Topmed Essential 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:
Essential
Quick Overview
Main: Adult: Child:
Total Cost pm: R1,588 R1,278 R645
Savings (per year): No savings option on this plan
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
Children: Pay for maximum 3 children
See full benefits below

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IN HOSPITAL PROCEDURES:
Essential
Benefits Gap benefits
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
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
Benefits Gap benefits
GP consultations:
  • No benefit, unless PMB
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
Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
  • Home births: covered
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
Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R298,320 per person per 12 month cycle
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DENTISTRY:
Essential
Benefits Gap benefits
Dentistry:
  • No benefit, unless PMB
Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • 100% scheme rate, limited to jaw fractures, congenital deformities and surgical treatments of pathological conditions
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MEDICATION:
Essential
Benefits Gap benefits
Chronic:
  • PMBs chronic: paid by scheme with a 30% co-payment for non-formulary
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
Benefits Gap benefits
Optometry:
  • No benefit
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MENTAL HEALTH:
Essential
Benefits Gap benefits
In-hospital:
  • 21 days per person
Out-of-hospital:
  • PMBs only
Trauma:
  • 12consults for 6 months from date of event
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OTHER BENEFITS:
Essential
Benefits Gap benefits
General Appliances:
  • No benefit
  • No benefit
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
Benefits Gap benefits
Flu vaccination:
  • No benefit
  • No benefit
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
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PROSTHETICS:
Essential
Benefits Gap benefits
Overal Limit:
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