisamajorsourceofdiscomfort.

The Fedhealth Conservative Back and Neck Rehabilitation Programme is designed to ease the pain of eligible members andhelpthemavoidspinalsurgery.Qualifyingmembersandbeneficiarieswillbeenrolledineitheraphysiotherapyprogramme, or a six-week multidisciplinary programme that involves assessment and treatment by a General Practitioner,physiotherapistandbiokineticist.Positiveoutcomesincludeimprovedflexibility,reducedpainandstiffness,andthereforeabetterqualityoflife.Theprogrammehasalsobeenproventopostpone,limitorassistinavoidingsurgery.Wheresurgeryiswarranted,itwillbepermittedwithinSchemeRules.

Pleasenote:Shouldyoudeclinetoparticipateintheprogrammepriortosurgery,therewillbeNObenefitforspinalsurgery.Inotherwords,theSchemewillnotpayforthehospital,surgeon,prosthesisoranythingrelatedtotheprocedure.And,ifspinalsurgeryisstillnecessary following successful completion of the programme, and you do receive authorisation from the Scheme, you will still have aco-paymentofR4200onthehospitalbill.Thisdoesnotapplytoemergencytreatment/PMB.

How can you access the programme? There are a number of ways to access the programme:

• The telephonic helpline on 0860002153• YoucouldbeidentifiedbytheSchemethroughpredictivemodelling• The Scheme might intervene prior to authorising your back and neck surgery• Managers might refer their employees to be assessed for eligibility • ReferralbyyourGPorspecialist.

Oncology (cancer) FullcoverforservicesthroughICONThe Scheme has contracted with Independent Clinical Oncology Network (ICON) for oncology treatment and you must use an ICONserviceproviderforalloncologyrelatedtreatment.IfyouhavenotreachedyourlimitfortheoncologybenefittheCoreBenefitBundlewillcoveryourtreatmentforthefollowinginfulluptothebenefitlimitaccordingtotheScheme’slevel1protocols:• Oncologist consultations• Visits, treatment and materials for chemotherapy and radiotherapy• Approved medication• Radiology and pathology

ICONisanetworkofoncologiststhatincludes75%ofallpracticingoncologistsinSouthAfrica.Forinformation,visitwww.cancernet.co.za or call 0860100572.

WepayICONoncologistsinfull.IfyoudonotuseanICONoncologist,youmustpay40%ofthecostfromyourownpocket. Thisappliestoallcarethattakesplaceeitherin-orout-of-hospital.

IfyouhavereachedyourlimitfortheOncologybenefitOnceyourbenefitlimitshavebeenreachedwewillonlycoverPMBs.YoumustmakeuseoftheDesignatedServiceProvider,ICON.Ifyouuseanyotherserviceprovider,youmustpay40%ofthecostfromyourownpocket.Youcannotgetthe40%backfromyourDay-to-DayBenefits.

Limitsforspecifictreatments

Oncology:chemotherapy,radiotherapy,approvedmedication,relatedconsultations,pathologyandgeneralradiology

We pay up to a limit of R444 700

Specialised medicine (eg, biologicals) Thereisnobenefitforspecialisedmedicineonthisoption

Brachytherapymaterials R44 300

OncologyDiseaseManagementProgramme(ODM)Ondiagnosisofcancer,itisimportantthatyouregisterontheOncologyDiseaseManagementProgramme(ODM).Youoryourtreating doctor can call them on 0860100572andregister.Theprogrammeaimstohelpyourdoctortoensurebesttreatmentandsupport. ChangesinyouroncologymedicineneedtobegiventoODMassoonaspossible.Pleasefaxthechangedtreatmentplanto 0214662303 or email cancerinfo@fedhealth.co.za.

Specialisedradiology(forexample,MRIorCTscans)We cover specialised radiology (for example MRI or CT scans) up to 100% of the Fedhealth Rate, whether you have it in- or out- of-hospital.YoumustpaythefirstR2200fornon-PMBscans.Youmustgetseparateauthorisationforaspecialisedradiologicalprocedure,whetherittakesplacein-orout-of-hospital.

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eOther treatments or procedures that you receive in hospital

Alllimitsinthissectionareperfamilyperyear,unlessotherwiseexplained.Allco-paymentsinthissectionarepereventandapplicableonthehospital/facilitybillonly.

Appliances,externalaccessoriesandorthotics(e.g.compressionstockingsforDVT)

Paidfromtheday-to-daybenefit.Doesnotaccumulatetothreshold.PaidfromthresholduptoR11600perfamilyperyear.Sub-limitofR4340perbeneficiaryforfootorthotics

Arthroscopicprocedures:other Youpayaco-paymentofR2400onthehospitalbill.(Seepage14forcover for doctors and specialists)

Arthroscopicprocedures:Hipandwrist Youpayaco-paymentofR2400onthehospitalbill.(Seepage14forcover for doctors and specialists)

Colonoscopy,UpperGIendoscopy Youpayaco-paymentofR2400onthehospitalbill.(Seepage14forcover for doctors and specialists)

Cornealgraft WepayuptoalimitofR20700perpersonregisteredonthescheme.(See page 14 for cover for doctors and specialists)

Jointreplacements Youpayaco-paymentofR4200onthehospitalbill.(Seepage14forcover for doctors and specialists)

SinglehipandkneereplacementswithCP* Noco-paymentifyouuseoneofthescheme’sCPs,ICPSorJointCare,fornon-PMBhipandkneejointreplacements.Seepage20

Singlehipandkneereplacements-voluntaryuseofnon-CP

You pay a co-payment of R26 200 on the hospital bill

Involuntaryuseofnon-CPforsinglehipandkneereplacements

You pay a co-payment of R4 200 on the hospital bill

Allopenherniarepairs Unlimitedcover.(Seepage14forcoverfordoctorsandspecialists)

HIV:Immunedeficiencyrelatedto HIVinfection

Unlimitedcover.(Seepage14forcoverfordoctorsandspecialists)

Organtransplantincludingimmunosuppressionmedication

WepayuptoalimitofR444700.(Seepage14forcoverfordoctorsand specialists)

Rhizotomiesandfacetpainblocks(limitedtooneofeitherprocedureforeachbeneficiaryeachyear)

Youpayaco-paymentofR4200onthehospitalbill.(Seepage14forcover for doctors and specialists)

Balloonsinuplasty Youpayaco-paymentofR4200onthehospitalbill.(Seepage14forcover for doctors and specialists)

Laparoscopicherniarepairs(bilateralinguinal,repeatedinguinalherniasandnissen/toupeyrepairsonly)

Youpayaco-paymentofR4200onthehospitalbill.(Seepage14forcover for doctors and specialists)

Laparoscopicprocedures Youpayaco-paymentofR4200onthehospitalbill.(Seepage14forcover for doctors and specialists)

Maxillo-facialsurgery Unlimitedcover.(Seepage14forcoverfordoctorsandspecialists)

Post-hospitalisationbenefit We pay for up to 30 days after discharge at 100% of the Fedhealth Rate.Seepage19.

PsychiatricServices:accommodationinageneralward,procedures,ECT,materialsandhospitalequipment,consultationsandvisits,medicinesandinjectionmaterial

WepayuptoalimitofR25100.(Seepage14forcoverfordoctors and specialists)

Renaldialysis(chronic):consultations,visits,allservices,materialsandmedicinesassociatedwiththecostofrenaldialysis

We pay up to a limit of R444 700 at 100% of the contracted rate at DesignatedServiceProvider.40%co-paymentonnon-useofDSP

Specialisedradiology(forexample, MRIorCTscans),whethertheprocedure isperformedin-orout-of-hospital

Unlimited at 100% of the Fedhealth Rate (as long as you get separate authorisation).Youpayaco-paymentofR2200fornon-PMBscans

Spinalsurgery Youpayaco-paymentofR4200onthehospitalbill.(Seepage14forcoverfordoctorsandspecialists).NobenefitunlessConservativeBackandNeckRehabilitationProgrammehasbeencompleted.Seepage15.Subjecttointernalprosthesisbenefitlimit.Seepage20

Terminalcare We pay up to a limit of R31 000 at 100% of the Fedhealth Rate

Wisdomteeth(surgicalremovalofimpactedwisdomteeth)

Youpayaco-paymentofR4200onthehospitalbill.(Seepage14forcover for doctors and specialists)

Some treatment and procedures done out of hospitalTosaveyourDay-to-DayBenefit,wepayforvarioustreatmentsthatarenotdoneinhospitalfromtheCoreBenefitBundle. ThishelpsmembersbecauseitmeansthatyourDay-to-DayBenefitwilllastlongereachyear.

Serviceslikephysicalrehabandtreatmentinsub-acutefacilitiesInmanycases,youmightbeabletobetreatedinasub-acutefacilityratherthanahospital.ThereisnolimitforthecoverwegiveforthisanditispaidfromtheCoreBenefitBundle.TreatmentissubjecttoPrescribedMinimumBenefitlevelofcareonlyandtomanagedcareprotocols.

NursinginsteadofhospitalisationIf it is possible to use nursing services (including private nurse practitioners and nursing agencies) instead of going to hospital, wewillcovertheexpensefromtheCoreBenefitBundle.Subjecttomanagedcareprotocols.

Proceduresperformedindaywards,dayclinicsanddoctor’sroomsTheCoreBenefitBundle(notDay-to-DayBenefits)coversmorethan60proceduresthatdonotrequireanovernightstayinhospitalandcansafelybeperformedindaywards,dayclinicsandthedoctor’srooms.Anexampleisatonsillectomy.

DoctorappointmentswithnetworkGPsIfyouuseaGPintheFedhealthnetwork,theappointmentispaidoutoftheCoreBenefitBundleandnotfromyourSavings.Members on flexiFED 4GRID and flexiFED 4ElectarerequiredtonominateuptotwoGPsintheFedhealthGPnetwork.

FemalecontraceptionIn most cases, female contraception, including the contraceptive pill, contraceptive rings and IUDs, is covered by the Core BenefitBundle.However,theCoreBenefitBundlewillnotcover:

• Femalecontraceptionthatisprescribedforreasonsotherthancontraception(forexample,forskinproblems).Examplesofcontraceptive pills that we do not cover are Cyprene-35 ED, Diane–35, Tricilest, Ginette and Minerva

• CostsofconsultationsorotherexpensesrelatedtotheIUD.TheCoreBenefitBundlecoversthecostoftheIUDitself, (forexample,Mirena)butdoesnotcoveranyrelatedcosts.WecoverthecostofanIUDeverysecondyear.

Othercostsforcontraceptionwillusuallybecoveredbysavings.

*ContractedProvider:MustuseICPSorJointCareforsinglenon-PMBhipandkneejointreplacements.Non-useofContractedProvider(CP)willresult inco-payment.

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MedicineyougetwhileinhospitaltotakeathomeThe scheme covers up to seven days of medicine that a doctor prescribes for you in hospital to take home with you (take-outmedicine).

TogetcoverfromtheCoreBenefitBundle,themedicinemustbothbedispensedbythehospitalandbeshownontheoriginalhospitalaccount.Ifyouaregivenaprescriptionfortake-outmedicineandtakethisprescriptiontoapharmacy,theclaimwillbepaidfromyourDay-to-DayBenefit(SavingsAccount)andnotfromtheCoreBenefitBundle.

Treatmentinthe30daysafteryourhospitalvisit(post-hospitalisationbenefit)ToprotectyourDay-to-DayBenefit,theschemecoverscertaintreatmentsupto30daysafterdischargefromhospitalfromtheCoreBenefitBundle.Thistreatmentissubjecttoprotocols.Thedaythatyouaredischargedcountsasthefirstdayofthe30daysofcover.

