in-hospital
benefit

• All authorised costs for hospitalisation are covered from this benefit at the reimbursement rate applicable to your option.

• Hospital costs will be covered unlimited from this benefit. Certain benefits are subject to and limited by case management protocols. These protocols have been introduced to ensure best quality treatment at best rates.

• Selected procedures performed in a day ward, day clinic and the doctors' rooms are also covered from this benefit and not from your Day-to-Day Benefit. For a list of these procedures please phone the Fedhealth Customer Call Centre on 0860 002 153 or visit the Fedhealth website on www.fedhealth.co.za

• Specialised Radiology, for example MRI and CT scans, are also covered from the In-Hospital Benefit whether the procedure is performed in hospital or not. Specialised Radiology will therefore be paid by the Scheme and will not be deducted from OHEB or your Savings. (Needs to be pre-authorised).

• Treatment received in a casualty ward for trauma as well as any other treatment in a casualty ward immediately followed by a hospital admission is covered from the In-Hospital Benefit. Trauma is defined as a physical injury to the body by an external force which requires immediate attention, for example stitches.

• Certain treatments arising from a hospital event, for example physiotherapy, x-rays and blood tests are covered for 30 days from date of discharge from the In-Hospital Benefit. For a list of these treatments please phone the Fedhealth Customer Call Centre on 0860 002 153 or visit the Fedhealth website on www.fedhealth.co.za

chronic disease benefit

The Chronic Disease Benefit covers 65 chronic conditions.
Formularies & DSP: The Scheme makes use of formularies and a Designated Service Provider (DSP) to manage the cost and ensure accessibility and appropriate level of care for all our members.
Formularies: A formulary is an approved list of medication for each of the chronic conditions covered by the Scheme. These formularies in no way compromise the quality of healthcare that you, the member, receives. Formularies are also subject to the Medicine Price List (MPL).
DSP: Fedhealth's DSP is the MEDI-Rite group of pharmacies, located in Shoprite supermarkets. Use of the DSP is dependent on your option choice.
Co-payments: If your option requires you to use Fedhealth's DSP (MEDI-Rite pharmacies), or is subject to one of Fedhealth's formularies, and you choose to rather use a service provider of your choice or out-of-formulary medication, please note that this will attract a 40% co-payment on the cost of medication. If this is in respect of a PMB condition, then the co-payment is not refundable from savings.
Medicine Price List (MPL): Your medication will be covered at MPL rates up to the limits as specified in your option. MPL is a reference price list that benchmarks each product against generically similar products. It does not restrict member's choice, but limits the amount that the Scheme will refund for each product. The MPL reference price is set at a level to
ensure that a number of medicines will be available without any co-payment.
Treatment Guidelines: The Scheme has established treatment guidelines for the 25 PMB conditions to ensure that you receive appropriate treatment for your condition. You will receive details of the treatment guidelines applicable to you once you register for one of these conditions and the Scheme has received your first claim related to this condition.
How to apply for the Chronic Disease Benefit: On diagnosis of a listed chronic condition you, your doctor or pharmacist will need to apply for chronic medication via telephone or online via the Medscheme website.

chronic disease benefit (continued)

Telephonically: You, your doctor or pharmacist can call Chronic Medicine Management (CMM) between 08h30 and 17h00, Monday to Friday, on 0860 100 608. The call will be routed to a consultant who will assist you with your application.

Online: You may also apply for chronic medication 24 hours a day by logging onto the Medscheme website (www.medscheme.co.za). If you have not completed an online application before, you will be prompted to register as a first time user since a login username and password will be requested. Once you have registered and your profile is open, click on Managed Care and then select Authorisations. Click on the beneficiary code for who you would like to apply and then click on the New Chronic Application button.

