Phoenix Health Fund’s Top Hospital Essentials $500 Excess and Mid Extras offers members all the same great comprehensive benefits as our Top Hospital cover, but removes full coverage for Pregnancy services, Assisted reproductive services, Gastric Banding and Psychiatric to help you save money. Additionally with this combination you get a great Mid Extras package for services such as dental, optical and physiotherapy and much more.
What’s Included in Hospital Cover
|Treatment for injuries sustained in an accident||Yes|
|Removal of Appendix||Yes|
|Removal of tonsils and adenoids||Yes|
|Joint reconstruction and investigations||Yes|
|Surgical removal of wisdom teeth (hospital charge only)||Yes|
|Pregnancy and birth related services||No|
|Fertility treatment (e.g IVF & GIFT programs)||No|
|Heart related services||Yes|
|Major eye surgery (including cataract and eye lens services)||Yes|
|Surgery on broken bones||Yes|
|Cosmetic surgery covered by Medicare||Yes|
|Cosmetic surgery (not covered by Medicare)||No|
|All other in-patient services where a Medicare benefit is payable||Yes|
Extras cover Inclusions
Unless otherwise stated, benefit limits apply per person per calendar year. year.
Please also note that this page does not include the full detail of all services covered, and that sublimits apply for some services. It is recommended that you either check your Online Member Services or contact us before your treatment to check exactly what you are covered for.
|Treatments||Benefit (for commonly claimed items)||Annual Limit|
|General Dental||011 – Periodic oral examination – $32.85
114 – Scale & clean – $62.10
121 – Fluoride treatment – $21.60
Inlays, onlays & Veneers- $1,000
Crowns/bridgework – $1,000
Implants – $1,000
Dentures – $1,000
Orthodontia – $1,000 ($1,000 lifetime limit)
|Major Dental and Endodontic||615 – Full crown veneered – $615.00
417 – Filling of one root canal – $153.00
|Orthodontic||Braces for upper/lower teeth – 80% of charge
Removal/ fitting of retainer – 80% of charge
* No benefit paid for sunglasses, where no sight correction is needed.
|Single vision lenses & frames – $198.00
Multi-focal lenses & frames – $200.00
Frame – $90.00
Single Vision Lenses – $108.00
Multifocal Lenses – $189.00
|Non PBS Pharmaceuticals
* No benefit paid for contraceptives and items purchased over the counter.
|Per eligible prescription – $45.00 (Paid after General PBS copayment has been paid)||$250|
* Benefits paid for approved acupuncture associations only.
|Chiro/Osteo Initial visit – $36.00
Chiro/Osteo Subsequent visit – $27.00
Chiropractic X-rays – $90
Acupuncture visits- $22.50
|Physiotherapy Initial visit – $45.00
Physiotherapy Subsequent visit – $33.30
Orthoptic Therapy Initial visit – $40.50
Orthoptic Therapy Subsequent visit – $39.60
Speech Therapy Initial visit – $76.50
Speech Therapy Subsequent visit – $40.50
Occupational Therapy Initial visit – $54.00
Occupational Therapy Subsequent visit – $36.00
* Including Myotherapy, Homeopathy, Naturopathy and Chinese Herbal Medicine (consultation only)Remedial Massage*Benefits paid for approved associations only. Click here for approved alternative therapy services.
|Natural Therapies visits – $22.50
Remedial Massage visits – $22.50
|Healthy Lifestyle Program
Approved Health Education, Health Screening, Health Management programs and Exercise Physiology only. Please contact the fund before you make a claim to check that the service provided is an approved program. Click here for more information
|Exercise Physiology visits – $27.00All other services – 80% of charge||$100|
|Podiatry||Initial visit – $39.60
Subsequent visit – $30.60
Podiatric devices – 80% of cost
|Aids and Appliances
* Contact the fund for items payable in this category.
|80% of charge
(after $20 copayment is made)
Important Hospital Information
For hospital services to which Phoenix Health Fund provides coverage, Top Hospital Essentials $500 Excess and Mid Extras provides coverage for:
- Private and public hospital services nationwide (after the up-front excess has been paid) with access to an extensive range of quality services and approved programs in private hospitals which have an agreement with Phoenix Health Fund.
- Public or Private Hospital bed – shared or private room (if available)
- Same day patient fees
- Theatre fees
- Intensive care
- Labour ward
- In hospital pharmacy
- Prosthesis (Commonwealth Government approved)
- All other in-patient services where a Medicare benefit is payable (not listed as an exclusion in the hospital table above)
Additional costs you may incur are:
- The amount the doctor charges above the Medicare schedule fee or “Access Gap” cover amount
- some drugs, pharmacy items and non-PBS drugs for personal use or on discharge; and possibly
- a co-payment for prostheses devices above the minimum benefit.
- There are a small number of public hospitals that do not have agreements with us. In these cases a personal payment may apply.
Phoenix Health Fund covers all medically necessary transport from a State Emergency Ambulance service. This also includes when an Ambulance is called to attend to you, but you do not subsequently need to be taken to hospital. Coverage is not offered when it is not medically necessary for you to be transported by an Ambulance.
If you are to be admitted into a public or private hospital as an in-patient for an excluded service on your policy, the fund will not pay a benefit.
If you are to be admitted into a public or private hospital as an in-patient for a restricted service, you will need to be aware of how your fund will pay your benefits.
Be aware that if you are admitted with a restricted service, significant out of pocket expenses can apply.
|Service Category||Benefit Rules|
If you are admitted to a hospital, you will pay an up-front excess of hospital costs until you have reached your excess maximum of $500 per person within a calendar year (1st January through to 31st December).
The excess is applied as follows:
- The full $500 excess is payable on the first overnight admission (private or public hospital), and
- A $250 up-front excess is payable on any day surgery admissions (private or public hospital).
- Maximum excess per family membership is $1000.
- Excess is waived for all dependent children on the Sole Parent or Family version of this policy.
Medical Gap cover
Phoenix Health Fund, as a member of the Australian Health Service Alliance, has “Access Gap” arrangements with more than 15,000 doctors Australia-wide. These arrangements minimise or eliminate Members’ out-of-pocket expenses when our Members are treated as admitted hospital patients.
If your doctor participates in the “Access Gap” scheme, you will either have no out-of-pocket expenses to pay or will know exactly how much you will have to pay before treatment begins. Your doctor can bill Phoenix Health Fund direct, so in most cases you will not be required to lodge a claim with us, making it easier for you.
To check whether your doctor participates in “Access Gap”, use our Doctor Search facility, or ask your doctor.
Top Hospital Essentials $500 Excess & Mid Extras waiting periods
- 12 month waiting periods for pre-existing conditions
- 2 month waiting periods for all other hospital items
- 2 month waits for general dental and endodontic claims
- 12 month waits for major dental and orthodontic claims
- 6 month waits for optical claims
- Nil waiting periods for emergency ambulance
- 2 month waits for all other extras item claims
For the complete description of the Fund rules, relating this product, please refer to the General Information section on our website.
Please ensure you have read and retained the information relating to your policy of choice before applying for membership.