Thisbenefitcoverstreatmentat100%oftheFedhealthRate.Itpaysfor:• Complicationsthatmightarisefromhospitalisation.• Physiotherapy, occupational therapy, speech therapy, general radiology, pathology tests and dietetics (limited to two consultationswithadieticianperhospitaladmission).

Thefollowingconditionsapplytothe30-daypost-hospitalisationbenefit:• Onlytreatmentasaresultofahospitaleventwillbecovered.Thetreatmentmustberelatedtotheoriginaldiagnosis.• Youmustgetanauthorisationnumberforthisbenefitinadditiontotheauthorisationnumberforthehospitaladmission.Ifyoudonotgetaseparateauthorisationnumberfromus,theclaimwillbepaidfromtheDay-to-DayBenefitsandnotfromtheCoreBenefitBundle.

Prosthesis benefit table

ExternalprosthesisWepayforexternalprosthesesuptoalimitofR11600perfamilyperyearatcost.ThisispaidoutoftheCoreBenefitBundle.

InternalprosthesisThereisaseparatebenefitforinternalprosthesis.Thebenefitdoesnotincludeosseo-integratedimplantsforreplacingteeth.Hipandkneebilateralreplacements will be allowed for up to double the amountforasinglehipandkneereplacement.

Internalprosthesis Cover Limitsperfamily

Aortastentgrafts 100% of cost R58 500

Detachableplatinumcoils 100% of cost R50 700

Cardiacstents 100% of cost R27 800

Cardiacvalves 100% of cost R27 800

Cardiacpacemakers 100% of cost R27 800

Intraocularlenses(perlens) 100% of cost R3 200

Shoulderreplacement 100% of cost R27 800

Elbowreplacement 100% of cost R27 800

Singlehipreplacement(SeeICPS&JointCarebelow) 100% of cost R27 800

Singlekneereplacement(SeeICPS&JointCarebelow) 100% of cost R27 800

TotalanklereplacementBonelengtheningdevicesSpinalplatesandscrewsCarotidstentsPeripheralarterialstentgraftsEmbolicprotectiondevicesOtherapprovedspinalimplantabledevices

100% of cost100% of cost100% of cost100% of cost100% of cost100% of cost100% of cost

Seecombinedbenefitlimitforallunlisted internal prostheses*

*Combinedbenefitlimitforallunlistedinternalprostheses 100%ofcost R25000

Improved Clinical Pathway Services (ICPS) and JointCare for non-PMB single hip and knee replacements

We’reallaboutthecoordinationofyourcaretoensureyourecoverquickerandmoreeffectively.That’swhywehaveappointedImprovedClinicalPathwayServices(ICPS)andJointCareasthecontractedproviders(CPs)fornon-PMBhipandkneereplacements.AclinicalpathwaymeansthatanetworkofrelevanthealthcarepractitionerswilloverseeeverystepofyourhiporkneereplacementjourneywithyourGP,fromGPreferraltosurgery,rightthroughtoyourfullrehabilitation.Asthepatient,youbenefitsincethiscoordinatedapproachhasbeenproventoresultinbetterhealthoutcomesandpatientsatisfaction.So,you’llbe back on your feet before you know it thanks to a managed process that includes your pre-op assessment, a rapid recovery plan, withpre-operativestrengthening,physiologicalanaesthesia,minimallytraumaticsurgery,andpostoperativephysiotherapy.

SinceICPSandJointCarearetheFedhealthCPsforsinglehipandkneereplacements,youwillhaveaR26200co-paymentifyouvoluntarilydeclinetousethemfornon-PMBhiporkneereplacements.

Pleasenote:non-PMBdoublehipandkneereplacements(bothatthesametime)arenotpartoftheCPsservicemodel.Should a double replacement of either hips or knees occur, the fee for service model will be used – applicable specialist rates, networkhospitals,prosthesisbenefitsandjointreplacementco-paymentswillapply.Subjecttoauthorisationandmanagedcareprotocols.

Contact ICPS on 0860002153 or via www.icpservices.co.za,andJointCareon0118833310.19 20

You must have authorisation YouneedauthorisationbeforetheCoreBenefitBundlewillcoveranyclaim,forexample,aplannedoremergencyhospitaladmission,specialisedradiology,selectedprocedures,30-daypost-hospitalisationbenefitorcasualtytreatment.

Contactusatleast48hoursbeforethehospitalstayortheprocedureYoumustcontactusatleast48hoursbeforeanytreatmentthatisnotanemergencyorthatisplanned.Youmustwritedowntheauthorisationnumberwegivetoyouandtakeitwithyoutohospital.

You must get a separate authorisation number for specialised radiology and for treatment covered in the 30 days after thehospitalvisit.Ifindoubt,pleasedocontactustofindoutifyouneedanauthorisationnumber.

Whenyoucontactus,havethisinformationreadyAre you being admitted as an in-patient or an out-patient to the hospital?In-patient:ifyouwillbestayingovernight.Out-patient:ifyouwillbeadmittedanddischargedthesameday(noovernightstay).

We need the following information to authorise your treatment:

1. Fedhealthmembershipnumber2.Dateofbirthofpatient3.Reasonforadmission,ICD10andapplicabletariffcodesfortheproposedtreatment(yourdoctormustgive

these to you)4.Dateofadmissionandtheproposeddateoftheoperationortreatment5.Thetreatingdoctor’snameandtelephoneandpracticenumbers6.Nameofthehospitalwithtelephoneandpracticenumbers7.ForaCTscan,MRIprocedureorsimilarprocedure,thenameoftheradiologicalpractice.

Phone us: 0860002153Monday to Thursday 08h30 – 17h00Friday 09h00 – 17h00

Email us: authorisations@fedhealth.co.za

AllcostscoveredfromtheCoreBenefitBundleneedtobepre-authorisedbytheAuthorisationCentreon

0860 002 153

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eHospital facilities you must usePrescribedlistofflexiFED 4GRIDnetworkhospitalsHospitalcostsarecoveredunlimitedifyouuseafacilityonthislist.Pleasenotethatthislistmaychange/expandduringtheyear.PleasecontacttheFedhealthCustomerContactCentreon0860002153 or refer to the website for the latest flexiFED 4GRIDNetworkHospitallist.

HOSPITAL NAME PROVINCE TOWN

Life Beacon Bay Hospital Eastern Cape East London

LifeStJamesHospital Eastern Cape East London

Greenacres Hospital Eastern Cape Greenacres

Port Alfred Hospital Eastern Cape Port Alfred

Settlers Hospital Eastern Cape Grahamstown

East London Eye Hospital Eastern Cape East London

Matatiele Private Hospital Eastern Cape Matatiele

Cuyler Clinic Eastern Cape Uitenhage

Mthatha Private Hospital Eastern Cape Mthatha

Queenstown Private Hospital Eastern Cape Queenstown

Pelonomi Private Hospital Free State Bloemfontein

Universitas Private Hospital Free State Bloemfontein

Vaalpark Hospital Free State Sasolburg

Riemland Clinic Free State Frankfort

Cairnhall Hospital Free State Bloemfontein

Kroon Hospital Free State Kroonstad

St Helena Hospital Free State Welkom

Clinix Botshelong-Empilweni Private Hospital Gauteng Vosloorus

Clinix Dr SK Matseke Memorial Hospital Gauteng Soweto

Clinix Solomon Stix Morewa Memorial Hospital Gauteng Johannesburg

Clinix Tshepo-Themba Private Hospital Gauteng Dobsonville

Akasia Hospital Gauteng Akasia

Bougainville Hospital Gauteng Daspoort

Clinton Hospital Gauteng Alberton

Femina Hospital Gauteng Arcadia

Garden City Hospital Gauteng Mayfair West

JakarandaHospital Gauteng Muckleneuk

Krugersdorp Hospital Gauteng Krugersdorp

LinksfieldHospital Gauteng LinksfieldWest

Linkwood Hospital Gauteng LinksfieldWest

Linmed Hospital Gauteng Benoni

Milpark Hospital Gauteng Parktown West

Montana Hospital Gauteng Montana Park

Moot Algemene Hospital Gauteng Rietfontein

Mulbarton Hospital Gauteng Mulbarton

N17 Hospital Gauteng Springs

Olivedale Hospital Gauteng Olivedale

Optiklin Eye Hospital Gauteng Benoni

Park Lane Hospital Gauteng Parktown

Pinehaven Hospital Gauteng Krugersdorp

Pretoria East Hospital Gauteng Moreleta Park

Rosebank Hospital Gauteng Rosebank

Sunward Park Hospital Gauteng Boksburg

Union Hospital Gauteng Alberton

Unitas Hospital Gauteng Centurion

Waterfall City Hospital Gauteng Midrand

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Arwyp Medical Centre Gauteng Kempton Park

Botshilu Private Hospital Gauteng Soshanguve

Lakeview Hospital Gauteng Benoni

Lenmed Health Ahmed Kathrada Private Hospital Gauteng Lenasia

Lenmed Health Daxina Private Hospital Gauteng Lenasia

Lenmed Health Randfontein Private Hospital Gauteng Randfontein

Lenmed Health Zamokuhle Private Hospital Gauteng Tembisa

Louis Pasteur Private Hospital Gauteng Pretoria

Medfem Clinic Gauteng Bryanston

Urolocare Hospital Gauteng Hatfield

Zuid-Afrikaanse Hospitaal Gauteng Pretoria

Naledi-NkanyeziPrivateHospital Gauteng Sebokeng

Cormed Clinic Gauteng Vanderbijlpark

Midvaal Private Hospital Gauteng Vereeniging

Kingsway Hospital KwaZulu-Natal Amanzimtoti

Parklands Hospital KwaZulu-Natal Overport

St Augustine’s Hospital KwaZulu-Natal Durban

Umhlanga Hospital KwaZulu-Natal uMhlanga Rocks

Ethekwini Hospital And Heart Centre KwaZulu-Natal Durban

Gateway Private Hospital KwaZulu-Natal Umhlanga Rocks

Hillcrest Private Hospital KwaZulu-Natal Hillcrest

Lenmed Health Shifa Private Hospital KwaZulu-Natal Mayville

Alberlito Hospital KwaZulu-Natal Ballito

Hibiscus Hospital KwaZulu-Natal Port Shepstone

La Verna Private Hospital KwaZulu-Natal Ladysmith

Margate Private Hospital KwaZulu-Natal Margate

St Anne’s Hospital KwaZulu-Natal Pietermaritzburg

The Bay Hospital KwaZulu-Natal Richards Bay

Kokstad Private Hospital KwaZulu-Natal Kokstad

Ahmed Al-Kadi Private Hospital KwaZulu-Natal Overport

Pholoso Hospital Limpopo Polokwane

Quality Care Private Hospital Limpopo Louis Trichardt

Zoutpansberg Private Hospital Limpopo Louis Trichardt

St Vincent’s Hospital Limpopo Bela-Bela

Emalahleni Private Hospital Mpumalanga Witbank

Kiaat Private Hospital Mpumalanga Nelspruit

Lowveld Hospital Mpumalanga Nelspruit

Nelspruit Surgiclinic Private Hospital Mpumalanga Nelspruit

Life Cosmos Hospital Mpumalanga Witbank

Ferncrest Hospital North West Rustenburg

Fochville Hospital North West Fochville

The Fountain Private Hospital North West Carletonville

MooiMed Private Hospital North West Potchefstroom

Rustenburg Medi Care Hospital North West Rustenburg

Sunningdale Hospital North West Klerksdorp

Vryburg Private Hospital North West Vryburg

Wilmed Park Private Hospital North West Klerksdorp

Clinix Victoria Private Hospital North West Mafikeng

JaneKeyserClinic Northern Cape Hartswater

Lenmed Health Kathu Private Hospital Northern Cape Kathu

The Royal Hospital and Heart Centre Northern Cape Kimberley

Mediclinic Cape Gate Western Cape Brackenfell

Day Clinics you must usePrescribedlistofflexiFED 4GRIDnetworkdayclinicspleasenotethatthislistmaychange/expandduringtheyear.Pleasecontact the FedhealthCustomerContactCentreon0860002153 or refer to the website for the latest Network Hospital and DayCliniclist.

