Topmed Comprehensive medical aid plan: 2017 vs 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:
Comprehensive
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R6,672 R5,506 R1,566
Cost 2017: (R6,070) (R5,010) (R1,425)
Gap (optional): KaeloXelus: R350 per family
(R600 per family if anyone is 60yrs+)
Overal Limit: Unlimited
PMBs: Day-to-day expenses for PMBs (eg. cancer) are always paid for by the scheme, according to protocols. Find out more
Savings: No savings option on this plan
Extended Fund: R9,816 R8,316 R2,172
Self Payment: R3216 R2412 R804
Above Threshold: Unlimited overall, with sublimits for some benefits. Find out more
Children: Pay for maximum 3 children

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Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family


IN HOSPITAL PROCEDURES:
Comprehensive
2017 v 2018 benefits Gap benefits Notes
Payout Rate for Specialists:
  • Up to 500% of scheme rate
  • In case of admission related to accident:
    • R300 per day, for days 1-13
    • R600 per day for days 14-20
    • R1,200 per day for days 21-30

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Hospital Choice:
  • Unlimited
Specialised Radiology:
  • R2,600 co-payment per scan
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Stomatherapy: R19,980 per family
Transplants:
  • Covered
Co-payments:
  • Gastroscopies and colonoscopies: R2,600
  • Specialised radiology: R2,600 per scan
  • Dentistry (in-hospital): R1,700
  • Impacted wisdom teeth: R1,120
  • Gap covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Alternatives to hospitals:
  • Private nursing and step down facilities and hospice: R139,200 per person for procedures and treatments
Casualty:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
Other:
  • Treatment of immunocompromised and opportunistic infections: R46,872 per family
  • Specialised surgery (new technology): R317,100 per family
  • Post-operative benefits after hip and knee replacement, heart attack, post crime trauma, stroke
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OUT OF HOSPITAL BENEFITS:
Comprehensive
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • Paid from day-to-day benefit, at 80% scheme rate when from above threshold benefit


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Childcare:
  • No benefit
Specialists consultations:
  • Paid from day-to-day benefit, at 80% scheme rate when from above threshold benefit
Pathology:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
General radiology:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
Specialised radiology:
  • R2,600 co-payment per scan
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
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MATERNITY BENEFITS:
Comprehensive
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • 300% scheme rate
  • Home births: covered

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Consultations:
  • 12 consults
  • Pre-natal vitamins
  • 2 paediatrician visits (newborn)
  • Paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme
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CANCER (ONCOLOGY):
Comprehensive
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • R596,640 per person, with 20% co-payment thereafter
  • Biological medicine: R337,716 per family, with 20% co-payment, part of the above limit
  • Herceptin: no co-payment for 9 week course
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.
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DENTISTRY:
Comprehensive
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • Standard and specialised dentistry: R24,072From day-to-day benefit, with 80% scheme rate when from above threshold benefit
  • In hospital for kids under 6yrs R1,700 co-payment.
  • In-hospital for dental clearance (12 teeth or more): R26,844 with a R1,700 co-payment
  • In hospital impacted wisdom teeth: R1,120 co-payment
  • Orthognathic surgery: 20% co-payment

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Orthodontics:
  • Orthodontics: fixed braces for under 18yrs, one family member at a time
Maxillo Facial Surgery:
  • 300% scheme rate, limited to jaw fractures, congenital deformities and surgical treatments of pathological conditions

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

MEDICATION:
Comprehensive
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • PMBs chronic: paid by scheme with a 30% co-payment for non-formulary
  • non-PMBs:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

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Acute (presrcibed) medication:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
Over-the-counter:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit. Max R168 per script
  • Vitamins and Minerals: M= R2,604, Adult= R2,148 and child=R600
Birth Control:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
On Discharge:
  • 7 days supply
Biological:
  • R337,716 per family
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OPTOMETRY:
Comprehensive
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • Paid from day-to-day benefit, with 20% co-payment when from above threshold
  • Contact lenses: R2,424 per person
  • No benefit for both spectacles and contacts in same year

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MENTAL HEALTH:
Comprehensive
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • 21 days per person

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Out-of-hospital:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
Trauma:
  • 12consults for 6 months from date of event
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OTHER BENEFITS:
Comprehensive
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
  • No benefit

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1.1. Hearing Aids:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
  • No benefit
1.2. Wheelchairs:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
  • No benefit
Dialysis:
  • Covered
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
  • No benefit
Emergency Transport:
  • 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
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WELLNESS/PREVENTATIVE BENEFITS:
Comprehensive
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • Covered
  • No benefit

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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

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

2017 v 2018 benefits Gap benefits Notes
Overal Limit:
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Sub-limits:
  • An additional R40,000 per sublimit, per event

    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