For both telephonic and online applications we will require the following information:

• Membership number
• Beneficiary date of birth
• Clinical examination information
• Diagnosis or ICD-10 code
• Product name or nappi code of prescribed medication
• Strength
• Prescription dates
• Directions for use
• Quantity
• Motivation

• Where more clinical information is required, members of the clinical team will review the information supplied and correspond with you and your doctor.
• Once your application has been approved: CMM will provide you with your medicine access card which will list the approved medicines to be covered from this benefit. Once you have received your medicine access card, your doctor will need to provide you with a repeat prescription for the approved medicines for a maximum of six months (your doctor is legally not allowed to give you a repeat for more than six months).
• What to do if your authorised chronic medication changes: If the doctor decides to change your medication, CMM needs to be advised. The quickest and simplest way would be for your

doctor to inform CMM telephonically on 0860 100 608. Within 24 hours, a temporary medicine access card will be faxed to your pharmacy enabling them to dispense your medicine without delay. Alternatively, you can also apply for the change in medication online at www.medscheme.co.za. Your new medicine access card will be mailed to you. Make sure your doctor provides you with an updated repeat prescription to match the approved medicines on your medicine access card.

Please note: paper applications will not be accepted for new or updates to existing chronic disease benefit authorisations.

Fedhealth offers Disease Management Programmes that support specific diseases. These programmes are offered at no additional cost to you.

Aid for AIDS (AfA)
AfA is a comprehensive HIV disease management programme with access to anti-retrovirals and related medicines as well as post-exposure preventative medication. Ongoing patient and provider support as well as regular monitoring of disease progression and response to therapy is provided. To join AfA call them in confidence on 0860 100 646. Your doctor may also call AfA on your behalf.

AsthmaCare
Most people with asthma should be able to enjoy a normal lifestyle, including getting a good night's sleep and being able to participate in sport and other normal daily activities. AsthmaCare enables you to achieve this by focusing on the appropriate use of medicine. The programme also provides education and counselling on issues that will help you to clearly understand and manage the disease. Phone 0860 101 306 or e-mail diseasemanagement@ medscheme.co.za for more detail or to register.

CardioCare
Anyone who has had angina or a heart attack is well aware of how important good medicine management is and how critical it is to tackle any lifestyle risks you may have. CardioCare focuses on members who have coronary heart disease, with the aim of preventing heart attacks. The programme promotes healthy lifestyle and the appropriate monitoring and treatment of risk factors. Phone 0860 101 306 or e-mail diseasemanagement@medscheme.co.za for more detail or to register.

Centre for Diabetes and Endocrinology (CDE)
Only available on Ultimax and Ultima 300
This programme offers you support to manage your diabetes and focuses on preventative measures such as diet, exercise and regular check-ups with specialists as well as medication and monitoring devices. To register on the programme, call (011) 712 6000 or e-mail cdecentr@iafrica.com

DiabeticCare
This programme helps you to control your blood sugar. It also addresses the importance of screening tests and the necessity of lifestyle adjustments, which can vastly improve the well being of diabetic patients. The programme also educates you on correct medicine management and monitoring. Phone 0860 101 306 or e-mail diseasemanagement@medscheme.co.za for more detail or to register.

Oncology Disease Management Programme (ODM)
On diagnosis of cancer, it is important that you register on ODM. Call ODM on 0860 100 572 and ask for an oncology application form. Alternatively the form can also be downloaded from the Fedhealth website, www.fedhealth.co.za. The application form should then be taken to your treating doctor for completion, after which it should be faxed to ODM on 021 466 2303, or scanned and e-mailed to cancerinfo@medscheme.co.za. The programme aims to assist your doctor to ensure best treatment and support. Your oncology benefit covers the following expenses: chemotherapy, radiotherapy, approved medication, related consultations, pathology and general radiology. Specialised radiology, for example MRI and CT scans, will be covered from the In-Hospital Benefit and will not affect your oncology benefit limit. A specialised medication benefit of R120 000 is included in the Oncology benefit, as a sub-limit, on all Ultima options. Remember that Fedhealth allows option upgrades any time of the year on diagnosis of a dread disease like cancer.

Changes in your oncology medication need to be communicated to ODM as soon as possible by faxing the amended treatment plan to 021 466 2303 or e-mailing cancerinfo@medscheme.co.za.

day-to-day benefit

OUT OF HOSPITAL EXPENSES BENEFIT (OHEB) AND SAVINGS
OHEB is available on Ultimax and Ultima 300.
Savings is available on Ultimax, Ultima 300 and Ultima 200.

