• Benefits, Fedhealth Plan, in-hospital, out-hospital, Scheme Plans

Fedhealth Maxima Exec:
in-and-out of hospital benefits (2025)

Contents:

This page has overview information on: Costs, In-hospital, Out of Hospital and Medicine benefits for Fedhealth Maxima Exec. Please consult and verify with the scheme or your broker for full benefits, and an explanation of all the "fine print".

Terminology:

  • PMBs: Prescribed Minimum Benefits. You can read more about PMBs, see a list of all PMB conditions or read more what "PMB only" benefit means.
  • DSPs: Designated Service Providers. Where stipulated, you must use specific providers to get full benefit.
  • Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product.
  • All schemes have extensive exclusions. We've tried to list the non-common ones here, but please consult your scheme or broker to get the full list.

Monthly Costs (2026)

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Fedhealth: Maxima Exec (2026)
Main member: Adult member: Child member:
Total Cost pm:
  • R12,273
  • R10,653
  • R3,792
Savings:
  • R12,528
  • R10,872
  • R3,864
Self Payment Gap:
(What you need to pay out of pocket before you can access the "Above Threshold" benefit)
  • R9,322
  • R5,208
  • R1,186
"Above Threshold" benefit (ATB):
Additional cover the scheme makes available to you, once you've paid the self payment gap.
  • Unlimited
  • Unlimited
  • Unlimited
Children Rates:
  • Up to 27yrs if student, otherwise up to 21yrs
  • Only pay for 3 children
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In-hospital Procedures (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Fedhealth: Maxima Exec
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
GPs and Specialists:
  • Doctors in network: paid in full
  • Doctors not in network: 200% scheme rate
Gap Cover:
Can push payout up to 700% scheme rate
(Plans coming soon)
Hospital Choice:
  • Choose any hospital except:
    • Zuid-Afrikaans Hospital (City of Tshwane),
    • Arwyp Medical Centre (Ekurhuleni),
    • Busamed Modderfontein Private Hospital (City of Johannesburg),
    • Hibiscus Hospital (Ugu),
    • Mooimed Private Hospital (Dr Kenneth Kaunda),
    • Capital Hospital (Durban).
  • Elective procedures at these 7 hospitals: R8,840 co-payment
Penalty for using other hospital:
  • Elective procedures at the 7 excluded hospitals: R8,840 penalty
 Gap Cover:
Can cover the penalty in full
(Plans coming soon)
Co-payments:
  • Arthroscopic procedures: R3,340 co-payment
  • Colonoscopy, upper GI endoscopy: R3,130 co-payment
  • Wisdom Teeth: R5,730 co-payment
  • Laparoscopic hernia repairs (bilateral inguinal, repeated inguinal hernias & Nissen/ Toupet hernia repairs only), laparoscopic procedures, rhizotomies and facet pain blocks: R5,370 co-payment
  • Single hip and knee replacement: no co-payment if contracted
  • Other joint replacements: R5,730 co-payment
  • Spinal Surgery: R7,510 co-payment
  • MRIs, CT scans etc: R2,960 co-payment
Note:
  • If you use a DSP (designated service provider), you never have to pay a co-payment for protocol treatment of a PMB (Prescribed Minimum Benefit). More info here
  • There might be other co-payments, especially if you don't use a DSP for a PMB or when buying medicine.
 Gap Cover:
Can cover most co-payments
(Plans coming soon)
Specialised Radiology:
  • MRI and CT Scan: R2,960 co-payment, in and out-of hospital
 Gap Cover:
Can cover most co-payments and increase sublimits
(Plans coming soon)
Scopes: Gap Cover:
Can cover most co-payments and increase sublimits
(Plans coming soon)
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Dietetics, occupational therapy and speech therapy: from day-to-day benefit , R19,400 per family if paid from Threshold. Does not accumulate to Threshold, but does pay from it.
Transplants:
  • R624,000
  • Corneal graft: R36,300 per person
Dialysis:
  • R624,000
Exclusions:
  • NB: See scheme's rules for all exclusions. All schemes have plenty!
 Gap Cover:
Coming soon
Alternatives to hospitals:
  • Nursing services: Unlimited
  • Sub acute facilities, physical rehab: Unlimited
  • Terminal care: R34,500 per person
Casualty/ER:
  • Emergency treatment, like stitches: R850 co-payment, unless PMB
 Gap Cover:
Can cover ER claims
(Plans coming soon)
Other:
  • Appliances, external accessories and orthotics, in and out of hospital: From day-to-day benefit
  • Physio, x-rays, pathology etc: Follow up treatment for 30 days post hospitalisation
PMBs = Prescribed Minimum Benefits (more info) | DSP = Designated Service Provider

