2016 TOPMED ACTIVE SAVER
Topmed Active Saver has been designed specifically for sportsmen and women and young families. It offers Unlimited Private Hospital cover and a 20% Medical savings Account for Out of Hospital Cover.
MAJOR MEDICAL BENEFITS
IN-HOSPITAL BENEFITS
Pre-authorisation (PAR) is required in respect of hospitalisation and the associated clinical procedures before treatment starts. In case of an emergency, within the next two business days, otherwise no benefits are allowed.
Extended Major Medical Benefit (100% of TT)
Post-operative benefits available for the following:
- Hip Replacement
- Heart Attack
- Stroke
- Knee Replacement
- Post-Crime Trauma
Benefits for hip and knee replacements for hospitalisation and associated Providers will only be covered in the event of trauma.
| Accommodation, theatre, medicine, material and hospital apparatus used during hospitalisation. | Unlimited[break]100% of AT at Preferred Provider Network. Other Networks 25% co-payment. |
| Treatment of Immunocompromise and Opportunistic Infections irrespective of cause | 100% of TT[break]Limited to R41 640 per family per year |
| Psychiatric Hospitalisation (PAR required – Benefits and treatment provided through Case Management Programme) | Limited to PMB |
| T.T.O – Medicine received on discharge from hospital | 100% of AT (MRP and formulary applies), maximum seven days supply |
| MEDICAL PRACTITIONERS (in hospital)[break]General Practitioners[break]Specialists (PMB DSP applies)[break]Associated clinical procedures (during authorised hospital treatment) | [break]100% of TT[break]100% of TT[break]100% of TT (Deductibles, specific limits and exclusions apply to certain procedures) |
| RADIOLOGY AND PATHOLOGY[break]Basic radiology and pathology[break]MRI scans, CT scans, radioisotope studies (during authorised hospital treatment)[break][break]PAR required | [break]100% of TT[break]100% of TT – subject to a R2 500 co-payment per scan |
| DENTISTRY (PAR required) | No benefit for in-hospital dentistry |
| Impacted Wisdom Teeth – 100% of TT limited to R11 892 per family per year (inclusive of all providers) | |
| AUXILIARY SERVICES (in hospital)[break]Blood transfusions[break]Physiotherapy, speech therapy, occupational therapy, social workers and dieticians[break]Clinical and Medical technologists[break]Internal medical and surgical accessories – PAR required | [break]100% of Cost[break]100% of TT[break][break]100% of TT[break]100% of AT. Subject to sub-limits as applied per clinical protocols. |
| Stomatherapy limited to PMB (PAR required) | |
| SCOPES (PAR required)[break]Gastroscopies and Colonoscopies[break]If performed in a hospital facility[break]If performed in a day clinic / doctor’s room | [break][break]R2 500 co-payment per scope[break]No co-payment |
OTHER BENEFITS
MATERNITY PROGRAMME / CONFINEMENTS
To enjoy this benefit you are required to register on the programme
when you are between 12 and 20 weeks into your pregnancy. To register call the Call Centre on 0860 00 21 58.
Registration on the programme entitles you to:
- 100% of TT for consultations
- 6 Ante-natal consultations, ante-natal classes and pre-natal vitamins
- 2 Scans per beneficiary per pregnancy (the costs of 3D-scans are limited to the cost of a 2D-scan)
- 2 Paediatrician visits (new born)
DISEASE MANAGEMENT / CASE MANAGEMENT
Disease Management is a holistic approach that focuses on the patient’s disease or condition, using all the cost elements involved. The intervention takes place by means of patient counselling and education, behaviour modification, therapeutic guidelines, incentives and case management.
| AIDS and HIV infections | Benefits and treatment provided through Case Management Programme – Limited to PMB |
| Organ transplants and kidney dialysis | Benefits and treatment provided through Case Management Programme – Limited to PMB |
| Oncology | Benefits and treatment provided through Oncology Case Management Programme – Limited to PMB |
| PAR required for all of the above | |
AMBULANCE SERVICES
ER24 is Topmed’s Preferred Provider for any ambulance services. If services are not rendered by (or through the intervention of) ER24, benefits will be limited to a specified maximum.
| Preferred Provider ER 24 (084 124)[break]Non-preferred Provider | 100% of AT[break]100% of TT, limited to R2 100 per family per year. |
SECONDARY FACILITIES
(step-down nursing, hospice & rehabilitation)
Benefits and treatment provided through Case Management Programme.[break]Limited to PMB
CHRONIC MEDICINE
Limited to PMB – 100% of AT (MRP and formulary applies) at a DSP and 70% of AT (MRP and formulary applies) for non-DSP or out of formulary.
INTERNATIONAL BUSINESS & LEISURE TRAVEL INSURANCE
R10 million per family per year (Medical expenses only, as provided by EuropAssist). Maximum of 90 days Travel must be declared before leaving.
MORE…
For Day-to-Day Benefits, Topmed Wellness Benefit, Unique Benefits, Prosthesis Benefits, Designated Service Provider (DSP) Networks and General Exclusions, please click on the link below to download the full Topmed Active Saver Benefit Guide.