Comprehensive

For those with considerable healthcare needs

Our Comprehensive Option is perfect for those looking for a full cover solution that includes rich day-to-day cover, and unlimited hospital cover, as well as specialised benefits not included on any other option.

What's Covered

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.

Click here for help understanding our terminology.

Access the Topmed Formulary for this plan here.

Click here to download the 2019 Comprehensive Benefit Guide.

Hospitalisation
  • Hospital CoverUnlimited Private Hospital Cover at 100% of the Agreed Tariff
  • Casualty Cover (Treatment delivered on day of injury – Trauma only) 300% of Topmed Tariff. 100% of Agreed Tariff for facility fee
  • Neo-natal confinement Unlimited
  • Elective Caesarean 300% of Topmed Tariff
  • Home Birth / Water Birth Subject to a registered service provider assisting with the birth
  • Ambulance Services 100% of Agreed Tariff at preferred provider. 100% of Topmed Tariff limited to R2,328 per family per annum for non-preferred provider
  • Specialised Surgery (New technology) Limited to R317 100 per family per annum. Managed Care Protocols apply
  • Psychiatric admissions Case Managed and limited to 21 days per beneficiary per annum
  • Immunocompromise and Opportunistic Infections 100% of Topmed Tariff. Limited to R46 872 per family per annum
  • TTO Medication (Received on discharge) 100% of Agreed Tariff. Max 7 days supply. (Topmed Reference Price and formulary applies)
  • Medical Practitioners and Specialists 300% of Topmed Tariff. Perscribed Minimum Benefits Designated Service Provider applies
  • Secondary Facilities (Step-down nursing, hospice and rehabilitation) Case Managed and limited to R139 200 per beneficiary per annum.
  • Dentistry 100% of Agreed Tariff from Yearly Limit thereafter, from Extended Cover at 80% of Topmed Tariff. A co-payment of R1 700 for extractions and fillings for children under 6 years including dental clearance. Dental clearance limited to R 26 844 per beneficiary per annum
  • Maxillo-Facial Surgery 300% of Topmed Tariff subject to clinical criteria and limited to jaw fractures, congenital deformities and pathological conditions
  • Impacted Wisdom Teeth 100% of Topmed Tariff subject to a co-payment of R1 120
  • Orthognathic Surgery 100% of Topmed Tariff subject to a 20% co-payment
  • Scopes (Gastroscopies and Colonoscopies) (Pre-authorisation required) 100% of Topmed Tariff subject to a R2 600 co-payment per scope. If performed in a day clinic/doctors rooms no co-payment applies
Radiology and Pathology during hospitalisation
  • Radiology and Pathology 100% of Topmed Tariff
  • MRI scans, CT scans, radioisotope studies (Pre-authorisation required) 100% of Topmed Tariff subject to a R2 600 co-payment per scan
Auxillary Services during hospitalisation
  • Blood transfusions 100% of Cost
  • Physiotherapy, speech therapy, occupational therapy, social workers and dieticians 100% of Topmed Tariff
  • Clinical and medical technologists 100% of Topmed Tariff
  • Internal medical and surgical accessories (additional Pre-authorisation required) 100% of Cost subject to sub-limits as applied per clinical protocols

Members are allocated a Yearly Limit for day-to-day claims. Once the Yearly Limit is depleted, and an Annual Threshold level is reached, members have access to Extended Cover benefits which are covered at 80% of Topmed Tariff.