• Day-to-day expenses such as visits to your GP and dentist and medication are covered from available funds in your OHEB and Savings Account. Should you join after 1 January, your annual benefit will be subject to proration.
• Your day-to-day benefit is the total of OHEB and Savings available plus amounts payable from the Safety Net Benefit when reached. Sub-limits will apply for claims refunded from OHEB and for accumulation to Safety Net.
• Day-to-day expenses will be refunded from OHEB first at the Fedhealth Rate and when it is depleted, from your Savings Account up to cost. Should claims refunded from OHEB be in excess of the allowed tariffs, the balance will be refunded from Savings.
• Over-the-counter medication (schedule 0, 1 and 2) will not be refunded from OHEB. It will be refunded from Savings.
• Year-end Savings Account balances will be carried over to the new year. Should you resign from the Scheme, any balances will be transferred to your new scheme. Amounts owing to the Scheme are payable to the Scheme on resignation.
• For prescribed medication, Fedhealth have capped the reimbursable dispensing fee on medicine at 26% with a maximum dispensing fee of R26 for products that have a cost (Single Exit Price) that exceeds R100. Fedhealth has negotiated these fees with a number of service providers in order to ensure that members will not have co-payments. It is in the interests of members to make use of these providers, not only to avoid co-payments, but also to ensure more effective management of day-to-day benefits. A list of pharmacies who have agreed to a preferential dispensing fee is available on www.fedhealth.co.za or call the Fedhealth Customer Call Centre on 0860 002 153. Please note that this is not applicable to the chronic disease benefit.

SELF-PAYMENT GAP
• It may happen that your OHEB and Savings have been
depleted before the required Safety Net Level has been
reached. This is referred to as a self-payment gap. You will now continue to pay for day-to-day expenses from your own pocket. In order to close this self-payment gap, you need to continue to submit these expenses to Fedhealth. These claims will not be refunded, but will accumulate towards your Safety Net Level.
• GP visits: During the self-payment gap, Fedhealth will however continue to cover GP visits unlimited providing you use a GP on the Fedhealth GP Network. To locate a GP on this network you can either call the Fedhealth Customer Call Centre on 0860 002 153 or visit www.fedhealth.co.za. This applies to all Ultima options except Ultima 200.

SAFETY NET BENEFIT
Not available on Ultima 200.

• The Safety Net Benefit pays for day-to-day expenses once OHEB and Savings have been depleted and your claims have accumulated up to the required level.
• Your Safety Net Level is reached through the accumulation of your claims paid from OHEB and Savings and your own pocket throughout the year at the Fedhealth Rate. Where limits apply, expenses will only accumulate up to this limit and this limit will also apply to refunds from Safety Net. However, further claims will be paid if Savings are available.
• Once you have reached the required Safety Net Level, your day- to-day expenses will now be refunded from the Safety Net Benefit. Many of your day-to-day expenses will be covered unlimited except for extended dentistry, optometry, prescribed medication, appliances and all auxiliary services for which only the remainder of the annual limit will apply. For example, if a family spends R14 000 on prescribed medication, a maximum of R13 650 (set sub-limit) will accumulate to their Safety Net Level. Once this family is in Safety Net, they will have no further prescribed medication benefit.

unique
to Fedhealth

At Fedhealth we pay more from Risk than any other scheme thereby allowing your Day-to-Day Benefit to go further.

SPECIALISED RADIOLOGY
Fedhealth covers specialised radiology, for example MRI and CT scans, from Risk irrespective of whether the procedure is performed in or out of hospital.

EMERGENCY TREATMENT
Treatment for trauma at a casualty ward, for example stitches and broken bones, is covered from Risk even if the patient is not admitted to hospital.

ORAL CONTRACEPTION
Monthly prescriptions for the pill are covered from Risk.

TAKE-OUT MEDICINES
Fedhealth pays for up to 7 days of medication received on discharge from hospital from Risk.