HOSPITAL NAME PROVINCE TOWN

Med Forum Theatre Eastern Cape PortElizabeth

Bethlehem Medical Centre Day Theatre Free State Bethlehem

Citymed Day Theatre Free State Bloemfontein

Cure Day Clinics - Bloemfontein Free State Bloemfontein

Welkom Medical Centre Free State Welkom

Boksburg Medical and Dental Centre Gauteng Boksburg

Constantia Clinic Gauteng Florida

Constantia Park Medical and Dental Centre Gauteng Garsfontein

Germiston Medical and Dental Centre Gauteng Germiston

Silverton Medical and Dental Theatre Gauteng Pretoria

The Berg Day Theatre Gauteng Bergbron

Protea Clinic Gauteng Krugersdorp

Advanced Groenkloof Day Hospital Gauteng Groenkloof

Medgate Day Hospital Gauteng Roodepoort

Advanced Soweto Eye Hospital Gauteng Soweto

Birchmed Surgical Centre Gauteng Kempton Park

Centre For Gynaecological Endoscopy Gauteng Morningside

Centre Of Advanced Medicine Gauteng Waverly

Centurion Eye Hospital Gauteng Centurion

Cure Day Clinics - Erasmuskloof Gauteng Erasmuskloof

Cure Day Clinics - Fourways Gauteng Fourways

Medkin Clinic Gauteng Pretoria

Cure Day Clinics - Midstream Gauteng Midstream

Edenvale Day Clinic Gauteng Edenvale

Ekurhuleni Surgiklin Day Clinic Gauteng Kempton Park

Fordsburg Day Clinic Gauteng Fordsburg

HOSPITAL NAME PROVINCE TOWN

Life Bay View Hospital Western Cape Mossel Bay

Life West Coast Private Hospital Western Cape Vredenburg

Blaauwberg Hospital Western Cape Sunningdale

Ceres Hospital Western Cape Ceres

Christiaan Barnard Memorial Hospital Western Cape Cape Town

Kuils River Hospital Western Cape Kuils River

N1 City Hospital Western Cape Goodwood

Bellville Medical Centre Western Cape Bellville

Busamed Paardevlei Private Hospital Western Cape Somerset West

Cape Eye Institute Western Cape Bellville

Gatesville Medical Centre Western Cape Gatesville

Mitchells Plain Medical Centre Western Cape Mitchells Plain

Tokai Medical Centre Western Cape Tokai

Rondebosch Medical Centre Western Cape Lansdowne

Mediclinic Louis Leipoldt Western Cape Bellville

Mediclinic Stellenbosch Western Cape Stellenbosch

Mediclinic Durbanville Western Cape Durbanville

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JohannesburgEyeHospital Gauteng Randburg

Kilnerpark Narkokliniek Gauteng Pretoria

Mayo Clinic Gauteng Roodepoort

Ocumed Eye And Laser Institute Gauteng Vanderbijlpark

Optimed Clinic Gauteng Johannesburg

Sandhurst Eye Centre Gauteng Sandton

Dr Nilesh Dayha Inc Gauteng Benoni

Twenty Twenty Eye Surgery Centre Gauteng Mulbarton

Visiclin Eye Clinic Gauteng Three Rivers

Visiomed Eye And Laser Centre Gauteng Randburg

Netcare Rehabilitation Hospital Gauteng Auckland Park

Umhlanga Eye Institute KwaZulu-Natal Umhlanga

Bluff Medical and Dental Centre KwaZulu-Natal Bluff

Malvern Medical and Dental Centre KwaZulu-Natal Malvern

Pinetown Medical and Dental Centre KwaZulu-Natal Pinetown

Westridge Surgical KwaZulu-Natal West Ridge

Howick Day Clinic KwaZulu-Natal Howick

KZN Day Clinic KwaZulu-Natal Umhlanga

Lorne Street Anaesthetic Clinic KwaZulu-Natal Durban

Shelly Beach Day Clinic KwaZulu-Natal Shelly Beach

Durban Eye Hospital KwaZulu-Natal Durban

Emalahleni Day Hospital Mpumalanga Witbank

Highveld Eye Hospital Mpumalanga Witbank

Potchefstroom Medical and Dental Centre North West Potchefstroom

Rustenburg Private Eye Clinic North West Rustenburg

Medi-Harts Day Clinic Northern Cape Hartswater

Kimberley Narco Clinic Northern Cape Kimberley

Mediclinic Upington Northern Cape Upington

Kraaifontein Medical and Dental Centre Western Cape Kraaifontein

Monte Vista Clinic Western Cape Monte Vista

Parow Medical and Dental Centre Western Cape Parow

Tokai Medical and Dental Centre Western Cape Tokai

Advanced Knysna Surgical Centre Western Cape Knysna

Advanced Panorama Surgical Centre Western Cape Panorama

Advanced Vergelegen Surgical Centre Western Cape Somerset West

Advanced Worcester Surgical Clinic Western Cape Worcester

Cape Dental Theatres Western Cape Wynberg

Cure Day Clinics - Bellville Western Cape Parow

Cure Day Clinics - Somerset West Western Cape Somerset West

Cure Day Clinics - St Stephens Paarl Western Cape Paarl

Driftwood Clinic Western Cape Constantia

George Surgical Centre Western Cape George

Kango Clinic (Kannaland Medical Clinic) Western Cape Oudtshoorn

The Surgical Institute Western Cape Durbanville

Thembani Theatres Western Cape Khayelitsha

Vidamed Day Hospital Western Cape Mossel Bay

WesfleurPrivateClinic Western Cape Atlantis

Advanced Durbanville Surgical Centre Western Cape Durbanville

Alchimia Clinic Western Cape Gardens

Hermanus Day Hospital Western Cape Hermanus

HOSPITAL NAME PROVINCE TOWN

Life St Mary’s Private Hospital Eastern Cape Umtata

Life Queenstown Private Hospital Eastern Cape Queenstown

Riemland Clinic Free State Frankfort

St Helena Hospital Free State Welkom

Botshilu Private Hospital Gauteng Soshanguve

Clinix Botshelong-Empilweni Private Hospital Gauteng Vosloorus

ClinixNaledi-NkanyeziPrivateHospital Gauteng Sebokeng

Clinix Tshepo-Themba Private Hospital Gauteng Soweto

Zamokhule Private Hospital Gauteng Tembisa

Pretoria West Hospital Gauteng Pretoria West

HelenJosephHospital Gauteng Auckland Park

Sebokeng Hospital Gauteng Sebokeng

Louis Pasteur Hospital Gauteng Pretoria

Clinix Solomon Stix Morewa Memorial Hospital Gauteng Johannesburg

Dr S K Matseke Memorial Hospital Gauteng Diepkloof

La Verna Private Hospital KwaZulu-Natal Ladysmith

Shifa Private Hospital KwaZulu-Natal Durban

Zoutpansberg Private Hospital Limpopo Polokwane

MediclinicTzaneen Limpopo Tzaneen

Life Piet Retief Hospital Mpumalanga Piet Retief

Clinix Itokolle-Victoria Private Hospital North West Mafikeng

Vryburg Private Hospital Northern Cape Vryburg

Lenmed Health Kathu Private Hospital Northern Cape Kathu

Ceres Private Hospital Western Cape Ceres

Bellville Medical Centre Western Cape Bellville

Mitchell’s Plain Medical Centre Western Cape Mitchell’s Plain

Hospital facilities you must usePrescribedlistofflexiFED 4ElectnetworkhospitalsHospitalcostsarecoveredunlimitedifyouuseafacilityonthislist.Pleasenotethatthislistmaychange/expandduringtheyear.PleasecontacttheFedhealthCustomerContactCentreon0860002153 or refer to the website for the latest flexiFED 4ElectNetworkHospitallist.

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Immunisation benefit for children

Ageofchild Vaccine

Atbirth Tuberculosis (Bacilles Calmette Guerin)OPV(0) Oral Polio Vaccine

6Weeks OPV(1) Oral Polio VaccineRV(1)RotavirusVaccineDTaP-IPV//Hib(1)Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilusinfluenzae type b CombinedHepB(1) Hepatitis B VaccinePCV7(1)PneumococcalConjugatedVaccine

10Weeks DTaP-IPV//Hib(2) Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilusinfluenzae type b CombinedHepB(2)Hepatitis B Vaccine

14Weeks RV(2)RotavirusVaccine (should not be administered after 24 weeks)DTaP-IPV//Hib(3) Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilusinfluenzae type b CombinedHepB(3) Hepatitis B VaccinePCV7(2)PneumococcalConjugatedVaccine

9Months MeaslesVaccine(1)PCV7(3)PneumococcalConjugatedVaccine

18Months DTaP-IPV//Hib(4) Diphtheria, Tetanus, acellular Pertussis (whooping cough), Inactivated Polio Vaccine and Haemophilusinfluenzae type b CombinedMeaslesVaccine(2)

6Years TdVaccine Tetanus and reduced strength of diphtheria Vaccine

12Years TdVaccine Tetanus and reduced strength of diphtheria Vaccine

Screening benefit

Thisbenefitcoversvariousscreeningandpreventativeprogrammesthataimtoimproveyourhealth.

Screeningtest Beneficiariesregisteredontheschemewhoqualifyforthebenefit

Limitofscreeningtests

Women’sHealth

Cervicalcancerscreening(Pap smear) Women, 21 to 65 years old 1 every 3 years

Men’sHealth

ProstateSpecificAntigen(PSA) Men, 45 to 69 years old 1 every year

Children’sHealth–seetableontherightfortheimmunisationbenefit

CardiacHealth

Cholesterolscreening(fulllipogram) Everyone 20 years old and older 1 every 5 years

General

Breastcancerscreeningwithmammography Everyone older than 45 1 every 3 years

Fluvaccination Everyone 1 every year

HIVfingerpricktestby contracted wellness network provider

Everyone 1 every year

Pneumococcalvaccination Everyone older than 65 1 per lifetime

Colorectalcancerscreening (faecaloccultbloodtest)

Everyone; 50 to 75 years old 1 every year

Healthriskassessments

Wellnessscreening(BMI,bloodpressure,fingerprickcholesterolandglucosetests)

Everyone 1 every year

Preventativescreeningbycontractedwellnessnetworkprovider(waist-to-hipratio,bodyfat%,flexibility,postureandfitness)

Everyone 1 every year

Active Disease Risk Management programmes

The Scheme offers the following programmes to help you address certain health issues:

Programme Beneficiariesregisteredontheschemewhoqualifyforthebenefit

ConservativeBackandNeckRehabilitationProgramme Qualifying members

DiabetesManagementProgramme Qualifying members

EmergingRiskBeneficiaryManagementProgramme Qualifying members

HighRiskBeneficiaryManagementProgramme Qualifying members

MentalHealthManagementProgramme Qualifying members

SmokingCessationProgramme Everyone

WeightManagementProgramme Qualifying members

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What is chronic medicine?TheChronicDiseaseBenefitcoverschronicmedicine.Chronicmedicineismedicinethatistakenforapersistentorotherwiselong-lastingcondition.Examplesofconditionsthatrequireongoingmedicinearehypertension,diabetesandasthma.Thisoptioncoverschronicmedicinefor42chronicconditions.

LimitsTheoveralllimitisR5680peryearperbeneficiary,uptoalimitofR11350peryearforeachfamily.

