Topmed Executive medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply. Pay for all children.

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

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Hospital Choice:
  • Unlimited
Specialised Radiology:
  • R2,500 co-payment per scan
Supplementary Services: (Physio, etc)
Transplants:
  • Covered
Co-payments:
  • Hysterectomy: R2,500
  • Hernia Repair: R5,000
  • Laparoscopic surgery: R2,000
  • Scopes: R2,500
  • Specialised radiology: R2,500 per scan
Alternatives to hospitals:
  • Private nursing and step down facilities and hospice: R131,676 per person

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

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Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • R2,500 co-payment per scan
Supplementary Services: (Physio, etc)
  • From day-to-day benefit, and limited to R5,748 per person and R16,980 per family

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

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Consultations:
  • 12 consults
  • 12 ante natal classes
  • Pre-natal vitamins
  • 2 paediatrician visits (newborn)
  • Paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R457,944 per person
  • Biological medicine: R266,256 per family, part of the above limit

Note: 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.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: from day-to-day benefit
  • Specialised dentistry: R14,208 from day-to-day benefit, with sub-limits.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

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Orthodontics:
  • Orthodontics: fixed braces for under 18yrs, from day-to-day benefit
Maxillo Facial Surgery:
  • 200% scheme rate, limited to severe trauma or facial deformity

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: paid by scheme
  • Limited to R8,650 per person and R17,350 per family. Thereafter, only PMBs medication is unlimited.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

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Acute (presrcibed) medication:
  • Paid from day-to-day benefit, limited to R10,644 per person and R21,084 per family
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, up to acute medicine limits
On Discharge:
  • 7 days supply
Notes:
  • For PMBs chronic medication, there is a 30% co-payment if you do not use designated provider, or if you use medicine that is not on the formulary

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OPTOMETRY:
Optometry:
  • R2,364 per person and R6,900 per family
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • 21 days per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

Compare with these plans:


Out-of-hospital:
  • Psychologists: R5,952 per family
  • Psychiatry: benefit shared with out-of-hospital specialist benefit
  • Paid from day-to-day benefit

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OTHER BENEFITS:
General Appliances:
  • Appliances: R2,700 per family
  • Oxygen, in and out of hospital: R22,740 per family
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

Compare with these plans:

1.1. Hearing Aids:
  • R14,208 per family every 3 years
  • Paid from day-to-day benefit
1.2. Wheelchairs:
  • R14,208 per family every 5 years
  • Paid from day-to-day benefit
Dialysis:
  • Covered
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport: ER24
International Coverage:
  • R10 million per family per year, maximum of 90 days
Other:
  • Post-operative benefits hip and knee replacement (trauma only), heart attack, post crime trauma, stroke

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

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Pneumonia vaccines:
  • Covered
    • 60yrs+
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered
    • , 15yrs+
Mammogram:
  • Covered for 40yrs+, every 2 years. Includes sonar.
PAS Test:
  • Covered, 40yrs+. Frequency dependant on age.
HIV Test:
  • Covered, 15yrs+

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,453 R3,554 R1,355
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (with co-payment), maternity, scopes, alternatives to hospitalisation, extended rehab benefits, preventative benefits. Limits apply. All else paid for from day-to-day benefits, which include an unlimited above threshold benefit or out-of pocket, unless PMB. Sub-limits apply.
Main: Adult: Child:
(S) Savings: R12,356 R10,656 R4,044

Compare with these plans:
Sub-limits:

    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