Family

When it comes to family health, we have you covered

Topmed Family was created with you and your loved ones in mind.

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 Family Benefit Guide.

Hospitalisation
  • Hospital CoverUnlimited Private Hospital Cover. 100% of Agreed Tariff
  • Casualty Cover (Treatment delivered on day of injury – Trauma only) 150% of Topmed Tariff . 100% of Agreed Tariff for facility fee
  • Neo-natal confinement 100% of Agreed Tariff limited to R424 140 per family per annum
  • Elective Caesarean 150% of Topmed Tariff limited to R23 016 for all services
  • 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 150% of Topmed Tariff . Prescribed Minimum Benefits - Designated Service Provider applies
  • 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 150% of Topmed Tariff subject to clinical criteria and limited to jaw fractures, congenital deformaties and pathological conditions
  • Impacted Wisdom Teeth 100% of Topmed Tariff subject to a co-payment of R1 200
  • 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.

Members are allocated a 20% 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 subject to sub-limits. M: R5 124 M1:R6 408 M2: R7 692 M3: R10 212 M4: R13 740 (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 and subject to 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 172 per beneficiary per annum / R6 468 per family per annum
  • Dentistry (Conservative and Specialised) 100% of Topmed Tariff from Savings, Self Payment Gap, thereafter Extended Cover subject to sub-limits. M: R7 428 M1 R8 280 M2: R9 252 M3: R10 308 M4: R11 184. A co-payment of R1 800 for extractions and fillings for children under 6 years
  • Clinical Psychology and Psychiatric Treatment 100% of Topmed Tariff from Savings, Self Payment Gap, thereafter Extended Cover subject to sub-limit of R7 236 per family per annum
Radiology and Pathology – Out of Hospital
  • Basic radiology 100% of Topmed Tariff from Savings, Self Payment Gap, thereafter Extended Cover subject to sub-limit of R4 044 per family per annum (excludes MRI & CT scans)
  • 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 from Savings, Self Payment Gap, thereafter Extended Cover subject to sub-limit of R4 512 per family per annum
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 from Savings, Self Payment Gap, thereafter Extended Cover limited to R4 824 per family per annum
  • Clinical and Medical Technologists 100% of Cost from Savings, Self Payment Gap, thereafter Extended Cover at 100% of Topmed Tariff
  • External medical and surgical appliances (Pre-authorisation required) 100% of Cost from Savings, Self Payment Gap, thereafter Extended Cover at 100% of Topmed Tariff limited to R4 824 per family per annum. Wheelchairs, hearing aids and external prostheses limited to R12 900 per family per annum
Chronic Medication (Registration required)
  • Chronic Conditions 26 Chronic Disease List + additional 8 chronic conditions (TRP and formulary applies)
    100% of Agreed Tariff limited to R11 976 per family per annum at a Designated Service Provider, thereafter unlimited. Prescribed Minimum Benefit and 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 and limited to R256 680 per family per annum
  • Kidney Dialysis Limited to R256 680 per family per annum
  • Oncology Case Managed and limited to R379 008 pb per 12 month cycle
  • Oncology Speciality Medicines and Biologicals No benefit
  • Stomatherapy Limited to R21 060 per family per annum. Thereafter Case Managed
TopBaby Maternity Programme (Registration required)
  • Antenatal Consultations (Tariff code 0190 / 0192) 150% of Topmed Tariff limited to 12 consultations
  • Antenatal Classes (Tariff code 88407) 150% 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
Family Principal member Adult dependant Student / minor dependant
Contribution R3 359 R2 686 R919
Savings Level R841 R671 R229
Total R4 200 R3 357 R1 148

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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