ToclaimunderthisbenefitYour condition:• Must be in the list of chronic conditions (given below); and• Mustmeetasetofdefinedcriteriatoqualifyforthebenefit(referredtoasclinicalentrycriteria).

Inotherwords,justbecauseyouhaveoneoftheconditionsonthelistbelow,doesnotmeanthatwewillcovertheexpensesoutoftheChronicDiseaseBenefit.Theconditionmustalsomeetasetofdefinedcriteria.Ifyouneedinformationonthecriteria,pleasecontactus.

ListofchronicconditionsThisbenefitcoversmedicineandtreatmentforasetof41chronicconditionsaswellasHIV/Aids.ThesearegiveninList1belowandList2onpage30.

List1:ConditionsthatareontheChronicDiseaseList(CDL)Seesection1,‘PrescribedMinimumBenefits(basiclevelofcoverforadefinedsetofconditions),foranexplanationofPrescribedMinimumBenefits.

Addison’s DiseaseAsthmaBipolar Mood DisorderBronchiectasisCardiac FailureCardiomyopathyChronic Renal DiseaseCOPD/Emphysema/ChronicBronchitisCoronary Artery DiseaseCrohn’s DiseaseDiabetes InsipidusDiabetes Mellitus type 1 & 2Dysrhythmias

EpilepsyGlaucomaHaemophiliaHIVHyperlipidaemiaHypertensionHypothyroidismMultiple SclerosisParkinson’s DiseaseRheumatoid ArthritisSchizophreniaSystemic Lupus ErythematosusUlcerative Colitis

IfyourconditionisonList1(CDL)

IfyouhavenotreachedyourlimitfortheChronicDiseaseBenefit:

Medicinesthatwecover(formulary)

Iftheconditionqualifiesforthebenefit,wecovermedicinesontheintermediateformularyonly,andonlyuptotheceilingpricegivenintheMedicinePriceList.Ifyouuseamedicinenotonthislist,youmustpay40%ofthecostfromyourownpocket.Youcannotgetthe40%backfromyourDay-to-DayBenefits.

Serviceprovidersyoushoulduse

Iftheconditionqualifiesforthebenefit,youcanuseanyserviceprovider.TheSchemepaysuptoanagreedratefordispensingfees.Youwillpaythedifferenceifthepharmacychargesmore.MediRite,Dis-Chem,ClicksandPharmacyDirectdonotchargemorethantheagreedrate.

IfyouhavereachedyourlimitfortheChronicDiseaseBenefit:

Medicinesthatwecover(formulary)

Iftheconditionqualifiesforthebenefit,wecovermedicinesontheintermediateformularyonly,andonlyuptotheceilingpricegivenintheMedicinePriceList.Ifyouuseamedicinenotonthislist,youmustpay40%ofthecostfromyourownpocket.Youcannotgetthe40%backfromyourDay-to-DayBenefits.

Serviceprovidersyoushoulduse Iftheconditionqualifiesforthebenefit,youcanuseanyserviceprovider.TheSchemepaysuptoanagreedratefordispensingfees.Youwillpaythedifferenceifthepharmacychargesmore.MediRite,Dis-Chem,ClicksandPharmacyDirectdonotchargemorethantheagreedrate.

List2:Additionalchronicconditionscoveredonyouroption

Acne (up to the age of 21)Ankylosing SpondylitisAnorexia NervosaAttentionDeficitDisorder(inchildrenonlyuptoageof18)Bulimia NervosaDepressionDermatomyositisEczema(uptotheageof18)

Generalised Anxiety DisorderNarcolepsyObsessive Compulsive DisorderPanic DisorderParaplegia/Quadriplegia(associatedmedicine)Post-Traumatic Stress SyndromeSclerodermaTourette’s Syndrome

IfyourconditionisonList2(AdditionalChronicConditions)

IfyouhavenotyetreachedyourlimitfortheChronicDiseaseBenefit

Medicinesthatwecover(formulary)

Iftheconditionqualifiesforthebenefit,wecovermedicinesontheintermediateformularyonly,andonlyuptotheceilingpricegivenintheMedicinePriceList.Ifyouuseamedicinenotonthislist,youmustpay40%ofthecostfromyourownpocket.

Serviceprovidersyoushoulduse Iftheconditionqualifiesforthebenefit,youcanuseanyserviceprovider.TheSchemepaysuptoanagreedratefordispensingfees.Youwillpaythedifferenceifthepharmacychargesmore.MediRite,Dis-Chem,ClicksandPharmacyDirectdonotchargemorethantheagreedrate.

Thereisnobenefitatallfortheadditionalchronicconditionsonceyourchronicbenefitisusedup.

Systemic Lupus ErythematosusUlcerative Colitis

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Havingachroniccondition:

AN EXAMPLEWhatthememberdoes Howtheexpenseisfunded

Lilyhasasthma and her doctor prescribes medicine thatshemusttakeregularly.

She decides to apply online on www.fedhealth.co.za ratherthanonthephone.Herdoctorgivesherthedetailsthattheonlineapplicationasksfor.

Chronic Medicine Management (CMM) at Fedhealth tell her that the application is accepted because her asthmameetstheclinicalcriteria.

Lily then gets the Medicine access card in the post aswellasbyemail.Shecantakeittoanypharmacytogetherwithherscripttobuyhermedicine.Sincethe Scheme pays up to an agreed rate for dispensing fees, Lily will pay the difference if the pharmacy sheuseschargesmore.MediRite,Dis-Chem,Clicksand Pharmacy Direct do not charge more than the agreedrate.IfLilywantstomakeuseofPharmacyDirect, a courier pharmacy, she can register with them and have her chronic medication delivered to anagreedaddress.

When Lily is buying her medicine, the pharmacist tells her that the prescribed medicine will not be covered in full but that there is a generic medicine thatwouldbecoveredinfull.Shedecidestochangeto the generic so that the full cost of the medicine is covered.

Because asthma is on the CDL, she will receive treatmentguidelineswithherletterfromCMM.These will tell her about which other expenses are coveredbyriskbenefits(thescheme).

LilyhasnotreachedthelimitfortheChronicDiseaseBenefit, so the cost of the medicine is covered in full, as long as the prescribed medicine is on the intermediate formulary and the costs fall within the ceiling price given on the Medicine PriceList.IfLilyusesmedicinethatisnotontheintermediateformulary, then Lily would have to pay 40% of the cost from herownpocket.

IfLilyhadreachedthelimitfortheChronicDiseaseBenefit, becauseasthmaisaPrescribedMinimumBenefitcondition,wewouldcovermedicinesthatareontheintermediateformulary.This means that there might be some medicines that we do notcoveratall.IfLilyusesmedicinesthatarenotontheintermediate formulary, then Lily would have to pay 40% of the costfromherownpocket.

We would only cover the medicine up to the ceiling price given ontheMedicinePriceList.

Lilycangethermedicinefromanypharmacy.SincetheScheme pays up to an agreed rate for dispensing fees, Lily willpaythedifferenceifthepharmacysheuseschargesmore.MediRite, Dis-Chem, Clicks and Pharmacy Direct do not charge morethantheagreedrate.

IfLilyhadaconditionthatisnotaPrescribedMinimumBenefit,therewouldbenocoveraftertheChronicDiseaseBenefithasreachedthelimit.

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CoverfortreatmentforHIV/Aids

ThereisunlimitedcoverforHIV/Aidstreatmentandpreventativemedicine.

Toqualifyforthisbenefit,youmustberegisteredonthescheme’sHIV/Aidsdiseasemanagementprogramme,AidforAids(AfA).YouhaveaccesstotheHIV/Aidsmedicinebenefitonlywhenyouareregistered.

AfA is a comprehensive HIV disease management programme with access to:

• Anti-retrovirals and related medicines• Post-exposure preventative medicine• Preventative medicine for mother-to-child transmission• Post-exposurepreventativemedicineafterrape.

Theprogrammegivesongoingpatientsupportandmonitorsthediseaseandresponsetotherapy.TojoinAfA,calltheminconfidenceon0860100646.YourdoctormayalsocallAfAonyourbehalf.

How to apply for the Chronic Disease Benefit

STEP 1: CollecttheinformationneededtoapplyYouwillneedthefollowinginformationtoapply.Ifyouneedhelpgatheringthisinformation,pleasecontactus.• Membership number• Dependant code• ICD10 code of your chronic condition• Drug name, strength and quantity• Prescribing doctor’s practice number• Diagnostictestresults,e.g.TotalCholesterol,LDL,HDL,glucosetests,thyroid(dependingonyourcondition).

STEP 2: ApplyYou have a choice of how to apply:Applybytelephone: You can call Chronic Medicine Management (CMM) between 08h30 and 17h00, Monday to Thursdayand09h00to17h00onFridays.Phone0860002153.ApplyontheFedhealthFamilyRoom: Go to www.fedhealth.co.za.YoucanapplyforthechronicdiseasebenefitintheFedhealthFamilyRoom.SimplyclickonHealth>RequestChronicPre-authorisation,andcompletetheform.Askyourdoctororpharmacisttoapplyonyourbehalf.TheycandoanonlineapplicationorcontactourProviderCallCentreon0861112666.

STEP 3: WewillgiveyouaresponserightawayWewillreplytoyourapplicationrightaway.Ifweneedmoreinformation,wewillletyou,yourdoctororyourpharmacistknowexactlywhatinformationtogivetous.

If we do not approve the application, we will give you the reasons why, and you will have the opportunity to ask us to reviewourdecision.

STEP 4: YougetyourmedicineaccesscardIfweapproveyourapplication,wewillgiveyouamedicineaccesscard.Yourmedicineaccesscardwillrecordthemedicalconditionforwhichwehaveapprovedtreatment.

We will give you treatment guidelines

The scheme has set up treatment guidelines if you have applied for conditions on List 1 to ensure that you have access to appropriatetreatmentforyourcondition.YouwillreceivedetailsofthetreatmentguidelineswithyourletterfromCMM.

If there is a co-payment on your medicine

Ifyoufindthatthemedicineyourdoctorhasprescribedforyouhasaco-payment,becauseitcostsmorethantheceilingpricegiven in the Medicine Price List, you can ask your pharmacist to help you to change it to a generic medicine that the scheme covers infull.Ifthemedicinehasaco-paymentbecauseitisnotintheformulary,thenyoushoulddiscussapossiblealternativewithyourprescribingdoctor.

We will approve a chronic condition, not individual chronic medications

Thankstoastreamlined,simplifiedapprovalprocessforchronicmedicationcalledDiseaseAuthorisation,youcanapplyforapprovalofachroniccondition,asopposedtoasinglechronicmedication. ThismeansthattheSchemewillapproveanentirelistofmedicationforyourspecificcondition(knownasabasketofmedicine).So,ifyourdoctorshouldeverchangeyourmedication,youwillmostlikelyalreadybeapprovedforit–providedit’sinthebasket.YouwillbeabletoviewtheapprovedmedicationforyourconditionintheFedhealthFamilyRoom.SimplyclickonHealth>Myauthorisations>Selectadependant>Trackauthorisationtype>Submit.Onamorepracticallevelitmeansthatwhenyouneedto change or add a new medicine for your condition, you can do this quickly and easily at your pharmacy with a new prescription, withouthavingtocontactFedhealthatall. If you would like to check what medicine is available to you in your condition’s basket, you can call Chronic Medicine Management (CMM)between08h30and17h00,MondaytoThursdayand09h00to17h00onFridays.Phone0860002153.

Chronic medication delivered to your door

To give you the added convenience of having your chronic medication delivered directly to you (home, work, temporary address ornearestPostOffice),youcanuseourpreferredprovider,PharmacyDirect,forfree-of-chargecourierservices.

