Topmed Executive 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:
Executive
Quick Overview
Main: Adult: Child:
Total Cost pm: R4,894 R3,906 R1,488

(Pay only for first 3)

Savings: R14,676 R11,712 R4,440
Self Payment:
(per year, if you use up all your savings)
R2,952 R2,952 R1,176
Above Threshold:
  • Once your savings are depleted, and you have paid the self payment gap, scheme will cover most out of hospital expenses at scheme rate, with sublimits for some benefits.
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Executive
Scheme Benefits: Gap Benefits:
Specialists:
  • 200% scheme rate
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Choose any hospital
  • No benefit
Specialised Radiology:
  • R2,600 co-payment paid by you or your gap cover
  • Gap cover pays co-payments for procedures approved by medical aid
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Stomatherapy: R19,980 per family
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
  • Sublimit increased as necessary
Transplants:
  • Covered
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Sublimits increased as necessary
Co-payments:
  • Hysterectomy: R2,700 co-payment
  • Hernia Repair: R5,300 co-payment
  • Laparoscopic surgery: R2,100 co-payment
  • Scopes: R2,600 co-payment
  • Specialised radiology: R2,600 co-payment per scan
  • Co-payments paid by you or your gap cover
  • Gap cover pays co-payments for procedures approved by medical aid
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
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
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
  • Sublimits increased as necessary
  • No benefit for out of hospital expenses or exclusions
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

No phone calls!
Our quote will include the right gap cover for this plan

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Executive
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R14,676 R11,712 R4,440
Self Payment:
(per year, if you use up all your savings)
R2,952 R2,952 R1,176
Above Threshold: Once your savings are depleted, and you have paid the self payment gap, scheme will cover most out of hospital expenses at scheme rate, with sublimits for some benefits.
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • Paid from day-to-day benefit
Childcare:
  • No extra benefit available
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

No phone calls!
Our quote will include the right gap cover for this plan

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MATERNITY BENEFITS:
Executive
Scheme Benefits Gap benefits
Hospital stay:
  • 200% scheme rate
  • Home births: covered
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

No phone calls!
Our quote will include the right gap cover for this plan

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CANCER (ONCOLOGY):
Executive
Scheme Benefits Gap benefits
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

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Our quote will include the right gap cover for this plan

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DENTISTRY:
Executive
Scheme Benefits Gap benefits
Dentistry:
  • Standard dentistry: from day-to-day benefit
  • Specialised dentistry: R15,024 from day-to-day benefit, with sub-limits.
Orthodontics:
  • Orthodontics: fixed braces for under 18yrs, from day-to-day benefit adn subject to specialised dentistry limit
  • No extra benefit available
Maxillo Facial Surgery:
  • 200% scheme rate, limited to jaw fractures, congenital deformities and surgical treatments of pathological conditions
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MEDICATION:
Executive
Scheme Benefits Gap benefits
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.
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

No phone calls!
Our quote will include the right gap cover for this plan

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OPTOMETRY:
Executive
Scheme Benefits Gap benefits
Optometry:
  • R2,496 per person and R7,296 per family
  • Paid from day-to-day benefit
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MENTAL HEALTH:
Executive
Scheme Benefits Gap benefits
In-hospital:
  • 21 days per person
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

No phone calls!
Our quote will include the right gap cover for this plan

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OTHER BENEFITS:
Executive
Scheme Benefits Gap benefits
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
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: ER24
  • 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

No phone calls!
Our quote will include the right gap cover for this plan

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WELLNESS/PREVENTATIVE BENEFITS:
Executive
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
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

No phone calls!
Our quote will include the right gap cover for this plan

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PROSTHETICS:
Executive
Scheme Benefits Gap benefits
Overal Limit:
  • An additional R40,000 per sublimit, per event
Sub-limits:
  • An additional R40,000 per sublimit, per event

No phone calls!
Our quote will include the right gap cover for this plan


    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