Out-of-hospital Procedures (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Fedhealth: Maxima Exec
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
Main Member: Adult: Child:
Savings:
  • R12,528
  • R10,872
  • R3,864
Self Payment Gap:
(What you need to pay out of pocket before you can access the "Above Threshold" benefit)
  • R9,322
  • R5,208
  • R1,186
"Above Threshold" benefit (ATB):
Additional cover the scheme makes available to you, once you've paid the self payment gap.
  • Unlimited
  • Unlimited
  • Unlimited
Other Day-to-Day Funds:
PMBs out of hospital:
  • All schemes must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here.
  • This can include consults with specialists, blood or other tests, radiology and medicine.
  • PMB benefits must never be paid from your savings account.
  • Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
  • See our Guide to PMBs for more information.
GP consultations:
  • Network GP: From day-to-day benefit , then paid by scheme
  • Non-Network GP: From day-to-day benefit . Does not accumulate to Threshold, but does pay from it.
Childcare:
  • Paediatrician: 1 consult, 0-1yr
  • Immunisations: Covered, 0-12yrs
  • Childhood illness specialised drugs: Covered, 0-18yrs
 Gap Cover:
Can pay for child ER visits
(Plans coming soon)
Specialist consultations:
  • Fedhealth Network: from day-to-day benefit , unlimited at cost once Threshold is reached. 10% co-payment if no GP referral
  • Non-Network: as above, but at scheme rate and does not accumulate to Threshold
Pathology:
  • From day-to-day benefit
  • Unlimited, once Threshold is reached
General radiology:
  • From day-to-day benefit
  • Unlimited, once Threshold is reached
Specialised radiology:
  • MRI, CT scans: R2,810 co-payment. In and out-of hospital
 Gap Cover:
Can pay co-payments and increase sublimits
(Plans coming soon)
Scopes: Gap Cover:
Can pay co-payments and increase sublimits
(Plans coming soon)
Supplementary Services: (Physio, etc)
  • Supplementary medical services: From day-to-day benefit . Paid from Threshold up to R12,900 per family
  • Alternative medical services (acupuncture, homeopathy, naturopathy, osteopathy and phytotherapy): From day-to-day benefit . Does not accumulate to or pay from Threshold.
General Appliances:
  • Appliances, external accessories and orthotics: From day-to-day benefit , unless PMB
  • Does not accumulate to Threshold, but paid from it up to R17,300 per family
  • Foot orthotics: R4,860 sub-limit per person
  • In and out of hospital
1.1. Hearing Aids:
  • See above
1.2. Wheelchairs:
  • See above
PMBs = Prescribed Minimum Benefits (more info) | DSP = Designated Service Provider

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.

Medication Benefit (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Fedhealth: Maxima Exec
Assume scheme pays all these costs, unless otherwise stated
Main Member: Adult: Child:
Savings:
  • R12,528
  • R10,872
  • R3,864
Self Payment Gap:
(What you need to pay out of pocket before you can access the "Above Threshold" benefit)
  • R9,322
  • R5,208
  • R1,186
"Above Threshold" benefit (ATB):
Additional cover the scheme makes available to you, once you've paid the self payment gap.
  • Unlimited
  • Unlimited
  • Unlimited
Other Day-to-Day Funds:
Chronic:
  • Additional 43 conditions
  • Overall benefit: R7,890 per person and R14,500 per family. Thereafter, the 27 PMB conditions only
Acute (prescribed) medication:
  • From day-to-day benefit
  • R7,940 per person and R14,700 per family, before and after Threshold
Over-the-counter:
  • From day-to-day benefit
  • Does not accumulate or pay from Threshold
Birth Control:
  • Oral, patches, contraceptive rings, certain injectables, and IUDs (including Mirena): Paid by scheme, if prescribed
On Discharge:
  • 7 days
Biological:
  • R194,600, per family
PMBs = Prescribed Minimum Benefits (more info) | DSP = Designated Service Provider

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.

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