2017 TOPMED NETWORK
TopMed Network is an exceptionally affordable plan designed to cover the Primary Care Needs of the younger family. Cover is through a defined network of providers. To make it even more affordable, contributions are income based.
MAJOR MEDICAL BENEFITS
Subject to referral from a Network GP and/or Specialist.
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)
Benefits for hip and knee replacements for hospitalisation and associated Providers will only be covered in the event of trauma.
|HOSPITALISATION (Subject to referral from a Network GP and/or Specialist)|
Pre-authorisation (PAR) is required in respect of hospitalisation and the associated clinical procedures before treatment starts. In case of emergency, within the next two business days, otherwise no benefit is allowed.
Accommodation, theatre, medicine, material and hospital apparatus used during hospitalisation.
|100% of AT [break] DSP Network of Hospitals and Day Clinics for defined list of procedures (75% of AT for non-DSP)|
|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 PMB|
|T.T.O – Medicine received on discharge from hospital||No benefit|
|MEDICAL PRACTITIONERS (consultations and procedures during authorised hospital treatment)|
Admission via Network GP or Specialist
Admission via non-network GP or Specialist
Associated clinical procedures
|[break][break]100% of TT |
70% of TT
100% of TT (70% of TT for non-network GP or Specialist)
(Deductibles, specific limits and exclusions apply to certain procedures)
|RADIOLOGY AND PATHOLOGY[break](during authorised hospital treatment)[break]Radiology and pathology [break]MRI scans, CT scans, radioisotope studies (during authorised hospital treatment) PAR required||[break] [break] 100% of TT[break]100% of TT – Subject to a R2 500 co-payment per scan.|
|SCOPES (PAR required)|
Gastroscopies and Colonoscopies
|[break]Day clinic or doctor’s room only|
|AUXILIARY SERVICES (during authorised hospitalisation) [break][break]Blood transfusions[break]Internal medical and surgical accessories[break]Physiotherapy, speech therapy, occupational therapy, social workers and dieticians[break]Clinical and Medical technologists||No referral required from a medical practitioner for auxiliary services, except in respect of external medical and surgical accessories.[break]100% of Cost[break]Limited to PMB[break]100% of TT [break] [break]100% of TT|
CONFINEMENTS (PAR required)
Benefits as described in respect of medical practitioners and hospitalisation. Benefits are limited to 1 confinement per family per year in a DSP Network Hospital
Benefits are also allowed in respect of:
- home births provided a registered service provider assists with the birth
- pregnancy tests and family planning (excluding contraceptives) if provided by the Primary Healthcare Provider
- pre and postnatal care, including 1 first trimester sonar scan if provided by the Primary Healthcare Provider.
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.
|Organ transplants and kidney dialysis (PAR required)||Benefits and treatment through Case Management Programme limited to PMB|
|Oncology||Benefits and treatment through Oncology Case Management Programme limited to PMB|
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. Limited to PMB
Subject to registration and approval according to the Chronic Medicine Formulary. Medication to be supplied by Network Provider as arranged with the beneficiary or supplier
SPECIFIC OPTION EXCLUSIONS
Injuries sustained during participation in a strike, picketing or riot, or during a physical struggle.
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 Network Benefit Guide.