30-DAY POST-HOSPITALISATION BENEFIT
To protect your Day-to-Day Benefit, the scheme provides for certain treatment up to 30 days after discharge from hospital to be paid from Risk. This includes physiotherapy, occupational therapy, radiology and pathology, x-rays and oxygen.

PROCEDURES PERFORMED IN DAY WARDS
More than 60 procedures that can safely be performed in day wards, day clinics and the doctors' rooms are also covered from the In-Hospital Benefit and not from the Day-to-Day Benefit, for example vasectomies, diagnostic laparoscopies and gastroscopies.

CHILD DEPENDANT STATUS UP TO 27 YEARS
Fedhealth will charge the child dependant rate for children still studying or dependent on the principal member up to the age of 27.

EMERGENCY TREATMENT FOR YOUR PET
Dogs and cats are part of your family, which is why Fedhealth members have Petsure. After an accident; cat or dog fight or any accidental injury that needs immediate medical attention, we will assist with the costs.

EMERGENCY MEDICAL SERVICES
As a Fedhealth member, you can contact Europ Assistance for a range of emergency services on 0860 333 432. These services include:
• Emergency road or air response
• Medical advice in any emergency situation
• Delivery of medication and blood
• Patient monitoring
• Care for stranded minors or frail companions

PROFESSIONAL SPORTS AND HAZARDOUS PURSUITS
Fedhealth is one of the few schemes that offers full cover to people who partake in professional, adventurous and even extreme sports, for example scuba diving, skydiving, bungee jumping, hunting and mountaineering.

FEDHEALTH BABY
The Fedhealth Baby programme has been put together by experts with you and baby in mind. From great giveaways, discounts, education and just plain fun, you'll find that the Fedhealth Baby programme is there to make your experience all the more special.

We offer the following benefits:
• A Fedhealth Baby Bag packed to the brim with quality
products; from all the Pigeon Baby care products you'll
ever need, to nappies and "Having your baby' Handbook
and more! All especially chosen to take care of your little
one from top to toe
• Discounts for the best baby brands including Huggies,
Chelinos, Living & Loving, Preggie Bellies and a whole lot more
• On-going communication and education in the form of
e-mails (to mum and dad!) and e-letters
• Health profiling for each trimester
• Monthly call-outs to high risk members

• E-mail registration for chronic risk communications
• 24 hour Medical Advice Line
• Doula (labour support) assistance during natural birth

In addition, a Fedhealth Baby representative will maintain contact over each trimester to make sure mother and baby are making healthy progress. Any Fedhealth member or dependant who is pregnant can register on the Fedhealth Baby programme at no additional cost by calling them on 0861 116 016

DISEASE MANAGEMENT PROGRAMMES
Fedhealth believes in holistic treatment for members suffering from serious diseases such as diabetes, AIDS and cancer by providing various management programmes.

WORKING IN AFRICA
Medical evacuation for South African contract workers exporting their skills to Africa.

TRAUMA COUNSELLING
After a traumatic experience, for example falling victim to crime or a motor vehicle accident, Fedhealth provides emotional and practical support through ICAS. Call them on 0800 212 695.

UNLIMITED GP VISITS
Fedhealth will continue to pay for unlimited GP visits once your Day-to-Day Benefit has been depleted and you are in your self-payment gap, providing you use a GP on the Fedhealth GP network.
(Not available on Ultima 200)

24-HOUR NURSELINE
The 24 hour Fedhealth Nurseline is available for assessing day-to-day symptoms, emergency medical advice, health knowledge (e.g. explanation of medical terms, procedures and test results), drug database (e.g. complete information on medication, contra indications, etc), stress management, poisoning and teenage support. Call them on 0860 333 432.