Day to Day Benefits – Out of Hospital
  • Casualty Cover (Non Trauma) Subject to day to day benefits
  • Medical Practitioners and Specialists – Including clinical procedures, visits (Prescribed Minimum Benefits - Designated Service Provider applies), material and injection material (excluding medicine) administered in a Doctor’s consulting room 100% of Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Topmed Tariff
  • Prescribed Acute Medication 100% of Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Agreed Tariff (Topmed Reference Price and formulary applies)
  • Reproductive Health – Oral, injectable and IUD contraceptives 100% Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Topmed Tariff (TRP and formulary applies)
  • Vitamins and Minerals 100% of Agreed Tariff from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Topmed Tariff. Subject to sub-limits. Member: R2 604 Adult: R2 148 Child: R600. (Topmed Reference Price and formulary applies)
  • OTC Medication 100% Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Topmed Tariff. Limited to R168 per script and does not accrue to Threshold. (Topmed Reference Price and formulary applies)
  • Optical Managed by PPN. 100% of Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover at PPN rates. Contact lenses limited to R2 424 per beneficiary per annum. No benefit for spectacles and contact lenses in the same year. PPN rates accrue to Threshold
  • Dentistry (Conservative and Specialised) 100% of Topmed Tariff from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Topmed Tariff. Limited to R24 072 per family per annum (Conservative and Specialised)
  • Clinical Psychology and Psychiatric Treatment 100% of Cost from Yearly Limit, Self Payment Gap thereafter Extended Cover at 80% of Topmed Tariff
Radiology and Pathology – Out of Hospital
  • Basic radiology 100% of Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Topmed Tariff
  • MRI scans, CT scans, radioisotope studies (Pre-authorisation required) 100% of Topmed Tariff subject to a R2 600 co-payment per scan (pre-authorisation required)
  • Basic pathology 100% of Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Topmed Tariff
Auxillary Services – Out of Hospital
  • Physiotherapy, speech therapy, occupational therapy, social workers, dieticians, podiatry,orthoptic treatment, audiometry, hearing aid acoustics, biokinetics, chiropractors, osteopaths, homeopaths, naturopaths and herbalists 100% of Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Topmed Tariff
  • Clinical and Medical Technologists 100% of Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Topmed Tariff
  • External medical and surgical appliances (Pre-authorisation required) 100% of Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover at 80% of Topmed Tariff.
Chronic Medication (Registration required)
  • Unlimited Chronic Conditions 100% of Agreed Tariff from Yearly Limit at a Designated Service Provider, thereafter unlimited from Extended Cover at 80% of Agreed Tariff. Click here for the Topmed Formulary.
  • Prescribed Minimum Benefits / Non-Formulary / Non-Designated Service Providers 70% of Agreed Tariff from Yearly Limit thereafter Extended Cover at 70% of Topmed Tariff
Disease Management Programmes (Registration required)
  • HIV / AIDS Case Managed
  • Organ Transplant Case Managed
  • Kidney Dialysis Case Managed
  • Oncology Case Managed and limited to R596 640 per beneficiary per 12 month cycle, thereafter 20% co-payment
  • Oncology Speciality Medicines and Biologicals Sub-limit of R337 716 per family per annum with a 20% co-payment. Accrues to overall oncology limit of R596 640
  • Stomatherapy Limited to R19 980 per family per annum. Thereafter Case Managed
TopBaby Maternity Programme (Registration required)
  • Antenatal Consultations (Tariff code 0190 / 0192) 300% of Topmed Tariff limited to 12 consultations
  • Antenatal Classes (Tariff code 88407) 300% of Topmed Tariff limited to 12 classes
  • Antenatal Scans (3D and 4D scans paid at 2D rate) Limited to 2 2D scans per beneficiary per pregnancy
  • Paediatrician Consultations Limited to 2 newborn visits
  • Prenatal Vitamins Formulary applies
  • Baby Bag Yes
  • Baby Immunisations (Subject to Department of Health Protocols) 100% of Topmed Tariff subject to Department of Health Protocols
Wellness Benefits
  • Screening Benefits (Health Assessment)
  • Immunisation Programme
  • Early Detection Tests
Extended Benefits (Pre-authorisation required)
  • Post total hip replacement 8 Physiotherapy sessions within 3 months post-op
  • Post total knee replacement 8 Physiotherapy sessions within 3 months post-op
  • Post crime trauma Combined total of 12 consultations within 6 months post-event with a Psychologist, Psychiatrist or Social Worker
  • Heart Attack Case Managed. Treatment must be prescribed by the treating Cardiologist/Physician
  • Stroke Case Managed. Comprehensive rehabilitation programme including therapy from a multi-disciplinary team 3 months post-event (acute) with a Physiotherapist, Occupational Therapist and Speech Therapist
Deductibles and Co-Payments
  • Kindly refer to Benefit Guide for specific deductibles and co-payments. Scheme policies and protocols apply
Prosthesis Benefits
  • Kindly refer to Benefit Guide for specific internal medical/surgical prostheses and appliance limits. Scheme policies and protocols apply
International Business and Leisure Travel Insurance
  • Foreign claims are limited to medical expenses only as provided by the Schemes’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
Comprehensive Principal member Adult dependant Student / minor dependant
Contribution R6 672 R5 506 R1 566
Savings Level N/A N/A N/A
Total R6 672 R5 506 R1 566

The Scheme only charges for a maximum of 3 children on this option.



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