Topmed Limited medical aid plan: 2017

Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB. Pay for all children.

View all plans in this scheme

IN HOSPITAL PROCEDURES:

Payout Rate for Specialists:

100% scheme rate, with co-payment

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

Hospital Choice:

Unlimited

Specialised Radiology:

Subject to Overall Annual Limit and 20% co-payment

Supplementary Services: (Physio, etc)

Subject to Overall Annual Limit and 20% co-payment

Transplants:

Subject to Overall Annual Limit and 20% co-payment

Co-payments:

Hospital account at private hospital: 50% of the first R4,950, then 10% of remainder up to a maximum of R10,650
All other accounts: 20% co-payment

Alternatives to hospitals:

Private nursing and step down facilities and hospice: 21 days per person

.
.

OUT OF HOSPITAL BENEFITS:

GP consultations:

R6,708 per family, including specialists with 20% co-payment

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

Specialists consultations:

See GP benefit, above

Pathology:

R4,824 per family, for radiology, pathology and histology
20% co-payment

General radiology:

R4,824 per family, for radiology, pathology and histology
20% co-payment

Specialised radiology:

3 scans per family, R15,000
20% co-payment

Supplementary Services: (Physio, etc)

Physiotherapist, Chiropractor and Biokineticist: R2,856 per family
Audiologist, Dietician, Occupational Therapist, Speech Therapist, Social Worker: R2,268 per family
Chiropodist, Homeopath, Naturopath, Osteopath, Podiatrist and Orthoptist: R2,268 per family
20% co-payment

.
.

MATERNITY BENEFITS:

Hospital stay:

Subject to Overall Annual Limit and 20% co-payment

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

Consultations:

2 consults

Scans:

2 x 2D scans, paid by scheme

.
.

CANCER (ONCOLOGY):

Overall coverage (in and out of hospital):

Subject to Overall Annual Limit and 20% co-payment

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.

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

.
.

DENTISTRY:

Dentistry:

Standard dentistry: R4,764 per family
Specialised dentistry: R7,596 per family
20% co-payment

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

Orthodontics:

See above

Maxillo Facial Surgery:

.
.

MEDICATION:

Chronic:

PMBs and non-PMBs: R10,884 per family. Thereafter, only PMBs are covered
20% co-payment for non-PMBs

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

Acute (presrcibed) medication:

R7,440 per family
20% co-payment

Over-the-counter:

Birth Control:

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

.
.

OPTOMETRY:

Optometry:

Test: R444 per person
Single vision, incl test: R876 per person
Bifocal, incl test: R1,308 per person
Multifocal, incl test: R1,740 per person
20% co-payment

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

.
.

MENTAL HEALTH:

In-hospital:

21 days per person

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

Out-of-hospital:

R4,248 per family
20% co-payment

.
.

OTHER BENEFITS:

General Appliances:

R5,076 per person
20% co-payment

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

1.1. Hearing Aids:

R12,132 per person every 2 years
Paid from Overall Annual Limit (OAL)
20% co-payment

1.2. Wheelchairs:

See "General Appliances" limit

Dialysis:

Subject to Overall Annual Limit and 20% co-payment

HIV:

Subject to Overall Annual Limit and 20% co-payment

Emergency Transport:

ER24

International Coverage:

R10 million per family per year, maximum of 90 days

Other:

.
.

WELLNESS/PREVENTATIVE BENEFITS:

Flu vaccination:

Covered

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

Pneumonia vaccines:

Covered

Back Rehabilitation Programme:

Biometric Screening:

Covered

Child Immunisation:

Covered

Pap Smear:

Covered

Mammogram:

Covered for 40yrs+, every 2 years. Includes sonar.

PAS Test:

Covered, 40yrs+. Frequency dependant on age.

HIV Test:

Covered, 15yrs+

.
.

PROSTHESIS:

Overal Limit:

	Main:	Adult:	Child:
Overall Annual Limit (OAL):
R1,000,000 per person
Contributions:
Total Cost:	R2,245	R600	R260
Children:	Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: most out-of-hospital claims, with 20% co-payment. Limits apply. All else paid from out of pocket, unless PMB.
	Main:	Adult:	Child:
(S) Savings:	R0-	R0-	R0-

Compare with these plans:

Topmed Savings 2017

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