important
user tips

PRE-AUTHORISATION
•You need authorisation for any benefit payable from the In-Hospital Benefit, for example, a planned or emergency hospital admission, specialised radiology, selected procedures, 30-day post-hospitalisation benefit and casualty ward treatment.
• The Authorisation Centre needs to be contacted at least 48 hours before admission for a non-emergency or planned procedure to obtain an authorisation number.
• In an emergency, or if you need to be admitted sooner than planned, you must obtain an authorisation number from the Authorisation Centre within two working days after admission.
• If you are unable to contact the Authorisation Centre yourself, then your doctor or a family member or the hospital can contact us on your behalf.
• We need the following information to authorise your treatment:
~ Membership number
~ Member or beneficiary date of birth
~ Reason for admission and applicable tariff codes for the proposed treatment
~ Date of admission and the proposed date of operation
~ The doctor's name, his/ her telephone and practice numbers, if available
~ Name of the hospital with telephone and practice numbers if available
~ For a CT scan, MRI procedure, etc., the name of the radiological practice is also required.

Contact number: 0860 103 951
(Monday to Friday 08h00 - 16h00)
Fax number: 0860 212 223
E-mail: authorisations.cpt@medscheme.co.za

HOW TO CLAIM
• In most cases your healthcare professional will submit your claim on your behalf directly to Fedhealth via Electronic Data Interchange (EDI). In this case, please do not also submit this claim.
• If the healthcare professional does not submit a claim on your behalf, or if you have settled the account yourself, all you need to do is sign the account from the healthcare professional indicating proof of payment and your membership number. Forward this to Fedhealth either by mail, fax or e-mail for fast and effective processing.

Postal address: Private Bag X3045 Randburg, 2125
Fax number: (011) 671 3842
E-mail: fedhealth@medscheme.co.za
• Should your healthcare professional inform you that the claim has not been paid, you can contact the Fedhealth Customer Call Centre to enquire on the status of the claim on 0860 002 153.
• If you have paid the healthcare professional, Fedhealth will refund you directly into your bank account.
• ICD - 10 coding: It's important to remember that all claims to a medical scheme must contain the correct ICD - 10 code. Claims not containing the correct code will be rejected.
• Please ensure that the Scheme is in possession of your updated banking details for refund purposes. To update your banking details, please phone the Fedhealth Customer Call Centre on 0860 002 153.
• Only claims received within four months of treatment will be processed.

CLAIMS AGAINST THE ROAD ACCIDENT FUND
• If you have been involved in a car accident, you may have a claim against the Road Accident Fund.
• Certain procedures will apply before claims will be paid by the Scheme.
• Please contact the MVA/ Third Party department at Fedhealth for further details.
Telephone number: (011) 669 3163/ 6/ 9
Fax number: (011) 669 2646
Postal address: P O Box 781692
Sandton, 2146

WHO CAN BE REGISTERED AS A DEPENDANT?
• Your spouse, partner, children or other family members who rely on you for financial care and support may be registered as your dependants.
• Fedhealth will charge the child rate for your child dependants until they turn 27. However, the child needs to be a full-time student, either living at home or in a residential situation at a tertiary education institution. If your child is not a student, Fedhealth needs confirmation that they are living at home, unmarried, and not in receipt of a regular income greater that the maximum social pension.

ELECTRONIC COMMUNICATION SERVICES
Managing your medical aid fast and effectively
• Real-time electronic communication
Fedhealth will e-mail and SMS a claim status to you showing claims that have been processed. Please ensure that Fedhealth has your correct cell number and e-mail address by calling the Fedhealth Customer Call Centre on 0860 002 153.

• Website
You can also view a full update of your benefit and claim status by registering on the Fedhealth website. You will have immediate access to all your personal information.
Fedhealth website: www.fedhealth.co.za

CREDIT CONTROL
Contributions to Fedhealth are paid monthly in arrears and should be received by the scheme by the 3rd of the following month.

FEDHEALTH'S BANKING DETAILS
Account name: Fedhealth Medical Scheme
Bank: Nedbank
Branch code: 19-84-05
Account number: 1984 563 009

LEAVING THE SCHEME
• Should you wish to resign from Fedhealth, we require three month's written notice.
• Any balance in your Savings Account is paid out to you or transferred to your new medical scheme's savings account, five months after you have left Fedhealth. This ensures that all outstanding claims have been received and processed. If there is a balance owing to the Scheme, this must be repaid to Fedhealth on resignation.
• Please note that as Fedhealth is an arrears scheme, your last contribution will be deducted by the 3rd of the month following your last day of membership.

