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.

COSTS and OVERVIEW:
Family
Quick Overview
Main: Adult: Child:
Total Cost pm: R3,836 R3,066 R1,048
Savings: 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
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

Compare to:
  • Coming soon!
  • Coming soon!
  • Coming soon!
  • Coming soon!
  • Coming soon!
Links will open in a side by side
comparison view

.

IN HOSPITAL PROCEDURES:
Family
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:
  • Unlimited
Specialised Radiology:
  • R2,600 co-payment per scan
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Stomatherapy: R19,980 per family
Transplants:
  • R243,528
Co-payments:
  • Joint replacement, spinal surgery, hiatus hernia repair: R7,900
  • Hysterectomy: R3,700
  • Laparoscopic surgery: R3,200
  • Cholecystectomy: R2,600
  • In-hospital scopes: R2,600 co-payment
  • Specialised radiology: R2,600 co-payment per scan
  • Sinus and nasal surgery: R2,100
  • Dentistry (in-hospital): R1,700
  • Impacted wisdom teeth: R1,120
  • Tonsils, adenoids, grommets: R1,050
  • 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:
  • Paid 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
.
.
.
.
OUT OF HOSPITAL BENEFITS:
Family
Benefits Gap benefits
GP consultations:
  • Paid from day-to-day benefit.
Childcare:
  • No benefit
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
.
.
MATERNITY BENEFITS:
Family
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
.
.
CANCER (ONCOLOGY):
Family
Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R359,592 per person
.
.
DENTISTRY:
Family
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
Maxillo Facial Surgery:
  • 150% scheme rate, limited to jaw fractures, congenital deformities and surgical treatments of pathological conditions
.
.
MEDICATION:
Family
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:
.
.
OPTOMETRY:
Family
Benefits Gap benefits
Optometry:
  • R2,064 per person and R6,132 per family per year
  • Paid from day-to-day benefit
.
.
MENTAL HEALTH:
Family
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
.
.
OTHER BENEFITS:
Family
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:
  • 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
.
.
WELLNESS/PREVENTATIVE BENEFITS:
Family
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
.
.
PROSTHETICS:
Family
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