PharmacyDirecthasaproventrackrecordoffriendlyprofessionalserviceandontimedeliveries.Formoreinformation,visitwww.pharmacydirect.co.za or get in touch by calling 0860027800,MondaystoFridaysfrom07h30to17h00.Remembertoinclude your Fedhealth membership number on all communication!

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s)Paying for day-to-day expenses (Day-to-Day Benefits)

Theschemegivesanoveralllimitfortheamountofcoveryouandyourfamilyhaveforday-to-daymedicalexpenses.Examples of day-to-day medical expenses are:

• Visits to doctors or specialists• Short-termcoursesofmedicine(forexample,antibioticsfortheflu)• Optometry (glasses)• Visitstothedentist.

Theseday-to-dayexpensesmaybepaidoutoftwodifferentbenefitsundertheoverallDay-to-DayBenefit.Thewaythebenefitsworkwillaffectthelimitsthataregiveninthetableonpage41,somakesureyoureadthiswholesection.

ThebasicsoftheSavingsAccountforday-to-daymedicalexpensesYouroptionhasanominalsavingscontribution.Thisallowsyoutotransfer/retainanyaccumulatedsavingsfromapreviousoptionorschemewhenjoiningthisoption.Youarealsoallowedtotopupthissavingsaccountatanytimeuptoamaximumannualamountof25%ofyourgrosscontribution.Anyclaimsubmitted(notpayablefromtheCoreBenefitBundle)willbefundedfromthissavingsaccountfirst.ThelimitoftheSavingsAccountbelowdependsonthesizeofyourfamily.Pleaserefertotheratestableonpage50.

TheSavingsAccountpaysforday-to-dayexpensesfromthebeginningoftheyearandpaysexpensesuptotheactualcost. Insomecases,ifyouhavemoneyavailableinyourSavingsAccount,youcanusethistopayco-payments.However,a co-paymentforaPrescribedMinimumBenefitconditioncannotbepaidfromyourSavingsAccount.

AnyremainingamountinyourSavingsAccountattheendoftheyearwillbecarriedovertothenextyear.TherearealsoimplicationsifyouleavetheScheme-seepage51.

TheMediVaultandWalletOnce your Savings Account runs out you will either have to pay for all your day-to-day medical expenses out of your own pocketoryoucanaccessyourMediVault.Youarenowallocatedmoneyforday-to-daymedicalexpensesavailableinyourpersonalMediVault.Thisamountisbasedonyourfamilycomposition,andisnotpro-rated,i.e.evenifyouonlyjoininAugust,you’llhavethesameamountavailableasyouwouldhaveinJanuary.Toaccessthesefunds,youcantransferit,infullupfront, orinpartasneeded,toyourWallet.

HowdoyouactivateyourMediVaultandtransferfundsintoyourWallet?For new members it will form part of the application form, should a potential member want to activate their MediVault on their joindate.MemberscancontactthemembercallcentreoraccesstheFedhealthFamilyRoomandcompletetherequiredsteps.An instalment calculator is made available to every user in the Family Room in order to guide the member through the process MediVaultactivationsforprincipalmemberswhoarebelowtheageof18canbefacilitatedbythelegalguardianorparent. MediVaulttransferstoWallet:TransferstothewalletmusttakeplaceinincrementsofR600.YoucantransferyourentireMediVaultbenefitintoyourWalletatonce,oryoucanmakemultipletransferstotheWalletprovidedtherearefundsavailableintheMediVault.TransfersoffundstotheWalletcanonlytakeplaceifyouhaveacceptedtheT’s&C’sandyourmembershipisactive. WhenwillfundsbeavailableinmyWalletandwhenwillFedhealthstartpayingforclaimsoutofmyWallet?Oncefundsaretransferreditisavailableimmediatelyforclaimspayment.Claimswillbepaidfromthebenefitoncetheclaimhasbeencapturedandfinalisedinoursystems.IfarejectedclaimneedstobepaidfromtheWalletyouneedtotransferfundsandimmediatelyrequestareversaloftheclaimtohaveitpaidforbyFedhealth.Claimswillalwaysbepaidfromavailablesavingsfirst,thereafteranyfundsintheWalletwillbeutilised.

Howistheinstalmentpaidback?Thepaymentmustbefacilitatedviaadebitorder.Theinstalmentperiodcanbereducedbypayingadditionalfeesintothestipulatedbankdetails.Pleasenotethiswillnotreduceyourmonthlyrepayment,itwillonlyreducetherepaymentperiod.Employergroupswill have to make decisions on how they will fund the MediVault as it will be based on how they have structured their employee benefits.ItisimportanttonotethattheMediVaultwillnotgainthebenefitbackastheinstalmentsarepaid.TheMediVaultwillonlybeavailableduringthebenefityear1Januaryto31December.Theinstalmentswillbeaseparatedeductionfromthemember’smonthlyriskcontributions.Thereforeyouwillhavetwodebitorders;oneforMediVaultinstalmentsandtheotherforthemembercontributions.Thesamewillapplytopaypoints.IfyoudeferfromyourMediVaultinstalmentonly,theMediVaultbenefitwillbecomesuspended.Ifyoucontinuetodeferonpayments,anITCprocesswillfollow.Ifyouterminateyourmembership,thetotalMediVaultamountutilisedwillbedueupontermination.Seepage50forbankdetails. Whatwillhappenifthereismembershipmovement:Addingofdependants:dependingonthefamilycompositionyoumaybeentitledtoahigherMediVaultvalueandthebenefitwillbeadjustedaccordingly.IfthefamilycompositionremainsunchangedthennoMediVaultadjustmentwilltakeplace.E.g.ifyouhave 5dependantsyoufallundertheM+2+composition.Addinganotherdependantwillkeepyouinthesamefamilycomposition.However if you have 1 dependant and you add another dependant your family composition will change and the MediVault will be increased.Removingofdependants:ifthefamilycompositionchangestheMediVaultwillreduce.Intheeventwhereyouhaveoverutilised the MediVault, you will continue with your instalments as at that point in time however you will not have a MediVault available totransferfundsintotheWallet.IfachilddependantbecomesanadultdependantthereisnochangeintheMediVaultasthebenefitissetatthefamilycomposition.Optionupgradeduringtheyear:ifyouupgradetoaplanwiththeMediVaultavailablethebenefitwilladjustaccordingtothenewplan.IfyouupgradetoaplanthatdoesnothavetheMediVaultavailableasabenefit,youwillcontinuetopayyourinstalmentsovertheremainingperiod.HowevernoMediVaultwillbeavailableevenifyoustillhadfundsleftintheMediVault.

MyMediVault

TheThresholdBenefit is intended to cover medical expenses if you still have day-to-day medical expenses even after your SavingsAccountisusedup.

Youmustpaywhileyouareintheself-paymentgapTheremightbeagapbetweenwhentheSavingsAccountrunsoutandtheThresholdBenefitkicksin.Duringthisgap(referredtoasaself-paymentgap),youwillhavetopayforallday-to-daymedicalexpensesoutofyourownpocket.

ThegapoccursbecausetheThresholdBenefitkicksinonlywhenallyourday-to-dayexpenseshaveaddeduptothethresholdlevelattheFedhealthRate.

Whenyouareintheself-paymentgap,youmuststillcontinuetosubmitallyourclaims.Eventhoughwewon’tbeabletorefundthem,theywillstilladduptowardsyourthresholdlevel.

Examplesofexpensesthatwillincreasetheself-paymentgap

flexiFED 4 flexiFED 4GRID flexiFED 4Elect

M R7500 R6600 R5700

M + 1 R14100 R12600 R10500

M + 2 R16200 R14400 R12300

M + 2+ R19500 R17400 R14700

Family composition | M – Member | M + 1:Memberplusonedependant(eitheradultorchild) | M + 2:Memberplustwodependants(eitheradultorchild) | M + 2+:Memberplustwoormoredependants(eitheradultorchild)

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• Usingalternativehealthcare(e.g.homeopathy)orhavingmedicinesprescribedfromalternativehealthcareproviders• Claiming for services that are charged above the Fedhealth Rate, for example if you go to doctors or specialists that

are not in the Fedhealth network• Claiming for medicines that are more expensive than the ceiling price given in the Medicine Price List• Claiming for more than the yearly limits, for example, for advanced dentistry and optical limits• Claiming for over-the-counter medicines• Using pharmacies that are not in the Fedhealth network• ClaimingforanyAdditionalMedicalServicee.g.speechtherapy• Claimingforappliances,externalaccessoriesandorthoticse.g.hearingaids.

WhentheThresholdBenefitkicksin,existinglimitsapplyOnceyouhavereachedtherequiredthresholdlevel,yourday-to-dayexpenseswillbepaidfromtheThresholdBenefit.Manyofyourday-to-dayexpenseswillbecoveredunlimited,butanyexistinglimitswillstillapply.Forexample,ifafamily spends R11 000 on optometry, a maximum of R10 190 will add up towards their threshold level because the limitforoptometryisR10190perfamily.OncethisfamilyisintheThresholdBenefit,theywillhavenomorecoverforoptometryfromtheThresholdBenefitastheirlimitwillhavebeenreached.

AlsotheThresholdBenefitpaysonlyuptotheFedhealthRateandthereisa20%co-payment on all claims paid from the ThresholdBenefit.Youhavetopayanydifferencefromyourownpocket.

Cover for doctors, specialists and medicines

GPsintheFedhealthnetworkIfyouuseaGP(GeneralPractitioner)intheFedhealthnetwork,yourconsultationispaidoutoftheCoreBenefitBundleandneverfromyourSavings.Thiscoverstheconsultationonly.TofindaGPintheFedhealthnetwork,gotoourwebsiteor the Fedhealth Family Room or call 0860002153.

Even if you’re in the self-payment gap, Fedhealth gives unlimited cover for GP consultations, as long as you use a GP whoisintheFedhealthnetwork.ThismeansthatyoualwayshaveunlimitedcoverforGPs,aslongasyouuseaGPintheFedhealthnetwork.

PleasenotethatamaximumoftwomentalhealthGPconsultationsperbeneficiaryperyearwillbecoveredfromRisk.(Combinedlimitwithout-of-networkGPs).

Members on flexiFED 4GRID and flexiFED 4ElectarerequiredtonominateuptotwoGPsintheFedhealthGPnetwork.

GPsnotintheFedhealthnetworkIf you do not use a GP in the Fedhealth network, the consultation will be paid from Savings and Wallet and will add up to thethresholdlevelat100%oftheFedhealthRate.WhenintheThresholdBenefit,theseconsultationsarepaidat100%oftheFedhealthRate.PleasenotethatamaximumoftwomentalhealthGPconsultationsperbeneficiaryperyearwillbecoveredfromSavingsandThreshold.(CombinedlimitwithnetworkGPs).

SpecialistsintheFedhealthnetworkSpecialistsintheFedhealthnetworkhaveagreedtoasetrateforconsultations.IfyouhaveSavingsandWalletavailable,theconsultationwillbepaidoutofthisbenefitatthisrate.Itwillalsoadduptowardsthethresholdlevelatthisrate. If you are in the self-payment gap, you will have to pay for the consultation from your own pocket but also only at the set rate.WhenyoureachthethresholdlevelandtheThresholdBenefitkicksin,wecovervisitstospecialistsintheFedhealthnetworkinfull.Beforeyouconsultaspecialist,pleaseseeyourGPtoobtainareferral.Ifreferralisnotobtainedtherewillbea20%co-paymentonspecialistclaimspaidfromtheRiskbenefit.

SpecialistsnotintheFedhealthnetwork

If you do not use a specialist in the Fedhealth network, the consultation will be paid from your Savings Account and Wallet up tocost.