FRAUD MANAGEMENT
You can help combat fraud by anonymously contacting our fraud hotline if you become aware of any healthcare professional or member abusing the system.
Fraud Hotline: 0800 112 811

medscheme
walk-in branches

For personal assistance, visit one of the following Medscheme Walk-in branches.

These branches are open Monday to Friday 08h30 - 16h00

Bloemfontein
Suite 13, Westdene Office Park, Pres. Reitz Avenue, Westdene, Bloemfontein

Cape Town
15th Floor, Atterbury House, 9 Riebeek Street, Cape Town

Durban
3rd Floor, 67 Old Fort Road

East London
Medscheme House, 39 Balfour Road, Vincent

Johannesburg
Office no. 1, Vusa House, Mezzanine Floor, Gandhi Square, Johannesburg

Nelspruit
The Upper Ground Floor, 11 Ferreira Street, Colfin House, Nelspruit

Port Elizabeth
1st Floor, Block 6, Greenacres Office Park, 2nd Avenue, Newton Park

Pretoria
Ground Floor, Benstra Building, 473B Church Street, Arcadia

Roodepoort
37 Conrad Street, Florida North

Vereeniging
2nd Floor, 36 Merriman Avenue

contact us

Fedhealth Customer Call Centre
Monday to Thursday 08h30 - 17h00
Friday 09h00 - 17h00
Tel: 0860 002 153
e-mail: fedhealth@medscheme.co.za
Web: www.fedhealth.co.za
Postal address: Private Bag X3045, Randburg 2125

Hospital Management Authorisation Centre
Monday to Friday 08h00 - 16h00
Tel: 0860 103 951
Fax: 0860 212 223
e-mail:authorisations.cpt@medscheme.co.za
Web: www.medscheme.co.za

Europ Assistance
Tel: 0860 333 432

Aid for AIDS
Monday to Friday 08h00 - 17h00
Tel: 0860 100 646
Fax: 0800 600 773
e-mail: afa@afadm.co.za
Web: www.aidforaids.co.za
SMS (call me): 083 410 9078

Centre for Diabetes and Endocrinology
Monday to Friday 08h30 - 17h00
Tel: (011) 712 6000
Fax: 086 560 5182
e-mail: members@cdecentre.co.za
Web: www.cdecentr.co.za
Postal address: P O Box 2900, Saxonwold, 2132

Chronic Medicine Management
Monday to Friday 08h30 - 17h00
Tel: 0860 100 608
Fax: 0800 223 670/ 80
e-mail: cmm@medscheme.co.za
Web: www.medscheme.co.za
Postal address: P O Box 38632, Pinelands, 7430

Disease Management
Monday to Friday 08h30 - 17h00
Tel: 0860 101 306
e-mail: diseasemanagement@medscheme.co.za
Web: www.medscheme.co.za

Fedhealth Baby
Monday to Friday 08h00 - 17h00
Tel: 0861 116 016
e-mail: info@babyhealth.co.za
Web: www.babyhealth.co.za

Fraud Hotline
Tel: 0800 112 811

ICAS (Trauma Counselling)
Tel: 0800 212 695

MVA Third Party Recovery Department
Monday to Friday 08h00 - 16h00
Tel: (011) 669 3163/ 6/ 9
Fax: (011) 669 2646
Postal address: MVA Third Party Recovery Department
P O Box 781692, Sandton, 2146

Oncology Disease Management
Monday to Friday 08h30 - 17h00
Tel: 0860 100 572
Fax: (021) 466 2303
e-mail: cancerinfo@medscheme.co.za
Web: www.medscheme.co.za
Postal address: P O Box 38632, Pinelands, 7430

This summary is for information purposes only and does not supersede the Rules of the Scheme. In the event of any discrepancy between the summary and the Rules, the Rules will prevail.