Topmed Executive 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:
Executive
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R4,894 R3,906 R1,488
Cost 2017: (R4,453) (R3,554) (R1,355)
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: R14,676 R11,712 R4,440
Self Payment: R2,952 R2,952 R1,176
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:
Executive
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:
  • Hysterectomy: R2,700
  • Hernia Repair: R5,300
  • Laparoscopic surgery: R2,100
  • Scopes: R2,600
  • Specialised radiology: R2,600 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:
  • From day-to-day benefit
Other:
  • Treatment of immunocompromised and opportunistic infections: R46,872per family
  • Stomatherapy: R18,900 per family
  • Post-operative benefits after hip and knee replacement, heart attack, post crime trauma, stroke
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OUT OF HOSPITAL BENEFITS:
Executive
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • Paid from day-to-day benefit


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Childcare:
  • No benefit
Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • R2,600 co-payment per scan
Supplementary Services: (Physio, etc)
  • From day-to-day benefit, and limited to R6,072 per person and R17,952 per family
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MATERNITY BENEFITS:
Executive
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • 200% scheme rate
  • Home births: covered

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Consultations:
  • 12 consults
  • 12 ante natal classes
  • Pre-natal vitamins
  • 2 paediatrician visits (newborn)
  • Paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme
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CANCER (ONCOLOGY):
Executive
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • R484,044 per person
  • Biological medicine: R281,436 per family, with a 20% co-payment, and part of the above limit
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:
Executive
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • Standard dentistry: from day-to-day benefit
  • Specialised dentistry: R15,024 from day-to-day benefit, with sub-limits.

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Orthodontics:
  • Orthodontics: fixed braces for under 18yrs, from day-to-day benefit adn subject to specialised dentistry limit
Maxillo Facial Surgery:
  • 200% 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:
Executive
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • PMBs chronic: paid by scheme with a 30% co-payment for non-formulary
  • non-PMBs: paid by scheme
  • Limited to R10,128 per person and R20,616 per family. Thereafter, only PMBs medication is unlimited.

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Acute (presrcibed) medication:
  • Paid from day-to-day benefit, limited to R11,256 per person and R22,284 per family
Over-the-counter:
  • Paid from day-to-day benefit, up to acute medicine limits
  • Not payable from above-threshold benefit
Birth Control:
  • Paid from day-to-day benefit, up to acute medicine limits
On Discharge:
  • 7 days supply
Biological:
  • R281,436 per family, as part of oncology limit
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OPTOMETRY:
Executive
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • R2,496 per person and R7,296 per family
  • Paid from day-to-day benefit

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

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Out-of-hospital:
  • Psychologists: R6,288 per family
  • Psychiatry: benefit shared with out-of-hospital specialist benefit
  • Paid from day-to-day benefit
Trauma:
  • 12consults for 6 months from date of event
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OTHER BENEFITS:
Executive
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • Appliances: R2,856 per family
  • Oxygen, in and out of hospital: R24,036 per family
  • Paid from day-to-day benefit
  • No benefit

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1.1. Hearing Aids:
  • R15,024 per family every 3 years
  • Paid from day-to-day benefit
  • No benefit
1.2. Wheelchairs:
  • R15,024 per family every 5 years
  • Paid from day-to-day 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:
Executive
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