Fedhealth Maxima Entryzone medical aid plan: 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

COSTS and OVERVIEW:
Maxima EntryZone
Quick Overview
Main: Adult: Child:
Total Cost pm: R1,424 R1,080 R482

(Pay only for first 3)

Savings (per year):
  • No savings option on this plan
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Maxima EntryZone
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% scheme rate
  • Network specialists covered in full
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Network or R6,100 co-payment
  • No benefit
Specialised Radiology:
  • You or your gap pay R2,800 co-payment
  • Gap cover pays co-payments for procedures approved by medical aid
Supplementary Services: (Physio, etc)
  • Physio: subject to protocols
  • Dietetics, occupational therapy and speech therapy: PMBs only
  • Otherwise, 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment
Transplants:
  • PMBs only
  • Corneal graft: no benefit
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments:
  • Adenoidectomy
  • all open hernia repairs
  • back and neck procedures
  • bunion procedures
  • colonoscopy, upper GI endoscopy
  • diagnostic cystoscopy
  • gastritis, dyspepsia, heartburn
  • hysterectomy (unless for cancer)
  • laparoscopic hernia repairs, laparoscopic procedures
  • spinal surgery
  • nasal procedures
  • skin biopsy/excision
  • tonsil/adenoid procedures (over 12yrs old)
  • varicose vein procedures
  • R5,900 co-payment paid by you or by your gap cover
  • Arthroscopic procedures: R7,500 co-payment
  • Elective caesarean: R11,000 co-payment paid by you or by your gap cover
  • Gap cover pays co-payments for procedures approved by medical aid
Alternatives to hospitals:
  • Terminal care: R29,500 per family
  • Physical rehabilitation, sub-acute facilities: PMBs only
  • Nursing services, private nurse practitioners, nursing agencies: Unlimited, at negotiated rate
  • No benefit
Casualty:
  • Paid by scheme at 100% scheme rate
  • li>R550 co-payment if not PMB
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • Post hospitalization treatment for up to 30 days after discharge, paid for by scheme. Includes physio, occupational therapy, speech therapy, ultrasounds, standard radiology and pathology
    Excluded procedures:
  • Balloon sinuplasty
  • Rhizotomies and facet pain blocks
  • Surgical extraction of wisdom teeth
  • Corneal grafts
  • Arthroscopic hip procedures
  • non-PMB arthroscopic wrist procedures
  • non-PMB joint replacements
  • No benefit for exclusions
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

No phone calls!
Our quote will include the right gap cover for this plan

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Maxima EntryZone
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • Network GP: 1 consult per person
  • Otherwise, no benefit unless PMB
  • Out of hospital treatment for conditions that are PMBs is always paid for by the scheme (not out of savings), but according to protocols
  • No benefit
Childcare:
  • Hearing test for newborns up to 8 weeks
  • Immunisations: Covered
  • No extra benefit available
Specialists consultations:
  • No benefit, unless PMB
  • No benefit
Pathology:
  • No benefit, unless PMB
  • No benefit
General radiology:
  • No benefit, unless PMB
  • No benefit
Specialised radiology:
  • Unlimited, paid by scheme. R2,800 co-payment, unless PMB
  • Co-payment paid for authorised out of hospital MRI and CT Scans
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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MATERNITY BENEFITS:
Maxima EntryZone
Scheme Benefits Gap benefits
Hospital stay:
  • Specialists from network, covered at full cost. Otherwise, 100% scheme rate
  • Elective caesarean: R11,000 co-payment
  • Doula benefit: R1,270 per delivery
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
  • In-hospital sublimits increased as necessary
Consultations:
  • 4 postnatal consultations with midwife
  • No benefit
Scans:
  • No benefit
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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CANCER (ONCOLOGY):
Maxima EntryZone
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • PMBs only at DSP
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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DENTISTRY:
Maxima EntryZone
Scheme Benefits Gap benefits
Dentistry:
  • Standard dentistry: No benefit, unless PMB
  • In-hospital wisdom teeth extraction: no benefit
  • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
Orthodontics:
  • You pay this out of pocket
  • No extra benefit available
Maxillo Facial Surgery:
  • Unlimited, subject to approval
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MEDICATION:
Maxima EntryZone
Scheme Benefits Gap benefits
Chronic:
  • No. of chronic conditions covered: 27
  • Co-payment if out of formulary: 40% co-payment
  • No benefit
Acute (presrcibed) medication:
  • No benefit
  • No benefit
Over-the-counter:
  • No benefit
  • No benefit
Birth Control:
  • Oral and injectible contraceptives only, subject to formulary
On Discharge:
  • 7 days supply
  • No benefit
Biological:
  • No benefit
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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OPTOMETRY:
Maxima EntryZone
Scheme Benefits Gap benefits
Optometry:
  • No benefit
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MENTAL HEALTH:
Maxima EntryZone
Scheme Benefits Gap benefits
In-hospital:
  • No benefit, unless PMB
  • No benefit
Out-of-hospital:
  • No benefit, unless PMB
  • No benefit
Trauma:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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OTHER BENEFITS:
Maxima EntryZone
Scheme Benefits Gap benefits
General Appliances:
  • No benefit, unless PMB
  • No benefit
1.1. Hearing Aids:
  • No benefit
  • No benefit
1.2. Wheelchairs:
  • No benefit
  • No benefit
Dialysis:
  • PMBs only
HIV:
  • Treatment includes rape- and post-exposure prophylaxis
  • No benefit
Emergency Transport: Europ Assistance
  • No benefit
International Insurance: 2018 benefits are coming soon!
  • No benefit
Other: 2018 benefits are coming soon!
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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WELLNESS/PREVENTATIVE BENEFITS:
Maxima EntryZone
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
Pneumonia vaccines:
  • No benefit
  • No benefit
Back Rehabilitation Programme:
  • Covered
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • Covered, 21-65yrs, every 3 years
  • No benefit
Mammogram:
  • Covered, 45-74yrs, every 3 years
  • No benefit
PAS Test:
  • No benefit
  • No benefit
HIV Test:
  • Covered
  • No benefit
Other:
  • Lipogram, every 5 years
  • 1 densitometry test per lifetime, 65yrs+
  • 1 colorectal cancer screening test, every 2 years for 50-75yrs
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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PROSTHETICS:
Maxima EntryZone
Scheme Benefits Gap benefits
Overal Limit:
  • External: PMBs only
  • Internal: PMBs only
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
Sub-limits:
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid

No phone calls!
Our quote will include the right gap cover for this plan


    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised