Topmed Limited 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:
Limited
Quick Overview
Main: Adult: Child:
Total Cost pm: R2,267 R990 R416
Savings (per year): No savings option on this plan
Gap (optional): KaeloXelus: R350 per family
(R600 per family if anyone is 60yrs+)
Overal Limit:
  • Public hospitals: Unlimited
  • Private hospitals: Up to R1,000,000 per person of cost with co-payment, then unlimited in public hospital
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 all children
See full benefits below

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IN HOSPITAL PROCEDURES:
Limited
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
Specialised Radiology:
  • Subject to Overall Annual Limit and 20% co-payment
Supplementary Services: (Physio, etc)
  • Subject to Overall Annual Limit and 20% co-payment
Transplants:
  • Subject to Overall Annual Limit and 20% co-payment
Co-payments:
  • Hospital account at private hospital: 50% of the first R5,220, then 10% of remainder up to a maximum of R11,280 in total
  • All other accounts: 20% co-payment
  • 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: 21 days per person
Casualty:
  • Subject to Overall Annual Limit and 20% co-payment
Other:
  • Treatment of immunocompromised and opportunistic infections: R46,872 per family
  • Medical appliances: R5,556 per person
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OUT OF HOSPITAL BENEFITS:
Limited
Benefits Gap benefits
GP consultations:
  • R7,080 per family, including specialists with 20% co-payment, unless PMB
Childcare:
  • No benefit
Specialists consultations:
  • See GP benefit, above
Pathology:
  • R5,088 per family, for radiology, pathology and histology
  • 20% co-payment
General radiology:
  • R5,088 per family, for radiology, pathology and histology
  • 20% co-payment
Specialised radiology:
  • 3 scans per family, R15,852
  • 20% co-payment
Supplementary Services: (Physio, etc)
  • Physiotherapist, Chiropractor and Biokineticist: R3,024 per family
  • Audiologist, Dietician, Occupational Therapist, Speech Therapist, Social Worker: R2,400 per family
  • Chiropodist, Homeopath, Naturopath, Osteopath, Podiatrist and Orthoptist: R2,400 per family
  • 20% co-payment
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MATERNITY BENEFITS:
Limited
Benefits Gap benefits
Hospital stay:
  • Subject to Overall Annual Limit and 20% co-payment
Consultations:
  • 2 consults
Scans:
  • 2 x 2D scans, paid by scheme
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CANCER (ONCOLOGY):
Limited
Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Subject to Overall Annual Limit and 20% co-payment
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DENTISTRY:
Limited
Benefits Gap benefits
Dentistry:
  • Standard dentistry: R5,040 per family
  • Specialised dentistry: R8,028 per family
  • 20% co-payment
Orthodontics: See above
Maxillo Facial Surgery: 2018 benefits are coming soon!
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MEDICATION:
Limited
Benefits Gap benefits
Chronic:
  • PMBs and non-PMBs: R11,508 per family. Thereafter, only PMBs are covered
  • 20% co-payment for non-PMBs
Acute (presrcibed) medication:
  • R7,860 per family
  • 20% co-payment
Over-the-counter:
Birth Control:
On Discharge:
  • 7 days supply
Biological:
  • No benefit
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OPTOMETRY:
Limited
Benefits Gap benefits
Optometry:
  • Test: R468 per person
  • Single vision, incl test: R924 per person
  • Bifocal, incl test: R1,380 per person
  • Multifocal, incl test: R1,848 per person
  • 20% co-payment
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MENTAL HEALTH:
Limited
Benefits Gap benefits
In-hospital:
  • 21 days per person
Out-of-hospital:
  • R4,488 per family
  • 20% co-payment
Trauma:
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OTHER BENEFITS:
Limited
Benefits Gap benefits
General Appliances:
  • R5,364 per person
  • 20% co-payment
  • No benefit
1.1. Hearing Aids:
  • R12,828 per person every 2 years
  • 20% co-payment
  • No benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
  • No benefit
Dialysis:
  • Subject to Overall Annual Limit and 20% co-payment
HIV:
  • Subject to Overall Annual Limit and 20% co-payment
  • No benefit
Emergency Transport:
  • No benefit
International Insurance:
  • R10 million per family per year, maximum of 90 days
  • No benefit
Other: 2018 benefits are coming soon!
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WELLNESS/PREVENTATIVE BENEFITS:
Limited
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
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PROSTHETICS:
Limited
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