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.

Limited
2018 Costs:
Total Cost pm:

Main member:

R2,267

Adult:

R990

Child: (Pay for all)

R416
Savings Account:
  • No savings option on this plan
2019 Costs:
Total Cost pm:

Main member:

R
(%)

Adult:

R

Child: (Pay for all)

R
In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Limited
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% 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:
  • Network
  • No benefit
Specialised Radiology:
  • Subject to Overall Annual Limit and 20% co-payment
  • Co-payment benefit pays the co-payments
Supplementary Services: (Physio, etc)
  • Subject to Overall Annual Limit and 20% co-payment
  • Co-payment paid
  • No benefit for exclusions
Transplants:
  • Subject to Overall Annual Limit and 20% co-payment
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
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 cover pays co-payments for procedures approved by medical aid
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
  • 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: R46,872 per family
  • Medical appliances: R5,556 per person
  • 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):
Limited
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
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:
  • R7,080 per family, including specialists with 20% co-payment, unless PMB
Childcare:
  • No extra benefit available
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

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

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MATERNITY BENEFITS:
Limited
Scheme 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

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

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CANCER (ONCOLOGY):
Limited
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Subject to Overall Annual Limit and 20% co-payment

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

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DENTISTRY:
Limited
Scheme Benefits Gap benefits
Dentistry:
  • Standard dentistry: R5,040 per family
  • Specialised dentistry: R8,028 per family
  • 20% co-payment
Orthodontics:
  • See above
  • No extra benefit available
Maxillo Facial Surgery: 2018 benefits are coming soon!
  • 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:
Limited
Scheme 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

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

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OPTOMETRY:
Limited
Scheme 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
  • 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:
Limited
Scheme Benefits Gap benefits
In-hospital:
  • 21 days per person
Out-of-hospital:
  • R4,488 per family
  • 20% co-payment
Trauma:

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

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OTHER BENEFITS:
Limited
Scheme 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: ER24
  • No benefit
International Insurance:
  • R10 million per family per year, maximum of 90 days
  • No benefit
Other: 2018 benefits are coming soon!

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

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WELLNESS/PREVENTATIVE BENEFITS:
Limited
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:
Limited
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