Best for limited healthcare needs, with in-hospital and day-to-day benefits

Topmed Limited is a traditional design option, with specific benefit limits reimbursed on an 80% basis for doctors and health care providers and a sliding scale co-payment for hospital accounts. Other than the hospital account, members must first pay and then submit claims on a claim form.

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 two working days, otherwise no benefits are payable.

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In-Hospital Major Medical
  • Overall Annual Limit (OAL) R1 million per beneficiary per year
  • All benefits are subject to Scheme Rules and Managed Care Protocols Sub-limits and co-payments apply as per Scheme Rules
  • Admission to Public Hospital Facility (PAR required) Unlimited
  • Admission to Private Hospital Facility (PAR required) DSP Network appliesUp to the Overall Annual Limit at 100% of Cost at a Designated Service Provider Hospital and 75% of Topmed Tariff at a non Designated Service Provider Hospital and thereafter unlimited through Public Hospital facilities. Individual benefit limits apply
  • Co-payment applies to the Hospital Account at Private Hospital Facilities50% of the first R5 220 per incident for the members account thereafter 10% of the remainder, up to a maximum co-payment of R11 200
  • All accounts other than a Hospital Account20% co-payment and individual benefit limits apply
In Hospital – Pre-Authorisation Required
  • Admission to General Ward Subject to Overall Annual Limit
  • Intensive Care Subject to Overall Annual Limit
  • Procedures, doctors and specialist in hospital Subject to Overall Annual Limit (Prescribed Minimum Benefits Designated Service Provider applies)
  • Psychiatric admissionMaximum 21 days per family per year
  • ProsthesesMaximum R33 504 per family per year
  • Surgical, electronic and nuclear appliancesR5 556 per beneficiary per year
  • Treatment of immunocompromise and opportunistic infectionsR46 872 per family per annum
  • Cancer treatmentSubject to Overall Annual Limit
  • Dialysis including hospital feeSubject to Overall Annual Limit
  • Pathology whilst admittedSubject to Overall Annual Limit
  • Radiology whilst admittedSubject to Overall Annual Limit
  • Blood transfusionSubject to Overall Annual Limit
  • TTO medicationMaximum of 7 days supply
  • Casualty and Day case proceduresSubject to Overall Annual Limit
  • Investigations e.g. gastroscopySubject to Overall Annual Limit
  • TopBaby (Registration required)2 Ante-natal consultations and 2 Scansper beneficiary per pregnancy (the costs of3D-scans are limited to the cost of a 2D-scan)

Day-to-day benefits are subject to specific benefit limits and are reimbursed on an 80% basis. Members must first pay their service providers and then submit claims with a claim form for reimbursement.

Day to Day Cover
  • Radiology and Pathology Maximum of R5 088 per family per year
  • CT and MRI scans 3 scans per family per year to a maximum of R15 852
  • Nursing Services and Hospice 21 days per beneficiary per year
  • Medical Appliances Max R5 364 per beneficiary per year
  • Optical Benefit (per beneficiary per year) Test alone – R468
  • Multifocals need clinical motivation Single vision (incl. test) R924, Bifocal (incl. test) R1 380, Multifocal (incl. test) – R1 848
  • General Dentistry Max R5 040 per family per year
  • Specialised Dentistry Max R8 028 per family per year
  • Hearing Aids Max R12 828 per beneficiary in a 24month period
  • Acute Medication Max R7 860 per family per year (TRP and formulary applies)
  • Chronic Medication Max R11 508 per family per year – thereafter Prescribed Minimum Benefits unlimited (Designated Service Provider, Topmed Reference Price and formulary applies)
  • Physiotherapy, Chiropractor and Biokineticist Max R3 024 per family per year for all services
  • Audiologist, Dietician, Occupational Therapist, Speech Therapist, Social Worker Max R2 400 per family per year for all services
  • General Practitioners and Specialists (Out Patient) – PMB DSP applies Max R7 080 per family per year for all services
  • General Practitioners and Specialists (Out Patient) for CDL – PMB DSP applies Subject to Scheme protocols and Designated Service Provider
  • Chiropodist, Homeopath, Naturopath, Osteopath, Podiatrist, and Orthoptist Max R2 400 per family per year for all services
  • Clinical Psychologist and Psychiatrist Max R4 488 per family per year for all services
24 Hour emergency line : 084 124 / 0861 101 569
  • Unlimited subject to using ER24. Other providers limited to R2 328 per family per year subject to overall annual limit
Wellness Benefits
  • Screening Benefits (Health Assessment)
  • Immunisation Programme
  • Early Detection Tests
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
Limited Principal member Adult dependant Student / minor dependant
Contribution R2 267 R990 R416
Savings Level N/A N/A N/A
Total R2 267 R990 R416

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