TheexpensewilladduptothethresholdlevelattheFedhealthRate.WhenintheThresholdBenefit,theconsultationsarealsopaidattheFedhealthRate.Beforeyouconsultaspecialist,pleaseseeyourGPtoobtainareferral.Ifreferralisnotobtainedtherewillbea20%co-paymentonspecialistclaimspaidfromtheRiskbenefit.

PrescribedmedicineThereisalimitforprescribedmedicine.Forexample,theindividuallimitisR5680.IfyouhavealreadyspentR3000accordingtotheceiling prices given in the Medicine Price List when you reach the threshold level, then you will only have R2 680 available to spend fromtheThresholdBenefitforprescribedmedicine.WhenyouareintheThresholdBenefit,yougetcoverforprescribedmedicineonlyattheceilingpriceoftheMedicinePriceList.Youareresponsibleforpayingthedifference.

DispensingfeesforprescribedmedicinePharmacieschargeadispensingfeeforeachprescribedmedicinethattheysell.TheschemehasagreedspecialratesfordispensingfeeswithpharmaciesintheFedhealthnetwork.IfyouuseapharmacyintheFedhealthnetwork,wewillcovertheagreeddispensingfeeinfullfromyoursavings.

TofindapharmacyintheFedhealthnetwork,gotothewebsiteorcall0860002153.

If you buy from a pharmacy not in the Fedhealth network, then you might have to pay the difference between the agreed dispensingfeeandthedispensingfeethatthepharmacycharges.

Over-the-countermedicineMedicineswithascheduleof0,1or2canbeboughtfromthepharmacywithoutaprescriptionfromyourdoctor.ThecostwillbepaidoutofyourSavingsAccountandWalletandtheamountwillnotadduptowardsyourthresholdlevel.

TheThresholdBenefitdoesnotcoverover-the-countermedicine.

FemalecontraceptionInmostcases,femalecontraceptioniscoveredbytheCoreBenefitBundle–seepage18.However,contraceptivepillsare paidfromyourSavingsAccountiftheyareprescribedforreasonsotherthancontraception(forexample,forskinproblems).ExamplesofcontraceptivepillsthatwedonotcoverundertheCoreBenefitBundleincludeCyprene-35ED,Diane–35,Tricilest,GinetteandMinerva.

TheconsultationandthecostofproceduresforIUDsarepaidfromyourSavingsAccount.OnlythecostoftheIUDitselfispaidfromtheCoreBenefitBundle.WecoverthecostofanIUDeverysecondyear.IfyourSavingsAccounthasrunoutyoucantransferfundsfromyourMediVaulttoyourWalletandthesefundscanbeusedtocoverthesecosts.IfyoudonottransferfundsfromyourMediVaulttoyourWalletyouwillhavetocoverthesecostsfromyourownpocket.

PregnancyPregnancycostsarecoveredfromtheSavingsAccountandWallet.YoushouldselectagynaecologistintheFedhealthnetwork.Consultationswillbecoveredinfullatthesetrateandwilladduptothethresholdlevelinfull.Ifthespecialistisnotinthenetwork,thenonlytheFedhealthRatewilladduptothethresholdlevel.UsingagynaecologistintheFedhealthnetworkwillensurethat in-hospitalclaimsarecoveredinfullandyouwillnothavetopayanyco-payments.

Atotaloftwo2Dultrasoundscansperpregnancywilladduptothethresholdlevel.

Specialisedradiology(forexample,MRIorCTscans)We cover specialised radiology (for example MRI or CT scans) up to 100% of the Fedhealth Rate, whether you have it in or out ofhospital.YoumustpaythefirstR2200fornon-PMBscans.Youmustgetseparateauthorisationforaspecialisedradiologicalprocedure,whetherittakesplacein-orout-of-hospital.

37 38

Payi

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r da

y-to

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exp

ense

s (d

ay-t

o-da

y be

ne�t

s)GPnon-network:

AN EXAMPLEWhatthememberdoes Howtheexpenseisfunded

Davidhasfluandwantstoseehisdoctor,DrMary.Hegoes onto www.fedhealth.co.zatoconfirmifDrMaryisontheFedhealthnetwork. Hefindsoutthatsheisnot.

He has a consultation with the doctor and she prescribes a course of antibiotics for him.

David then goes to the pharmacy to buy the medicine that was prescribed forhim.Hemakessurethathe asks for a generic version of the antibiotics and he makes sure that he goes to a pharmacy in the Fedhealth network.

TheconsultationBecause Dr Mary is not in the Fedhealth network, this is how the consultation will be funded:

IfDavidhasfundsavailableinhisSavingsAccount,theconsultationiscoveredinfull.However,onlytheFedhealthRateaddsuptothethresholdlevel.

If David does not have enough money in his Savings Account, he can transfer funds fromhisMediVaulttohisWalletandthesefundscanbeusedtocoverthesecosts.IfDaviddoes not transfer funds from his MediVault to his Wallet he will have to cover these costs fromhisownpocket.

TheprescribedmedicineDavid had not reached the limit for prescribed medicine and had asked for a generic ofthemedicinewhichfellwithintheceilingpriceontheMedicinePriceList.So:

If he has money in the Savings Account, it will pay the expense and the full amount addsuptothethresholdlevel.

If David does not have enough money in his Savings Account, he can transfer funds fromhisMediVaulttohisWalletandthesefundscanbeusedtocoverthesecosts.IfDaviddoes not transfer funds from his MediVault to his Wallet he will have to cover these costs fromhisownpocket.

(If David had chosen a medicine that cost more than the ceiling price on the Medicine PriceList,thedifferencewouldnotadduptothethresholdlevel).

Goingtoseeaspecialist:

AN EXAMPLEWhatthememberdoes Howtheexpenseisfunded

John’sfamilydoctorhasreferred him to a specialist because of an ongoing sore throat.Hehasaconsultationwiththespecialist.

IfthespecialistisintheFedhealthnetworkThis is how the consultation will be funded:

IfJohnhasmoneyavailableinhisSavingsAccount,theconsultationiscoveredinfullatthesetrateandaddsuptothethresholdlevelinfull.

IfJohndoesnothaveenoughmoneyinhisSavingsAccount,hecantransferfundsfromhisMediVaulttohisWalletandthesefundscanbeusedtocoverthesecosts.IfJohndoes not transfer funds from his MediVault to his Wallet he will have to cover these costs fromhisownpocket.

IfthespecialistisnotintheFedhealthnetworkThis is how the consultation will be funded:

IfJohnhasmoneyavailableinhisSavingsAccount,theconsultationiscoveredinfull.However,onlytheFedhealthRateaddsuptothethresholdlevel.IfJohndoesnothave enough money in his Savings Account, he can transfer funds from his MediVault tohisWalletandthesefundscanbeusedtocoverthesecosts.IfJohndoesnottransferfunds from his MediVault to his Wallet he will have to cover these costs from his own pocket.

Over-the-countermedicine:

AN EXAMPLEWhatthememberdoes Howtheexpenseisfunded

Andy feels unwell and decides to follow his pharmacist’s recommendationtotakeanover-the-counterflumedicine.

HechoosesapharmacywithintheFedhealthnetwork.

Whethertheexpenseiscovereddependsonhisbenefits:

If Andy has enough money in his Savings Account to cover the medicine, he will not have to pay anything from hisownpocket.

If Andy does not have enough money in his Savings Account, he can transfer funds from his MediVault to his Walletandthesefundscanbeusedtocoverthesecosts.If Andy does not transfer funds from his MediVault to his Wallethewillhavetocoverthesecostsfromhisownpocket.

The cost of over-the-counter medicine does not add up to thethresholdlevel.

Visitingadoctor(GeneralPractitioner):

AN EXAMPLEWhatthememberdoes Howtheexpenseisfunded

Maryhasfluandwantstoseeherdoctor,DrChris.Shegoes onto www.fedhealth.co.zatoconfirmifDrChrisisontheFedhealthnetwork.Shefindsoutthatheis.

She has a consultation with the doctor and he prescribes acourseofantibioticsforher.

Mary then goes to the pharmacy to buy the medicine that wasprescribedforher.Shemakessurethatsheasksforageneric version of the antibiotics and she makes sure that shegoestoapharmacyintheFedhealthnetwork.

TheconsultationBecause Dr Chris is in the Fedhealth network, Fedhealth hasagreedasetratefortheconsultation.Thisishowtheconsultation will be funded:

Theconsultationispaidoutofriskbenefits(CoreBenefitBundle).

TheprescribedmedicineMary had not reached the limit for prescribed medicine and had asked for a generic of the medicine which fell withintheceilingpriceontheMedicinePriceList.So:

If she has money in the Savings Account, it will pay the expense and the full amount adds up to the threshold level.IfMarydoesnothaveenoughmoneyinherSavingsAccount, she can transfer funds from her MediVault to her Walletandthesefundscanbeusedtocoverthesecosts.If Mary does not transfer funds from her MediVault to her Wallet she will have to cover these costs from her own pocket.

(If Mary had chosen a medicine that cost more than the ceiling price on the Medicine Price List, the difference wouldnotadduptothethresholdlevel).

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Payi

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exp

ense

s (d

ay-t

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s)Day-to-daymedicalexpense Limits Howthe

SavingsAccountandWalletcoverstheexpense

Howtheexpenseaddsuptowardsthethresholdlevel

HowtheThresholdBenefitcoverstheexpense

Biokinetics,chiropractics The Additional Medical Services limit of R11 600 per family per year applies (combined limit)

At cost Does not add up to threshold level

Covered at Fedhealth Rateup to the limit

Dentistry(Advanced):Inlays, crowns, bridges, mounted study models, metal base partial dentures, osseo-integrated implants, orthognathic surgery, oral surgery, orthodontic treatment, periodontists, prosthodontists and dental technicians

Limit of R7 400 per person per year, up to an overall limit of R22 100 per family per year

At cost Adds up at Fedhealth Rate to the maximum of the limit

Covered at Fedhealth Rate up to the limit

Dentistry(Basic) No limit At cost Adds up at Fedhealth Rate

Covered at Fedhealth Rate

Femalecontraception SeeFemalecontraceptionpaidoutofCoreBenefitBundle(page18)andFemalecontraceptionpaidoutofDay-to-DayBenefits(page38).

GeneralPractitioners:*PleasenoteonlytwomentalhealthconsultationsperbeneficiarywillbepaidfromtheCoreBenefitBundle

FedhealthNetworkGPs No limit – you are always covered even in the self-payment gap

Never paid from savings

Does not add up to threshold level

Covered from CoreBenefitBundle

Non-FedhealthNetworkGPs No limit At cost Adds up at Fedhealth Rate

Covered at Fedhealth Rate

All cover in day-to-day benefits

Inthetablebelow,certainexpensesaresubjecttolimits.TheselimitsapplytotheaccumulationofclaimstothethresholdlevelaswellastherefundofclaimsfromtheThresholdBenefit.Forexample,ifafamilyspendsR11000onoptometry, amaximumofR10190willadduptowardstheirthresholdlevelbecausethelimitforoptometryisR10190perfamily.OncethisfamilyisintheThresholdBenefit,theywillhavenomorecoverforoptometryfromtheThresholdBenefitastheirlimitwillhavebeenreached.AlsotheThresholdBenefitpaysonlyuptotheFedhealthRateandthereisa20% co-paymentonallclaimspaidfromtheRiskBenefitexceptconsultationswithnetworkGPs.Networkspecialistconsultationswillalsoattractaco-paymentifnoGPreferralisobtained.Youhavetopayanydifferencefromyourownpocket.

