Topmed Family 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 from savings, or from out of pocket, unless PMB. Pay for all children.

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • R2,500 co-payment per scan
Supplementary Services: (Physio, etc)
Transplants:
  • R230,400
Co-payments:
  • Joint replacement, spinal surgery, hiatus hernia repair: R7,500
  • Hysterectomy: R3,500
  • Laparoscopic surgery: R3,000
  • Cholecystectomy: R2,500
  • In-hospital scopes: R2,500 co-payment
  • Specialised radiology: R2,500 co-payment per scan
  • Sinus and nasal surgery: R2,000
  • Dentistry (in-hospital): R1,600
  • Impacted wisdom teeth: R1,060
  • Tonsils, adenoids, grommets: R1,000
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: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • R4,056 per family from day-to-day benefit
General radiology:
  • R3,624 per family from day-to-day benefit
Specialised radiology:
  • R2,500 co-payment per scan
Supplementary Services: (Physio, etc)
  • R4,032 per family from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
  • 100% scheme rate
  • Elective caesarean: R20,652
  • Home births: covered
  • Neo-natal hospitalisation: R380,700 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

Compare with these plans:

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):
  • R340,200 per person

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: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Paid from day-to-day benefit, up to limits below
  • In hospital: for kids under 6yrs. R1,600 co-payment
  • In hospital impacted wisdom teeth: R1,060 co-payment
  • Plastic/acrylic dentures: one set every 4 years
MM1M2M3M4
R6,660R7,440R8,304R9,252R10,032
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

Compare with these plans:

Orthodontics:
  • Orthodontics: fixed braces for under 18yrs, one family member at a time
Maxillo Facial Surgery:
  • 150% scheme rate, limited to severe trauma or facial deformity

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
  • non-PMBs: 8 extra conditions covered
  • Limited to R10,752 per family. Thereafter, only PMBs medication is unlimited.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit, up to limits below
MM1M2M3M4
R4,596R5,760R6,900R9,156R12,324
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
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:
  • R1,956 per person and R5,800 per family per year
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

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: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

Compare with these plans:


Out-of-hospital:
  • R6,492 per family
  • Paid from day-to-day benefit

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OTHER BENEFITS:
General Appliances:
  • R4,332 per family
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

Compare with these plans:

1.1. Hearing Aids:
  • R11,568 per family
  • Shared with wheelchair, hearing aid and external prostheses benefit
  • Paid from day-to-day benefit
1.2. Wheelchairs:
  • R11,568 per family
  • Shared with wheelchair, hearing aid and external prostheses benefit
  • Paid from day-to-day benefit
Dialysis:
  • R230,400
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: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

Compare with these plans:

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: R3,490 R2,790 R954
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 from savings, or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R8,376 R6,696 R2,292

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