2017 TOPMED ESSENTIAL
TopMed Essential is a Pure Hospital plan for the younger members who want cover for catastrophic events and who are happy to cover their Out of Hospital needs themselves. In-Hospital cover is unlimited at any Private Hospital at up to 100% of the TT.
Please note: that this is a hospital plan only and no benefits are provided for day-to-day expenses.
MAJOR MEDICAL 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
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|
|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|
|MEDICAL PRACTITIONERS (in hospital)[break]General Practitioners[break]Specialists (PAR required) (PMB DSP applies)[break]Associated clinical procedures (during authorised hospital treatment)||[break]100% of TT[break]100% of TT[break]100% of TT|
|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||No benefit for in-hospital dentistry|
|MAXILLOFACIAL SURGERY||100% of TT subject to clinical criteria and limited to jaw fractures, congenital deformities and surgical treatment of pathological conditions|
|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.|
|SCOPES (PAR required)[break]|
Gastroscopies and Colonoscopies
|[break][break]100% of TT|
If performed in a hospital facility R2 500 co-payment per scope
If performed in a day clinic/doctor’s room 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:
- 100% of TT for consultations
- 6 Ante-natal consultations
- 12 ante-natal classes
- 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 R282 216 per beneficiary per 12 month cycle|
|PAR required for all of 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. Benefits for clinical procedures and treatments during a stay in a secondary facility will be limited to R131 676 per beneficiary per year
Limited to PMB – 100% of AT (TRP and formulary applies) at a DSP and 70% of AT (TRP and formulary applies) for non-DSP or out of formulary
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. Maximum of 90 days cover. 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 Hospital Benefit Guide.