Day-to-daymedicalexpense Limits HowtheSavingsAccountandWalletcoverstheexpense

Howtheexpenseaddsuptowardsthethresholdlevel

HowtheThresholdBenefitcoverstheexpense

Additionalmedicalservices:Audiology,dietetics,genetic counselling, hearing aid acoustics, occupational therapy, orthoptics, podiatry, private nursing*, psychologists, speech therapy, social workers

Limit of R11 600 per family per year for the total of all additional medical services in and out-of-hospital

At cost Does not add up to threshold level

Covered at Fedhealth Rate up to the limit

Alternativehealthcare:Acupuncture, homeopathy, naturopathy, osteopathy and phytotherapy (including medicines prescribed by alternative healthcare professionals)

No limit At cost Does not add up to threshold level

Not covered

Antenatalscans Two 2D antenatal scans per person per year

At cost Adds up at Fedhealth Rate to the maximum of the limit

Covered at Fedhealth Rate up to the limit

Appliances,externalaccessoriesandorthotics: Hearingaids,wheelchairsetc.

Limit of R11 600 perfamilyperyear.Sub-limit of R4 340 per person for foot orthotics in and out-of-hospital

At cost Does not add up to threshold level

Covered at Fedhealth Rate up to the limit

*PrivatenursingthatfallsoutsidetheAlternativestoHospitalisationBenefit

41 42

Payi

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s (d

ay-t

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s)Day-to-daymedicalexpense Limits Howthe

SavingsAccountandWalletcoverstheexpense

Howtheexpenseaddsuptowardsthethresholdlevel

HowtheThresholdBenefitcoverstheexpense

SpecialistsexcludingPsychiatrists

FedhealthNetwork SpecialistsNetwork GP referral required for consultations (including PMB conditions) to be paid from Risk benefit

No limit Up to set rate

Adds up at set rate

Covered at set rate (Fedhealth network specialists will only charge the setrate).20%co-payment if GP referral not obtained

Non-FedhealthNetworkSpecialistsNetwork GP referral required for consultations (including PMB conditions) to be paid from Risk benefit

No limit At cost Adds up at Fedhealth Rate

Covered at Fedhealth Rate.20%co-payment if GP referral not obtained

Specialists:Psychiatrists

FedhealthNetwork PsychiatristsNetwork GP referral required for consultations (including PMB conditions) to be paid from Risk benefit

The Additional Medical Services limit of R11 600 per family per year applies (combined limit)

Up to set rate

Does not add up to threshold level

Covered at set rate up to the limit (Fedhealth network specialists will only charge the setrate).20%co-payment if GP referral not obtained

Non-FedhealthNetworkPsychiatristsNetwork GP referral required for consultations (including PMB conditions) to be paid from Risk benefit

The Additional Medical Services limit of R11 600 per family per year applies(combined limit)

At cost Does not add up to threshold level

Covered at Fedhealth Rate up to thelimit.20%co-payment if GP referral not obtained

Day-to-daymedicalexpense Limits HowtheSavingsAccountandWalletcoverstheexpense

Howtheexpenseaddsuptowardsthethresholdlevel

HowtheThresholdBenefitcoverstheexpense

Optometry:Frames, single vision, bifocal, multifocal or special lenses, lens add-ons, contact lenses, Readers and optometric examinations

Limit of R3 340 per person per year, up to an overall limit of R10 190 per family per year

At cost Adds up at Fedhealth Rate to the maximum of the limit

Covered at Fedhealth Rate up to the limit

Over-the-countermedication No limit At cost Does not add up to threshold level

Not covered

Pathology No limit At cost Adds up at Fedhealth Rate

Covered at Fedhealth Rate

Physiotherapy The Additional Medical Services limit of R11 600 per family per year applies (combined limit)

At cost Does not add up to threshold level

Covered at Fedhealth Rateup to the limit

Prescribedmedication Limit of R5 680 per person per year, up to an overall limit of R11 400 per family per year

At cost Adds up at the MPL to the maximum of the limit

Covered up to MPL up to the limit

Radiology(General) No limit At cost Adds up at Fedhealth Rate

Covered at Fedhealth Rate

Radiology(Specialised) PaidfromtheCoreBenefitBundleifpre-authorisedupto100%oftheFedhealthRate,whetheryouhaveitin-orout-of-hospital.YoumustpaythefirstR2200fornon-PMB scans

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How to claimIfthehealthcareprofessionalorthehospitalclaimsonyourbehalfYourhealthcareprofessionalusuallysendsyourclaimtousonyourbehalf.Inthiscase,youdonotneedtoclaimaswell.If your healthcare professional tells you that they have not been paid, you can check your claims status on the Fedhealth Family Room or contact us on 0860002153.

IfyouneedarefundbecauseyoupaidthemedicalexpenseIf your healthcare professional does not claim on your behalf, or if you have already paid, you must send us the:• Proof of payment• Theclaim(theaccount).Makesuretheaccountshows: - Your membership number - TheICD10andprocedurecodes -Thepracticenumber.

Ifweapprovetheclaimaccordingtotheschemerules,Fedhealthwillrefundyoudirectlyintoyourbankaccount. Youmustmakesurethatwehaveyourcorrectbankdetails.Toupdateyourbankdetails,calluson0860002153oremailmember@fedhealth.co.za

YoumustclaimwithinfourmonthsofthedateofthetreatmentTheschemewillonlyconsiderclaimsthatwereceivewithinfourmonthsofthetreatmentdate.Weprocessclaimsthatwereceiveafterfourmonthsonlytoshowontaxcertificates.Wewillnotpayanyclaimsthatwereceiveafterfourmonths.

Send your claims to:

YoucansubmitclaimsontheFedhealthFamilyRoom. GotoQuickactions>Submitaclaim.

Youcanemail,faxorposttheclaimstous.Email: claims@fedhealth.co.zaFax number: 0116713842

Postaladdress:Private Bag X3045Randburg2125

If you have been in a car accident

Ifyouwereinjuredinacaraccident,youmayhavetogothroughcertainprocedureswiththeRoadAccidentFundbeforetheschemewillpayanyclaims.

PleasecontacttheMVA/ThirdPartyRecoveryDepartmentatFedhealthformoreinformation:

Telephonenumber: 0800 117 222

How

to c

laim

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About your scheme and membershipPrincipalmembersandregistereddependantsarecoveredbythescheme.

MembersTheprincipalmembercanaddorremovedependants.Inthissection,weuse‘you’fortheprincipalmember.

DependantsWhocanberegisteredasadependantYou can register the following people as dependants:• Your spouse or partner• Your children• Otherfamilymembersif,accordingtotheschemerules,theyrelyonyouforfinancialcareandsupportandhavebeen approvedbytheScheme.Before you add a dependant, if a company pays your medical aid contribution, you should check how much of the contributionyourcompanywillpay.

CriteriaforchildrenFedhealthwillchargethechildrateforyourchilddependantsuntiltheyturn27.However,thechildneedstobeeither:• A full-time student, who is living at home or in a residential situation at a tertiary education institution; or • Livingathome,unmarried,andnotreceivingaregularincomegreaterthanthemaximumsocialpension.

AddinganewbornbabyYoumustregisterbabieswithin30daysaftertheyareborn.Thirdgenerationbabies(youradultchilddependant’sbaby)willnotbecoveredfromdateofbirthandwillbesubjecttonormalunderwriting.Ifacompanypaysyourmedicalaidcontribution,youmusttellthesalarydepartmentthatyouaregoingtoaddanewbornasadependant.Fedhealthdoesnotchargeforthebabyforthemonthinwhichthebabyisborn.

YoumustgiveusthesedocumentsforregisteringdependantsToregisteradependant,youmustfillinaMemberRecordAmendmentForm.Forthefollowingtypesofdependants, we need this information:

Typeofdependant Extradocumentwemayneed

Anewbornbaby Acopyofthebaby’sbirthcertificateornotificationofbirthfromthehospitalThe baby’s ID number when they are registered

Abiologicaloradoptedchildovertheageof21years

Proof of registration from a full time tertiary institution for the current year if a full timestudent,oranaffidavitforthedependantconfirmingresidency,employment,income and marital status

Anadoptedchild Proof of legal adoption

Afosterchild Legal proof that the child is a foster child

Abrotherorsister,grandchild,nepheworniece,thirdgenerationbaby

Anaffidavitconfirmingresidency,employment,incomeandmaritalstatusofchildand both parents

Aparentorgrandparentoftheprincipalmember

Anaffidavitconfirmingresidency,employment,incomeandmaritalstatus

Aspouseorpartner Marriagecertificate,ifavailable

Membership cards

Wewillsendtwomembershipcardsforfamilieswithoneormoredependants.Pleasecontactusifyouwantmoremembershipcardsforyourdependants.

Membershipe-cardAs part of Fedhealth’s drive to support a paperless environment, we’ve introduced membership e-cards which you can use insteadofaphysicalcard.Youre-cardisavailableintheFedhealthFamilyRoomonlinememberportal,oryoucanaccessitfromtheFedChatapp.SimplyshareitwithyourhealthcareserviceproviderviaemailorSMS.

Removing a dependant from your membership

Toremoveadependant,youmustfillinaMemberRecordAmendmentForm.Ifacompanypaysyourmedicalaid,your HRDepartmentmuststamptheformandsendittothescheme.

How we communicate with you

WeemailandSMSyourclaimstatusFedhealthwillemailandSMSaclaimstatustoyou.Thisshowstheclaimsthatwehavereceivedandprocessed.

MakesurewehaveyourcorrectemailaddressandcellnumberPlease ensure that Fedhealth has your correct cell phone number and email address by calling the FedhealthCustomerContactCentreon0860002153.

YoucanfindyourclaimandbenefitinformationonourwebsiteFedhealthwebsiteVisit the Fedhealth website at fedhealth.co.za to access our interesting LivingFedhealthyblog brimming with must-reads, as well as allourproductbrochures,optionselectionformsandrelateddocuments.

FedhealthFamilyRoomTheFamilyRoom (accessedviafedhealth.co.za) allows you to: obtain hospital pre-authorisation; apply for chronic medication; submitclaims;locatenetworkpharmacies,GPsandSpecialistsusingthelocatortool;updatepersonalinformation;conductbenefitenquiries;trackclaimsubmissionsandclaimsduetoyou;joincommunitiesbasedonyourinterests;earnrewards;andreadallthelatestSchemenews.

MicrositeOurmicrositeisacooltoolforpotentialandexistingmemberstohelpthemfindtheperfectflexiFED option based on their needs andfamilycomposition.Itcanalsobeaccessedthroughfedhealth.co.za

The site also features LiveChat - this is an innovative feature that allows you to raise any important medical aid questions you may haveonthesiteduringofficehours.Skilledconsultantsattendtoyourqueriesinapersonal,one-on-onecapacity,withouttheneedforphonecalls.Youarealsoabletoobtainhospitalandchronicdiseaseauthorisations on the site using LiveChat.

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YoucanmessageFedhealthfreeofchargewiththeFedChatMobileAppFedChatisavailableasafreedownloadtoApple,Windows,BlackberryandAndroidusers.ThisdedicatedInstantMessenger channel offers you the convenience of being able to communicate with Fedhealth service consultants during officehours,withoutthecostofaphonecallorSMS,asFedChat uses the same data you use for email and Internet browsing.

TheFedhealthFamilyRoom–thehubofyourrelationshipwithFedhealthThe FedhealthFamilyRoom is our online member portal that allows you to manage aspects of your Fedhealth membershiplikesubmittingclaimsandobtainingpre-authorisations.Theportalalsoenablesyoutojoinahostofcommunitiesbasedonyourinterests,earnrewards,andstayuptodateonthelatestSchemenews.Accessitviafedhealth.co.zaandregistertoenjoyallthegreatfeatures.

flexiFED Contributions

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p

Member Adult Child*

Risk Savings TOTAL Risk Savings TOTAL Risk Savings TOTAL

Anyhospital 3 006 25 3 031 2 662 22 2 684 919 8 927

GRID 2 676 22 2 698 2 369 20 2 389 818 7 825

Elect 2 255 19 2 274 2 035 17 2 052 703 6 709

flexiFED 4

*Uptoamaximumofthreechildren.

Option changes

YoucanupgradetoahigheroptionYoucanupgradetoahigheroptionwithmorecomprehensivebenefitsanytimeoftheyear,butonlyondiagnosisofadreaddiseaseorinthecaseofalife-changingevent,forexamplepregnancy.

Theoptionupgradewillonlybeallowedwithin30daysofdiagnosis.Ingeneral,optionchangesareonlyallowedwitheffectfrom1Januaryeveryyear.

Paying for your medical aid

YoumustpaybythethirdofeachmonthYoupayyourcontributionstoFedhealtheachmonthforthepreviousmonth’scover(youpayinarrears).Youmustpaybythethirddayofeachmonth.Ifwedonotreceivepaymentbythethirddayofthemonth,wewillsuspendyourcover.

Ourbankdetails

For Risk Contribution For MediVault Instalment

Accountname Fedhealth Medical Scheme Fedhealth Medical Scheme PMSA

Bank Nedbank Nedbank

Branchcode 19-84-05 19-87-65

Accountnumber 1984 563 009 1029 279 489

Pleaseuseyourmembershipnumberasreference.WhenmakingapaymentforMediVaultinstalmentspleaseuseMediVaultandyourmembershipnumber.

Leaving the scheme

ThreemonthsofnoticetoleaveIfyouwanttoleaveFedhealth,youmustgiveusthreemonths’noticeinwriting.

LastcontributionBecause you pay at the start of the month for the previous month’s cover, your last contribution will be deducted in the monthafteryourlastdayofmembership.Wewilldeductyourlastcontributionbythethirddayofthemonthafteryourlastdayofmembership.

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Extra servicesThesearetheextraservicesyougetfromFedhealth.Theydonotaffectanyoftheschemebenefits.

24-hourNurseLineon0860333432The 24-hour Fedhealth Nurse Line is available for:

• Assessing day-to-day symptoms• Emergency medical advice, including for poisoning• Health education (for example, you can call if you need an explanation of medical terms, procedures and test results)• Drug database (complete information on medicines, including when you should not take medicines, etc)• Stress management• Teenagesupport.

MediTaxiMembersonanyoptionwho’vehadhospitalauthorisationscanaccessthe24/7MediTaximedicaltaxibenefittotakethem to follow-up doctor’s appointments, if they’ve undergone an authorised operation or medical treatment that preventsthemfromdriving.MediTaxiprovidestransportfromthemember’shometotheapprovedhealthcareserviceprovidersuchasphysiotherapists,doctors,specialistsoraradiologypractice,andincludesthereturntrip.

• Tripsarelimitedtotworeturntripspermember/beneficiaryperannum.• Thepick-upordrop-offpointmustbeinJohannesburg,Pretoria,CapeTownandDurban,andthetotaltripshould notexceed50km.• TheserviceisavailabletovalidatedFedhealthmembers.EuropAssistanceSAwillnotrequestanymedicalinformation tosupportvalidationforthebenefit.

AmountinSavingsAccount–ifyouspentlessthanyoupaidinWepaythebalanceinyourSavingsAccounttoyournewmedicalscheme’ssavingsaccountfivemonthsafteryouhaveleftFedhealth.Thisensuresthatwecanpayoutanyoutstandingclaims.YoumustprovideuswiththenameofyournewschemeaswellasyourmembershipnumbersowecantransferyourSavingsAccountbalance.Ifyournewschemedoesnothaveasavingscomponent,thenwewillpaythebalancetoyou.Pleasemakesurewehaveyourup-to-datebankingdetailstomakethisrefund.

AmountinSavingsAccount–ifyouspentmorethanyoupaidinIf you leave the scheme and have spent more than the monthly contributions you have paid into the Savings Account, youwillhavetorefundtheschemewiththedifference.Youmustmaketherefundwithin10daysafterthelastdayofmembership.

MediVaulttransfersAnyoutstandinginstalmemtsbecomedueimmediately.TheSchemecanoffsetanydebtfromremainingsavingsbalances before refunds are processed

Whistle-blowing on fraud

Weaskyoutohelpustocombatfraud.Ifyouknowofanythingthatmightinvolveahealthcareprofessionalor amemberusingthemedicalschemeinappropriately,pleasecontactus.Youdonothavetodiscloseyourname.FraudHotline:0800112811

BookingtheMediTaxiserviceWhen Fedhealth members phone to book a trip, they need to provide their a) membership number, b) date of operation, and c) healthcareprovider’sdetails.• Members need to save the number *130*3272*31# for Emergency Medical Service (EMS), Nurse Line and MediTaxi as a contact on their phones (under Europ Assistance or a name they’ll remember for emergencies);•WhentheyneedtobookMediTaxi,membersneedtochoosethisnumberandselecttheservice(EMS,NurseLineorMediTaxi). An SMS will be sent to the Europ Assistance Emergency Contact Centre who’ll phone them back within the agreed emergency timelinesforeachservice:EMS–120seconds;NurseLine–2hours;andMediTaxi–2hoursbeforepick-up.

SOSCallMeIntimesofemergency,it’sonlyhumantopanic,whichcouldmakeitdifficultforFedhealthmemberstogetintouchwiththeEuropAssistanceContactCentrewhenit’scritical.Alackofairtimecouldalsopreventmembersfromgettingintouchwithus.

To resolve this, Europ Assistance has implemented the SOS Call Me service – a user-friendly call-back service that means we will call membersbackwhentheyneedusatnocosttothem.AllFedhealthmembersandtheirdependantscanusethisfreeservice.

Memberscanselectthreeoptionsontheservice:1.EmergencyMedicalServices(EMS)2.NurseLine3.MediTaxi

HowtousetheSOSCallMeservice:• Members should save the number *130*3272*31# for EMS, Nurse Line and MediTaxi as a contact on their phone (under Europ Assistance or a name they will remember for emergencies);• Inanemergency,membersmustchoosethisnumberandselecttheservice(EMS,NurseLineorMediTaxi).AnSMSwillbesentto the Europ Assistance Emergency Contact Centre who’ll phone the member back within the agreed emergency timelines for each service:EMS–120seconds;NurseLine–2hours;andMediTaxi–2hoursbeforepick-up.

TheFedhealthBabyProgrammeFedhealth offers a FREE top-notch baby programme designed to offer the best advice, support and personalised care during every stageofpregnancyandbeyond.

Moms on the programme can look forward to doula support during pregnancy and labour, a Fedhealth Baby bag packed with items like organic goodies and a baby book, various discounts and vouchers, ongoing support and communication, and a baby medical adviceline.

Pregnant members and dependants can call 0861 116 016 or email info@babyhealth.co.zaformoreinformationandtoregister.

Paed-IQThere has been a growing need from parents and caregivers for reliable, appropriate and up to-date information and advice regardingeverydaychildhoodhealthproblems.Assuch,FedhealthisintroducingthePaed-IQservicetoparentsandcaregivers in2019.

Paed-IQ aims to:• Provideyoungfamilieswithchildrenuptotheageof14yearswith24-houraccesstopaediatricsupportandadvice. This enhances the level of care parents can provide to their children by means of a paediatric telephone triage service, fromadatabaseofinformationoncommonhealthconditionsinchildren.• Reduce emergency paediatric expenditure and unnecessary clinical interactions for members by offering clinical childcare assessment,triageandtelephonicguidance.

Paed-IQ also hosts a live Facebook chat where parents and caregivers can talk to a Paed-IQ paediatrician to answer any questions.ThisisavailableonWednesdaysbetween12:00pmand14:00pm,andonFridaysfrom10:00amto12:00pmby calling 0860 444 128.

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lsMedscheme Client Service CentresForpersonalassistance,visitoneofthefollowingMedschemeClientServiceCentres.

ThesebranchesareopenMondaytoFriday08h30–16h00

Bloemfontein – Medical Suites 4 and 5, First Floor, Middestad Mall, Corner West Burger and Charles StreetsCapeTown–IconBuilding,GroundFloor,CnrLowerLongStreet&HansStrijdomAvenue,CapeTownDurban – Ground Floor, 102 Stephen Dlamini Road, Musgrave, DurbanPortElizabeth–1stFloor,Block6,GreenacresOfficePark,2ndAvenue,NewtonParkPretoria–NedbankPlaza,GroundFloor,Shop17,631SteveBikoStreet,ArcadiaRoodepoort – Shop 21 & 22, Flora Centre, Cnr Ontdekkers and Conrad Roads, Florida North, RoodepoortVereeniging – Ground Floor, 36 Merriman Avenue

Contact usFedhealthCustomerContactCentreMonday to Thursday 08h30 – 17h00Friday 09h00 – 17h00Tel: 0860 002 153email:member@fedhealth.co.zaWeb:www.fedhealth.co.zaPostal address: Private Bag X3045, Randburg 2125

HospitalAuthorisationCentreMonday to Thursday 08h30 – 17h00 Friday 09h00 – 17h00Tel: 0860 002 153 email:authorisations@fedhealth.co.zaWeb:www.fedhealth.co.za

AmbulanceServicesEurop AssistanceTel: 0860 333 432

AidforAIDSMonday to Friday 08h00 – 17h00Tel: 0860 100 646Fax: 0800 600 773email:afa@afadm.co.zaWeb:www.aidforaids.co.zaSMS (call me): 083 410 9078

ChronicMedicineManagementMonday to Thursday 08h30 – 17h00Friday 09h00 – 17h00Tel: 0860 002 153email:cmm@fedhealth.co.zaPostal address: P O Box 38632 Pinelands 7430

DiseaseManagementMonday to Friday 08h00 – 16h30Tel: 0860 002 153email:dm@fedhealth.co.za

EmotionalWellbeingProgrammeTel: 087 365 8664

FedhealthBabyMonday to Friday 08h00 – 17h00Tel: 0861 116 016email:info@babyhealth.co.zaWeb:www.babyhealth.co.za

FedhealthPaed-IQTel: 0860 444 128

FraudHotlineTel: 0800 112 811

MVAThirdPartyRecoveryDepartmentMonday to Friday 08h00 – 16h00Tel: 0800 117 222

MediTaxiDial *130*3272*31#

OncologyDiseaseManagementMonday to Friday 08h00 – 16h00Tel: 0860 100 572Fax: 021 466 2303email:cancerinfo@fedhealth.co.zaPostal address: P O Box 38632, Pinelands, 7430

SOSCallMeDial *130*3272*31#

Preferred Provider Pharmacies ClicksTel: 0860 254 257Tolocateastoregoto:www.clicks.co.zaandselect Store Locator

Dis-ChemCare-Line: 0860 347 243Tolocateastoregoto:www.dischem.co.zaand select Store Locator

MediRitePharmacyTel: 0800 222 617Tolocateastoregoto:www.medirite.co.zaand select Store Locator

PharmacyDirectMonday to Friday 07h30 – 17h00Tel: 0860 027 800Fax:0866114000/1/2/3/4email:care@pharmacydirect.co.zaWeb:www.pharmacydirect.co.zaSMS (call me): 083 690 8934

February 2019

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We let you be YOUFedhealth Customer Contact Centre 0860 002 153Corner Ontdekkers Road and Conrad Street, Absa Building Block F, Florida, 1716 • Private Bag X3045, Randburg 2125

www.fedhealth.co.za

Pleasenote:AllFedhealthbenefitsaresubjecttoregisteredSchemeRules,andassuch,thisdocumentonlyaimstoprovideasummaryofsuchbenefits.ForthefullSchemeRules,pleasevisitfedhealth.co.zaorcontacttheFedhealthCustomerContactCentreon0860002153toobtainacopy.