Topmed Family 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.

Family
2018 Costs:
Total Cost pm:

Main member:

R3,836

Adult:

R3,066

Child: (Pay only for first 3)

R1,048
Savings Account (yr): R9,216 R7,356 R2,508
Self Payment Gap:
R2,964 R2,966 R1,584
Above Threshold: 12,480 9,000 2,640
2019 Costs:
Total Cost pm:

Main member:

R
(%)

Adult:

R

Child: (Pay only for first 3)

R
Self Payment Gap:
R R R
In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Family
Scheme Benefits: Gap Benefits:
Specialists:
  • 150% 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:
  • R243,528
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Sublimits increased as necessary
Co-payments:
  • Joint replacement, spinal surgery, hiatus hernia repair: R7,900 co-payment
  • Hysterectomy: R3,700 co-payment
  • Laparoscopic surgery: R3,200 co-payment
  • Cholecystectomy: R2,600 co-payment
  • In-hospital scopes: R2,600 co-payment
  • Specialised radiology: R2,600 co-payment per scan
  • Sinus and nasal surgery: R2,100 co-payment
  • Dentistry (in-hospital): R1,700 co-payment
  • Impacted wisdom teeth: R1,120 co-payment
  • Tonsils, adenoids, grommets: R1,050 co-payment
  • 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:
  • Paid 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):
Family
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R9,216 R7,356 R2,508
Self Payment:
(per year, if you use up all your savings)
R2,964 R2,966 R1,584
Above Threshold: 12,480 9,000 2,640
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:
  • R4,284 per family from day-to-day benefit
General radiology:
  • R3,828 per family from day-to-day benefit
Specialised radiology:
  • R2,600 co-payment per scan
Supplementary Services: (Physio, etc)
  • R4,260 per family from day-to-day benefit

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

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MATERNITY BENEFITS:
Family
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
  • Elective caesarean: R21,840
  • Home births: covered
  • Neo-natal hospitalisation: R402,396 per family
Consultations:
  • 12 consults
  • 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):
Family
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R359,592 per person

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

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DENTISTRY:
Family
Scheme Benefits Gap benefits
Dentistry:
  • Paid from day-to-day benefit, up to limits below
  • In hospital: for kids under 6yrs. R1,700 co-payment
  • In hospital impacted wisdom teeth: R1,120 co-payment
  • Plastic/acrylic dentures: one set every 4 years
MM1M2M3M4
R7,044R7,860R8,772R9,780R10,608
Orthodontics:
  • Orthodontics: fixed braces for under 18yrs, one family member at a time
  • No extra benefit available
Maxillo Facial Surgery:
  • 150% 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:
Family
Scheme Benefits Gap benefits
Chronic:
  • PMBs chronic: paid by scheme with a 30% co-payment for non-formulary
  • non-PMBs: 8 extra conditions covered
  • Limited to R11,364 per family. Thereafter, only PMBs medication is unlimited.
Acute (presrcibed) medication:
  • Paid from day-to-day benefit, up to limits below
MM1M2M3M4
R4,860R6,084R7,296R9,684R13,032
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
On Discharge:
  • 7 days supply
Biological:

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

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OPTOMETRY:
Family
Scheme Benefits Gap benefits
Optometry:
  • R2,064 per person and R6,132 per family per year
  • 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:
Family
Scheme Benefits Gap benefits
In-hospital:
  • 21 days per person
Out-of-hospital:
  • R6,864 per family
  • 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:
Family
Scheme Benefits Gap benefits
General Appliances:
  • R4,854 per family
  • Paid from day-to-day benefit
  • No benefit
1.1. Hearing Aids:
  • R12,240 per family
  • Shared with wheelchair, hearing aid and external prostheses benefit
  • Paid from day-to-day benefit
  • No benefit
1.2. Wheelchairs:
  • R12,240 per family
  • Shared with wheelchair, hearing aid and external prostheses benefit
  • Paid from day-to-day benefit
  • No benefit
Dialysis:
  • R243,528
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:
Family
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:
Family
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