2017 TOPMED EXECUTIVE
TopMed Executive is a top end benefit plan for the higher claimer. It offers Unlimited Private Hospital cover at up to 200% of the TT. Out of Hospital cover is provided through a 25% Medical Savings Account and generous After Threshold benefits.
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
|Accommodation, theatre, medicine, material and hospital apparatus used during hospitalisation.||Unlimited|
100% of AT
|Treatment of Immunocompromise and Opportunistic Infections irrespective of cause||100% of TT|
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)|
Specialists (PMB DSP applies)
Associated clinical procedures (during authorised hospital treatment)
200% of TT
200% of TT
200% of TT (Deductibles and specific limits apply to certain procedures.)
|RADIOLOGY AND PATHOLOGY|
Basic radiology and pathology
MRI scans, CT scans, radioisotope studies
100% of TT
100% of TT – subject to a R2 500 co-payment per scan
|MAXILLOFACIAL SURGERY||200% of TT subject to clinical criteria and limited to jaw fractures, congenital deformities and surgical treatment of pathological conditions|
|AUXILIARY SERVICES (in hospital)|
Physiotherapy, speech therapy, occupational therapy, social workers and dieticians
Clinical and Medical technologists
Internal medical and surgical accessories – PAR required
100% of Cost
100% of TT
100% of TT
100% of AT. Subject to sub-limits as applied per clinical protocols.
|Stomatherapy limited to R18 900 per family per year (PAR required if limit exceeded)|
|SCOPES (PAR required)|
Gastroscopies and Colonoscopies
|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:
- 200% 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 – 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 R457 944 per beneficiary per 12 month cycle. Speciality medicines and biologicals – sub-limit of R266 256 per family per year with 20% co-payment (accrues to overall oncology limit of R457 944)|
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)|
|100% of AT|
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
100% of AT at a DSP (TRP and formulary applies)
For PMB CDL’s 70% of AT for non-DSP or non-formulary (TRP and formulary applies)
PMB and non-PMB conditions accrue to limit of R9 576 per beneficiary, R19 500 per family per year thereafter PMB unlimited
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 Executive Benefit Guide.