Fedhealth Blue Door D medical aid plan: 2017

Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB. Pay for all children. Income-limited plan: R10,501-R12,000pm only

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
  • Covered in full for specialists and GPs in Fedhealth network
  • Otherwise, 100% scheme rate, limited to R2,000 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Network, or R10,000 co-payment
Specialised Radiology:
  • R12,100 per person and R24,400 per family
Supplementary Services: (Physio, etc)
Transplants:
  • PMBs only, in state facilities
Co-payments:
Alternatives to hospitals:
  • PMBs only, excludes hospice

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Contracted GP: Unlimited
  • Not contracted GP: 2 consults
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Specialists consultations:
  • 2 consults per family with network specialist
Pathology:
  • Unlimited subject to referral and basic protocols
General radiology:
  • Unlimited subject to referral and basic protocols
Specialised radiology:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

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MATERNITY BENEFITS:
Hospital stay:
  • R32,900 per event and R48,700 per family
  • Elective Caesarean: R10,000 co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Consultations:
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
Note: All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: paid by scheme
  • Plastic dentures: 1 set per person every two years
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics:
  • No benefit
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • Unlimited if dispensed by network GP
Over-the-counter:
  • No benefit
Birth Control:
On Discharge:
  • 7 days supply
Notes:
  • Chronic meds: if not on the formulary, 40% co-payment

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OPTOMETRY:
Optometry:
  • One test, frame and lenses per person every 2 years, subject to sub limits
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • R8,010
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:
  • 2 psychiatric consults per family

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OTHER BENEFITS:
General Appliances:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
  • PMBs only, at state facilities
HIV:
  • Covered if on the management program
Emergency Transport: Europ Assistance
International Coverage:
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
Child Immunisation:
Pap Smear:
Mammogram:
PAS Test:
HIV Test:

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,754 R1,375 R677
Children: Pay for all children
Income limit: R10,501-R12,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: prescribed medication, GP consults, dentistry, optometry. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Sub-limits:

    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