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FEDHEALTH maxima EXEC GRID 2019

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Medical Aid Year: 
2019
In Hospital Benefits
Hospital Rate of Payment: 
100% of Scheme Rate
Hospitals: 

No overall annual limit

Specialists: 
Unlimited cover at cost
Dialysis: 
Unlimited at Designated Service Provider. 40% co-payment on use of non-DSP.
Organ Transplants: 
Unlimited
Oncology / Cancer: 
Unlimited
Prosthesis: 

Internal Various sub-limits apply
Aorta Stent Grafts R58 500
Bone lengthening devices See combined benefit limit for all unlisted internal prosthesis*
Cardiac pacemakers R58 500
Cardiac stents R50 100
Cardiac valves R44 500
Carotid Stents See combined benefit limit for all unlisted internal prosthesis*
Detachable platinum coils R50 700
Elbow replacement R44 500
Embolic Protection Devices See combined benefit limit for all unlisted internal prosthesis*
Hip replacement R44 500
Intraocular lenses (per lens) R3 200
Knee replacement R44 500
Other approved spinal implantable devices See combined benefit limit for all unlisted internal prosthesis*
Peripheral Arterial Stent Grafts See combined benefit limit for all unlisted internal prosthesis*
Shoulder replacement R44 500
Spinal plates and screws See combined benefit limit for all unlisted internal prosthesis*
Total ankle replacement See combined benefit limit for all unlisted internal prosthesis*
*Combined benefit limit for all unlisted internal prosthesis *R36 100
External R21 800 at cost

Medical and Surgical Appliances: 
Limit of R15 500 per family per year with a sub-limit of R4 340 for foot orthotics
In Hospital Dentistry: 
Hospitalisation and anaesthetist covered for children up to the age of 7
Take home Medicine: 
Up to 100% of MPL. Limited to 7 days medication per hospital event
Rehabilitation, Hospice and Step-down facilities: 
Unlimited at negotiated tariff
Treatment for Mental Health: 
Limited to 2 mental health consultations per beneficiary per year
HIV / AIDS: 
Unlimited (see HPT)
Day-to-day benefits
GP consultations: 

Network GPs and Specialists Unlimited cover at cost
Non-network GPs Up to 100% of Fedhealth Rate

Specialist consultations: 

Network GPs and Specialists Unlimited cover at cost
Non-network Specialists Up to 200% of Fedhealth Rate

Over-the-counter (OTC) Medicine: 

Does not accumulate to or pay from threshold

 

Optometry benefits: 
R3 340 per beneficiary per year, R10 190 per family per year before and after Threshold. Subject to Savings, OHEB and Threshold
Basic dentistry: 
Unlimited at 100% of the Fedhealth Rate
Specialised Dentistry: 
Limit of R7 400 per person per year, up to an overall annual limit of R22 100 per family per year
Pregnancy benefits: 
Limited to 2 x 2D antenatal scans per pregnancy before and after Threshold. Subject to Savings, OHEB and Threshold
Chronic Conditions
Chronic Conditions: 

CDL Addison’s Disease, Asthma, Bipolar Mood Disorder, Bronchiectasis, Cardiac
Failure, Cardiomyopathy, COPD/Emphysema/Chronic Bronchitis, Chronic
Renal Disease, Coronary Artery Disease, Crohn’s Disease, Diabetes Insipidus,
Diabetes Mellitus type 1 & 2, Dysrhythmias, Epilepsy, Glaucoma, Haemophilia,
HIV, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple Sclerosis,
Parkinson’s Disease, Rheumatoid Arthritis, Schizophrenia, Systemic Lupus
Erythematosus, Ulcerative Colitis

Additional conditions on maxima PLUS
(CDL as above + the following 40)

Alzheimer’s Disease, Angina, Ankylosing Spondylitis, Anorexia Nervosa,
Attention Deficit Disorder (in children only), Barrett’s Oesophagus, Benign
Prostatic Hyperplasia, Bulimia Nervosa, Conn’s Syndrome, Cushing’s
Syndrome, Cystic Fibrosis, Deep Vein Thrombosis, Depression,
Dermatomyositis, Gastro-Oesophageal Reflux Disease, Generalised Anxiety
Disorder, Gout, Hypoparathyroidism, Menopause, Motor Neuron Disease,
Muscular Dystrophy, Myasthenia Gravis, Narcolepsy, Obsessive Compulsive
Disorder, Osteoporosis, Paget’s Disease of the Bone, Pancreatic Disease,
Panic Disorder, Paraplegia/ Quadriplegia (associated medicine), Pemphigus,
Polyarteritis Nodosa, Post-Traumatic Stress Syndrome, Pulmonary
Interstitial Fibrosis, Scleroderma, Stroke, Thromboangitis Obliterans,
Thrombocytopaenic Purpura, Tourette’s Syndrome, Valvular Heart Disease,
Zollinger-Ellison Syndrome

Preventative Care Benefits
Preventative Benefits: 

Women’s health Cervical cancer screening

(Pap smear) Women, ages 21 to 65. 1 every three years

Children’s health Immunisation Programme

(as per state EPI) Birth to 12 years

Cardiac health Cholesterol screening

(full lipogram) All lives, aged 20 and older. 1 every five years
General Flu vaccination All lives; 1 every year
HIV finger prick test All lives; 1 every year
Breast cancer screening with mammography All lives, aged 45 and older. 1 every three years
Men’s health Prostate Specific Antigen (PSA) Men, ages 45 to 69. 1 every year
Over 50s Pneumococcal vaccination All lives; aged 65 and older. 1 per lifetime
Colorectal cancer screening (faecal occult blood test) All lives; ages 50 to 75. 1 every year
Bone densitometry Women; aged 65 and older and Men;
aged 70 and older. 1 every two years

Health risk
assessments

Wellness screening (BMI, blood pressure, finger
prick cholesterol & glucose tests) All lives; 1 every year
Preventative screening by contracted wellness
network provider (waist-to-hip ratio, body fat %,
flexibility, posture & fitness)

All lives; 1 every year

Total Contributions
Total Contribution Main Member: 
4750.00
Total Contribution Adult: 
4116.00
Total Contribution Child*: 
1482.00
maxima EXEC Grid
Monthly Medical Savings
Savings Child*: 
209.00
Savings Adult: 
580.00
Savings Main Member: 
670.00
Risk Contributions
Risk Contribution Main Member: 
4080.00
Risk Contribution Adult: 
3536.00
Risk Contribution Child: 
1273.00
Medical Aid Plan Name Term: 
Any