2017 TOPMED COMPREHENSIVE
Topmed Comprehensive is for those with considerable healthcare needs. It offers Unlimited Private Hospital cover at up to 300% of the Topmed Tarriff (TT). Fully Comprehensive Out of Hospital cover is unlimited after Threshold and includes Unlimited Chronic benefits.
Pre-authorisation (PAR) is required in respect of hospitalisation and the associated clinical procedures before treatment starts or, 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 R44 340 per family per year|
|Psychiatric Hospitalisation (PAR required – Benefits and treatment provided through Case Management Programme)||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 (TRP and formulary applies), maximum seven days supply|
|SPECIALISED SURGERY (New Technology) (PAR required)||[break]Limited to R300 000 per family per year Managed Care protocols applicable|
|MEDICAL PRACTITIONERS (in hospital)[break]General Practitioners[break]Specialists (PMB DSP applies)[break]Associated clinical procedures (during authorised hospital treatment)||[break]300% of TT[break]300% of TT[break]300% of TT|
|RADIOLOGY AND PATHOLOGY[break](during authorised hospital treatment)[break]Basic radiology and pathology[break]MRI scans, CT scans, radioisotope studies[break]PAR required||[break][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]Anaesthetic in hospital||[break][break][break]100% of Cost limited to hospital account[break]300% of TT|
|R1600 co-payment for extractions and fillings for children under 6 years and dental clearance (standard extraction of 12 teeth or more). Dental clearance limited to R25 392 per beneficiary per year|
|IMPACTED WISDOM TEETH[break](PAR required)||100% of TT subject to R1 060 co-payment|
|ORTHOGNATHIC SURGERY[break](PAR required)||100% of TT subject to 20% co-payment|
|MAXILLO-FACIAL SURGERY||300% of TT subject to clinical criteria and limited to jaw fractures, congenital deformities and surgical treatment of pathological conditions|
|SCOPES (PAR required)|
Gastroscopies and Colonoscopies
|100% of TT[break] If performed in a hospital facility R2 500 co-payment per scope[break] If performed in a day clinic/doctor’s room no 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 |
100% of TT [break]
100% of TT
100% of Cost subject to sub-limits as applied per clinical protocols
|Stomatherapy limited to R18 900 per family per year (PAR required if limit exceeded)|
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:
- 300% 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.|
|Oncology||Benefits and treatment provided through Oncology Case Management Programme. R564 444 per beneficiary per 12 month cycle thereafter 20% co-payment. Speciality medicines and biologicals sub-limit of R319 500 per family per year with 20% co-payment (accrues to overall oncology limit of R564 444)[break] Herceptin for early stage Breast Cancer no co-payment for 9 week course|
PAR required for all the above.
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 200 per family per year.|
(step-down nursing, hospice & rehabilitation)
Benefits and treatment provided through Case Management Programme[break]Benefits for clinical procedures and treatments during a stay in a secondary facility will be limited to R131 676 per beneficiary per year
Chronic – including PMB (member must apply for this benefit) 100% of AT at a DSP (TRP and formulary applies)[break] For PMB CDL’s 70% of AT for non-DSP or non-formulary (TRP and formulary applies) [break]Payable from Yearly Limit thereafter Extended Cover (unlimited) [break]Non-PMB payable from Extended Cover at 80% once Yearly Limit is depleted
INTERNATIONAL BUSINESS & LEISURE TRAVEL INSURANCE
Foreign claims are limited to medical expenses only as provided by the Scheme’s policy, limited to R10 million per family per year, subject to authorisation and applicable conditions.[break] Maximum of 90 days cover.[break] Travel must be declared before departure
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 Comprehensive Benefit Guide.