Topmed Network A medical aid plan: 2017

Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB. Pay for all children. Income-limited plan: R0-R1,000pm only

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: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Network
Specialised Radiology:
  • R2,500 co-payment per scan
Supplementary Services: (Physio, etc)
Transplants:
Co-payments:
  • Hysterectomy: R3,500
  • Cholecystectomy: R2,500
  • Tonsils, adenoids, grommets: R500
  • Specialised radiology: R2,500 per scan
Alternatives to hospitals:

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Network GPs: Basic primary care
  • Non-Network GPs: 3 visits per year, R1,236 per family, for emergencies only
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Specialists consultations:
  • Network: R1,500 per family
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:
Hospital stay:
  • One confinement per year
  • Home births: covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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Consultations:
  • Supervision of uncomplicated pregnancy up to week 20
Scans:
  • 1 x 2D scan, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
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: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: network provider only. Includes 1 set of plastic dentures per family every 2 years.
  • Specialised dentistry: no benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics:
  • No benefit
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
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:
On Discharge:
  • No benefit
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:
  • One test, one set of lenses, one standard frame or contacts to the value of R444 per person every 2 years
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:

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OTHER BENEFITS:
General Appliances:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
HIV:
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport: v
International Coverage:
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Pneumonia vaccines:
Back Rehabilitation Programme:
Biometric Screening:
Child Immunisation:
  • Covered
Pap Smear:
Mammogram:
PAS Test:
HIV Test:

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R319 R319 R319
Children: Pay for all children
Income limit: R0-R1,000 (other limits)
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: scopes, medicine, dentistry, optometry, supplementary services, radiology, pathology. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

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