Topmed ActiveSaver 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:
Active Saver
Quick Overview
Main: Adult: Child:
Total Cost pm: R1,598 R1,598 R529

(Pay for all)

Savings: R3,072 R3,072 R1020
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Active Saver
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% scheme rate
  • 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:
  • Choose any hospital
  • No benefit
Specialised Radiology:
  • R2,600 co-payment paid by you or your gap cover
  • Gap cover pays co-payments for procedures approved by medical aid
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment approved by medical aid
  • No benefit for out-of-hospital services
Transplants:
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments:
  • Hysterectomy: R3,700
  • Cholecystectomy, specialised radiology, scopes (in-hospital): R2,600
  • Tonsils, adenoids, grommets: R550
  • Co-payments paid by you or your gap cover
  • Gap cover pays co-payments for procedures approved by medical aid
Alternatives to hospitals:
  • PMBs only
Casualty:
  • 100% scheme rate for treatment received on day of injury. Accident and trauma only
  • Otherwise, from day-to-day benefit
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • Treatment of immunocompromised and opportunistic infections: R46,872 per family
  • Stomatherapy: PMBs only
  • Post-operative benefits after hip and knee replacement, heart attack, post crime trauma, stroke
    Exclusions:
  • Musculoskeletal conditions
  • hiatus hernia repair
  • functional reconstruction of nasal septum,
  • endoscopic sinus surgery,
  • reconstruction of palate and uvula,
  • gaucher's
  • Sublimits increased as necessary
  • No benefit for out of hospital expenses or 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.

.
.
.
.
OUT OF HOSPITAL BENEFITS (non-PMB):
Active Saver
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R3,072 R3,072 R1020
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:
  • Paid from day-to-day benefit, unless PMB
Childcare:
  • No extra benefit available
Specialists consultations:
  • Paid from day-to-day benefit, unless PMB
Pathology:
  • Paid from day-to-day benefit, unless PMB
General radiology:
  • Paid from day-to-day benefit, unless PMB
Specialised radiology:
  • Paid from day-to-day benefit, unless PMB
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit, unless PMB

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

.
.
MATERNITY BENEFITS:
Active Saver
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
  • Elective caesarean: no benefit
  • Home births: covered
Consultations:
  • 6 consults
  • Pre-natal vitamins
  • 2 paediatrician visits (newborn)
  • Paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme

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

.
.
CANCER (ONCOLOGY):
Active Saver
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • PMBs only

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

.
.
DENTISTRY:
Active Saver
Scheme Benefits Gap benefits
Dentistry:
  • Standard dentistry: from day-to-day benefit
  • In-hospital: impacted wisdom teeth: R13,380 per family
  • Root canal, dental surgery, metal frame dentures, orthodontics, orthognathic surgery and implants: no benefit
Orthodontics:
  • No benefit
  • No extra benefit available
Maxillo Facial Surgery:
  • No benefit
  • 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

.
.
MEDICATION:
Active Saver
Scheme Benefits Gap benefits
Chronic:
  • PMBs chronic: paid by scheme with a 30% co-payment for non-formulary
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
  • Paid by scheme
On Discharge:
  • 7 days supply
Biological:
  • No benefit

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

.
.
OPTOMETRY:
Active Saver
Scheme Benefits Gap benefits
Optometry:
  • Paid from day-to-day 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

.
.
MENTAL HEALTH:
Active Saver
Scheme Benefits Gap benefits
In-hospital:
  • PMBs only
Out-of-hospital:
  • From day-to-day benefit, unless PMB
Trauma:

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

.
.
OTHER BENEFITS:
Active Saver
Scheme Benefits Gap benefits
General Appliances:
  • Paid from day-to-day benefit
  • No benefit
1.1. Hearing Aids:
  • Paid from day-to-day benefit
  • No benefit
1.2. Wheelchairs:
  • Paid from day-to-day benefit
  • No benefit
Dialysis:
  • PMBs only
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
  • No benefit
Emergency Transport: ER24
  • No benefit
International Insurance:
  • R10 million per family per year, maximum of 90 days
  • No benefit
Other:
  • Post-operative benefits hip and knee replacement (trauma only), heart attack, post crime trauma, stroke

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

.
.
WELLNESS/PREVENTATIVE BENEFITS:
Active Saver
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
Pneumonia vaccines:
  • Covered
  • 60yrs+
  • No benefit
Back Rehabilitation Programme: 2018 benefits are coming soon!
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • Covered
  • , 15yrs+
  • No benefit
Mammogram:
  • Covered for 40yrs+, every 2 years. Includes sonar.
  • No benefit
PAS Test:
  • Covered, 40yrs+. Frequency dependant on age.
  • No benefit
HIV Test:
  • Covered, 15yrs+
  • No benefit
Other:
  • Bone densitometry: 50yrs+, every 3 years
  • Glaucoma test: 40yrs+
  • Tetanus: as required
  • No benefit

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

.
.
PROSTHETICS:
Active Saver
Scheme Benefits Gap benefits
Overal Limit:
  • An additional R40,000 per sublimit, per event
Sub-limits:
  • An additional R40,000 per sublimit, per event

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