Topmed Network A medical aid plan: 2017 vs 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 A
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R348 R348 R348
Cost 2017: (R319) (R319) (R319)
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
Savings: No savings option on this plan
Children: Pay for all children
Income band: This plan is only available to households with income in R0-R1,000pm band.
View other income bands

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Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family


IN HOSPITAL PROCEDURES:
Network A
2017 v 2018 benefits Gap benefits Notes
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

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Hospital Choice:
  • Network
  • R12,800 per person per year for use of a non-network hospital
Specialised Radiology:
  • PMB only per scan
Supplementary Services: (Physio, etc)
  • 100% scheme rate
Transplants:
  • PMBs only, in State facilities
Co-payments:
  • Gap covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Alternatives to hospitals:
  • PMBs only
Casualty:
  • Unlimited in public hospital
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
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OUT OF HOSPITAL BENEFITS:
Network A
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • Network GPs: Basic primary care
  • Non-Network GPs: 3 visits per year, R1,236 per family, for emergencies only


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Childcare:
  • No benefit
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
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MATERNITY BENEFITS:
Network A
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • One confinement per year
  • Home births: covered

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Consultations:
  • Pre and postnatal care, from Primary Healthcare Provider
Scans:
  • 1 x 2D scan, paid by scheme
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CANCER (ONCOLOGY):
Network A
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • PMBs only
All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
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DENTISTRY:
Network A
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • Standard dentistry: network provider only. Includes 1 set of plastic dentures per family every 2 years.
  • Specialised dentistry: no benefit

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Orthodontics:
  • No benefit
Maxillo Facial Surgery: 2018 benefits are coming soon!

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

MEDICATION:
Network A
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • PMBs chronic: paid by scheme

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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
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OPTOMETRY:
Network A
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • One test, one set of lenses, one standard frame OR contacts to the value of R444 per person every 2 years

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MENTAL HEALTH:
Network A
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • PMBs only

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Out-of-hospital:
  • PMBs only
Trauma:
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OTHER BENEFITS:
Network A
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • PMBs only
  • No benefit

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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:
  • No benefit
International Insurance:
  • No benefit
  • No benefit
Other: 2018 benefits are coming soon!
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WELLNESS/PREVENTATIVE BENEFITS:
Network A
2017 v 2018 benefits Gap benefits Notes
Flu vaccination: 2018 benefits are coming soon!
  • No benefit

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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

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

2017 v 2018 benefits Gap benefits Notes
Overal Limit:
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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