Topmed Essential 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:
Essential
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R1,588 R1,278 R645
Cost 2017: (R1,458) (R1,174) (R592)
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
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:
Essential
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:
  • Network or only paid at 75% scheme rate
Specialised Radiology:
  • R2,600 co-payment per scan
Supplementary Services: (Physio, etc)
  • 100% scheme rate
Transplants:
  • PMBs only
Co-payments:
  • In-hospital scopes: R2,600 co-payment. No co-payment if done in doctor's rooms
  • Specialised radiology: R2,600 co-payment per scan
  • 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:
  • 100% scheme rate for treatment received on day of injury. Accident and trauma only
Other:
  • Treatment of immunocompromised and opportunistic infections: R46,872 per family
  • Post-operative benefits after hip and knee replacement, heart attack, post crime trauma, stroke
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OUT OF HOSPITAL BENEFITS:
Essential
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • No benefit, unless PMB


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Childcare:
  • No benefit
Specialists consultations:
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • Post-operative benefits hip and knee replacement (trauma only), heart attack, post crime trauma, stroke
  • Otherwise, no benefit
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MATERNITY BENEFITS:
Essential
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • 100% scheme rate
  • Home births: covered

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Consultations:
  • 3 consults
  • Pre-natal vitamins
  • 1 paediatrician visits (newborn)
Scans:
  • 1 x 2D scans, paid by scheme
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CANCER (ONCOLOGY):
Essential
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • R298,320 per person per 12 month cycle
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:
Essential
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • No benefit, unless PMB

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Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • 100% 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:
Essential
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • PMBs chronic: paid by scheme with a 30% co-payment for non-formulary

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Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • 7 days supply
Biological:
  • No benefit
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OPTOMETRY:
Essential
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • No benefit

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

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Out-of-hospital:
  • PMBs only
Trauma:
  • 12consults for 6 months from date of event
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OTHER BENEFITS:
Essential
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • No benefit
  • No benefit

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1.1. Hearing Aids:
  • No benefit
  • No benefit
1.2. Wheelchairs:
  • No 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:
  • 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:
Essential
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • No benefit
  • No benefit

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Pneumonia vaccines:
  • No benefit
  • No benefit
Back Rehabilitation Programme: 2018 benefits are coming soon!
  • No benefit
Biometric Screening: 2018 benefits are coming soon!
  • No benefit
Child Immunisation:
  • No benefit
  • No benefit
Pap Smear:
  • No benefit
  • No benefit
Mammogram:
  • No benefit
  • No benefit
PAS Test:
  • No benefit
  • No benefit
HIV Test:
  • No benefit
  • No benefit
Other:
  • No benefit
  • 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