Topmed Comprehensive medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply. Pay for all children.

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • R2,500 co-payment per scan
Supplementary Services: (Physio, etc)
Transplants:
  • Covered
Co-payments:
  • Gastroscopies and colonoscopies: R2,500
  • Specialised radiology: R2,500 per scan
  • Dentistry (in-hospital): R1,600
  • Impacted wisdom teeth: R1,060
Alternatives to hospitals:
  • Private nursing and step down facilities and hospice: R131,676 per person

.
.

OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Paid from day-to-day benefit, at 80% scheme rate when from above threshold benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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:
  • R2,500 co-payment per scan
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

.
.

MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Consultations:
  • 12 consults
  • 12 ante natal classes
  • Pre-natal vitamins
  • 2 paediatrician visits (newborn)
  • Paid by scheme
Scans:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

.
.

CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R564,444 per person, with 20% co-payment thereafter
  • Biological medicine: R319,500 per family, part of the above limit
  • Herceptin: no co-payment for 9 week course

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: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

.
.

DENTISTRY:
Dentistry:
  • Standard and specialised dentistry: R22,776From day-to-day benefit, with 80% scheme rate when from above threshold benefit
  • In hospital: for kids under 6yrs and dental clearance R1,600 co-payment
  • In hospital impacted wisdom teeth: R1,060 co-payment
  • Orthognathic surgery: 20% co-payment
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics:
  • Orthodontics: fixed braces for under 18yrs, one family member at a time
Maxillo Facial Surgery:
  • 300% scheme rate, limited to severe trauma or facial deformity

.
.

MEDICATION:
Chronic:
  • PMBs chronic: covered
  • non-PMBs:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
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
  • Vitamins and Minerals: M= R2,460, Adult= R2,028 and child=R564
Birth Control:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
On Discharge:
  • 7 days supply
Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

.
.

OPTOMETRY:
Optometry:
  • Paid from day-to-day benefit, at set rates when from above threshold
  • Contact lenses: R2,292 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

.
.

MENTAL HEALTH:
In-hospital:
  • 21 days per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit

.
.

OTHER BENEFITS:
General Appliances:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

1.1. Hearing Aids:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
1.2. Wheelchairs:
  • Paid from day-to-day benefit, with 80% scheme rate when from above threshold benefit
Dialysis:
  • Covered
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport: ER24
International Coverage:
  • R10 million per family per year, maximum of 90 days
Other:
  • Post-operative benefits hip and knee replacement (trauma only), heart attack, post crime trauma, stroke

.
.

WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Pneumonia vaccines:
  • Covered
  • 60yrs+
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered
  • , 15yrs+
Mammogram:
  • Covered for 40yrs+, every 2 years. Includes sonar.
PAS Test:
  • Covered, 40yrs+. Frequency dependant on age.
HIV Test:
  • Covered, 15yrs+

.
.

PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,070 R5,010 R1,425
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
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