Topmed Network C 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:
Network C
Quick Overview
Main: Adult: Child:
Total Cost pm: R1,397 R1,397 R391

(Pay for all)

Savings (per year):
  • No savings option on this plan
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
Income band:
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Network C
Scheme Benefits: Gap Benefits:
Specialists:
  • 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:
  • PMB only per scan
  • No benefit
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
Transplants:
  • PMBs only, in State facilities
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments: .
Alternatives to hospitals:
  • PMBs only
Casualty:
  • Unlimited in public hospital
  • 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: PMBs only
  • No cover for injuries sustained during strike, picketing, riot or physical struggle
  • 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):
Network C
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:
  • Network GPs: Basic primary care
  • Non-Network GPs: 3 visits per year, R1,236 per family, for emergencies only
Childcare:
  • No extra benefit available
Specialists consultations:
  • Network: R1,500 per family, including any radiology and pathology requested
Pathology:
  • Basic blood tests covered if requested by GP
General radiology:
  • Basic x-rays covered if requested by GP
Specialised radiology:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

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

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MATERNITY BENEFITS:
Network C
Scheme Benefits Gap benefits
Hospital stay:
  • One confinement per year
  • Home births: covered
Consultations:
  • Pre and postnatal care, from Primary Healthcare Provider
Scans:
  • 1 x 2D scan, paid by scheme

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

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CANCER (ONCOLOGY):
Network C
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • PMBs only

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

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DENTISTRY:
Network C
Scheme Benefits Gap benefits
Dentistry:
  • Standard dentistry: network provider only. Includes 1 set of plastic dentures per family every 2 years.
  • Specialised dentistry: no benefit
Orthodontics:
  • You pay this out of pocket
  • 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:
Network C
Scheme Benefits Gap benefits
Chronic:
  • PMBs chronic: paid by scheme
Acute (presrcibed) medication:
  • Covered if dispensed by Network GP or pharmacy, according to formulary
Over-the-counter:
  • R216 per family per year, with a maximum of R72 per script
Birth Control:
  • No benefit
On Discharge:
  • No benefit
Biological:
  • No benefit

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

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OPTOMETRY:
Network C
Scheme Benefits Gap benefits
Optometry:
  • One test, one set of lenses, one standard frame OR contacts to the value of R444 per person every 2 years
  • 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:
Network C
Scheme Benefits Gap benefits
In-hospital:
  • PMBs only
Out-of-hospital:
  • PMBs only
Trauma:

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

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OTHER BENEFITS:
Network C
Scheme Benefits Gap benefits
General Appliances:
  • PMBs only
  • No benefit
1.1. Hearing Aids:
  • No benefit
  • No benefit
1.2. Wheelchairs:
  • No benefit
  • No benefit
Dialysis:
  • PMBs only, in State facilities
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
  • No benefit
Emergency Transport: v
  • No benefit
International Insurance:
  • No benefit
  • 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:
Network C
Scheme Benefits Gap benefits
Flu vaccination: 2018 benefits are coming soon!
  • No benefit
Pneumonia vaccines: 2018 benefits are coming soon!
  • No benefit
Back Rehabilitation Programme: 2018 benefits are coming soon!
  • No benefit
Biometric Screening: 2018 benefits are coming soon!
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear: 2018 benefits are coming soon!
  • No benefit
Mammogram: 2018 benefits are coming soon!
  • No benefit
PAS Test: 2018 benefits are coming soon!
  • No benefit
HIV Test: 2018 benefits are coming soon!
  • No benefit
Other:
  • No benefit

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

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PROSTHETICS:
Network C
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