2016 TOPMED PALADIN COMPREHENSIVE
Topmed Paladin is for the established family with mid to high healthcare needs. It offers Unlimited Private Hospital cover at up to 150% of the TT and comprehensive Out of Hospital cover with a generous After Threshold benefit.
MAJOR MEDICAL 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
- Knee Replacement
- Post-Crime Trauma
|Accommodation, theatre, medicine, material and hospital apparatus used during hospitalisation.||Unlimited[break]100% of AT|
|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 21 days per beneficiary per year|
|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]150% of TT[break]150% of TT[break]150% of TT (Deductibles and specific limits apply to certain procedures.)|
|RADIOLOGY AND PATHOLOGY[break]Basic radiology and pathology[break]MRI scans, CT scans, radioisotope studies[break][break]PAR required||[break]100% of TT[break]100% of TT – subject to a R2 500 co-payment per scan|
|DENTISTRY[break]Dentist and other providers’ accounts are paid from Yearly Limit at TT thereafter from Extended Cover[break]Hospitalisation (PAR required)[break][break]Anaesthetic in hospital||[break]100% of AT limited to hospital account[break][break]150% of TT|
|R1500 co-payment for: Extractions and fillings for children under 6 years and dental clearance (standard extraction of 12 teeth or more).[break]Dental clearance limited to R23 844 per beneficiary per year.|
|IMPACTED WISDOM TEETH[break]|
|100% of TT – subject to R1 000 co-payment|
|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]150% of TT[break][break]150% of TT[break]100% of AT. Subject to sub-limits as applied per clinical protocols.|
|Stomatherapy limited to R17 748 per family per year (PAR required if limit exceeded).|
|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|
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:
- 150% of TT for consultations
- 12 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.|
|Organ transplants and kidney dialysis||Benefits and treatment provided through Case Management Programme. Limited to R216 000 per family per year.|
|Kidney dialysis||Benefits and treatment provided through Case Management Programme. Limited to R216 000 per family per year.|
|Oncology||Benefits and treatment provided through Oncology Case Management Programme. R530 000 per beneficiary per 12 month cycle thereafter 20% co-payment. Speciality medicines and biologicals – sub-limit of R300 000 with 20% co-payment (accrues to overall oncology limit of R530 000). Herceptin for early stage Breast Cancer – no co-payment for 9 week course.|
|MAXILLO-FACIAL SURGERY||150% of TT. Subject to clinical criteria and limited to jaw fractures, congenital deformities and surgical treatment of pathological conditions.|
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.|
(step-down nursing, hospice & rehabilitation)
Benefits for clinical procedures and treatments during a stay in a secondary facility will be limited to R123 648 per beneficiary per year.
100% of AT at a DSP (MRP and formulary applies).[break]For PMB CDL’s – 70% of AT for non-DSP or non-formulary (MRP and formulary applies).[break]Payable from Yearly Limit then from Chronic Benefit sub-limit of R10 104 per
family per year, thereafter PMB’s unlimited.
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 Paladin Comprehensive Benefit Guide.