Executive

Fully comprehensive, easy access medical cover

Topmed Executive is a fully comprehensive medical aid option for individuals with extensive healthcare and lifestyle needs, who need easy access to cover when the need arises.

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 Executive Benefit Guide.

Hospitalisation
  • Hospital CoverUnlimited Private Hospital Cover. 100% of Agreed Tariff
  • Casualty Cover (Treatment delivered on day of injury – Trauma only) 200% of Topmed Tariff . 100% of Agreed Tariff for facility fee
  • Neo-natal confinement Unlimited
  • Elective Caesarean 200% 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 460 per family per annum for non-preferred provider
  • Specialised Surgery (New technology) No benefit
  • Psychiatric admissions Case Managed and limited to 21 days per beneficiary per annum
  • Immunocompromise and Opportunistic Infections 100% of Topmed Tariff . Limited to R49 404 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 200% of Topmed Tariff
  • Secondary Facilities (Step-down nursing, hospice and rehabilitation) Case Managed and limited to R146 712 per beneficiary per annum
  • Dentistry Subject to day to day benefits
  • Maxillo-Facial Surgery 200% of Topmed Tariff subject to clinical criteria and limited to jaw fractures, congenital deformaties and pathological conditions
  • Impacted Wisdom Teeth 100% of Topmed Tariff limited to the Specialised Dentistry limit of R15 840 per family per annum. Subject to clinical criteria
  • Orthognathic Surgery No benefit
  • Scopes (Gastroscopies and Colonoscopies) (Pre-authorisation required) 100% of Topmed Tariff subject to a R2 750 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 750 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. Additional Pre-Authorisation Required.

Members are allocated a 25% Medical Savings Account for Day-to-day claims. Once the Savings Account is depleted, and an Annual Threshold level is reached, members have access to additional Above Threshold benefits, subject to specific benefit limits.

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 Topmed Tariff . A maximum of 2 visits may be utilised for out-patient consultations
  • Prescribed Acute Medication 100% of Agreed Tariff from Savings, Self Payment Gap, thereafter Extended Cover limited to R11 868 per beneficiary / R23 484 per family per annum. (Topmed Reference Price and formulary applies)
  • Reproductive Health – Oral, injectable and IUD contraceptives 100% of Topmed Tariff from Savings, Self Payment Gap, thereafter Extended Cover subject to acute medication sub-limit. (Topmed Reference Price and formulary applies)
  • Vitamins and Minerals No benefit
  • OTC Medication 100% of Agreed Tariff from Savings subject to combined acute medication sub-limit. No benefit in Extended Cover. (Topmed Reference Price and formulary applies)
  • Optical Managed by PPN. 100% of PPN rates from Savings, Self Payment Gap, thereafter Extended Cover limited to R2 628 per beneficary / R7 692 per family per annum
  • Dentistry (Conservative and Specialised) Conservative Dentistry – 100% of Topmed Tariff from Savings, Self Payment Gap, thereafter Extended Cover for a specified list of benefits Specialised Dentistry – Limited to R15 840 per family per annum. Limits apply before and after Threshold
  • Clinical Psychology and Psychiatric Treatment 100% of Topmed Tariff limited to R6 624 per family per annum
Radiology and Pathology – Out of Hospital
  • Basic radiology 100% of Topmed Tariff
  • MRI scans, CT scans, radioisotope studies (Pre-authorisation required) 100% of Topmed Tariff subject to a R2 750 co-payment per scan
  • Basic pathology 100% 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 Topmed Tariff subject to a combined limit of R6 396 per beneficiary per annum / R18 924 per family per annum
  • Clinical and Medical Technologists 100% of Topmed Tariff
  • External medical and surgical appliances (Pre-authorisation required) 100% of Cost from Yearly Limit, Self Payment Gap, thereafter Extended Cover subject to sub-limits. Appliances: R 3 012 Oxygen: R 25 326 Wheelchairs: R 15 840 (1 in 5 years) Hearing Aids: R 15 840 (per family per 3 year cycle)
Chronic Medication (Registration required)
  • Chronic Conditions 26 Chronic Disease List + additional 30 Chronic Conditions (TRP and formulary applies)
    100% of Agreed Tariff limited to R10 600 per beneficiary per annum, R21 732 per family per annum at a Designated Service Provider, thereafter PMB unlimited. Topmed Reference Price and formulary applies.
  • Prescribed Minimum Benefit: Non-Formulary and/ or Non-Designated Service Providers 70% of Agreed Tariff subject to limit
Disease Management Programmes (Registration required)
  • HIV / AIDS Case Managed
  • Organ Transplant Case Managed
  • Kidney Dialysis Case Managed
  • Oncology Case Managed and limited to R510 180 per beneficiary per 12 month cycle
  • Oncology Speciality Medicines and Biologicals Sub-limit of R296 628 per family per annum with a 20% co-payment. Accrues to overall oncology limit of R510 180
  • Stomatherapy Limited to R21 060 per family per annum. Thereafter Case Managed
TopBaby Maternity Programme (Registration required)
  • Antenatal Consultations (Tariff code 0190 / 0192) 200% of Topmed Tariff
  • Antenatal Classes (Tariff code 88407) 200% 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
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
Executive Principal member Adult dependant Student / minor dependant
Contribution R4 020 R3 208 R1 224
Savings Level R1 339 R1 069 R405
Total R5 359 R4 277 R1 629

The Scheme only charges for a maximum of 3 children on this option. The savings levels listed are compulsory and will be added to the contributions.



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