Network

Your basic needs covered in times of emergency

Topmed Network is an affordable medical plan, with premiums based on your monthly household income. Our Network of trusted healthcare providers has your basic needs covered in times of emergency.

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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Click here to download the 2019 Network Benefit Guide.

Hospitalisation
  • Hospital CoverLimited to Prescribed Minimum Benefits only. Designated Service Provider Hospitals/Day Clinics at 100% of Agreed Tariff. Non-Designated Service Provider at 75% of Agreed Tariff (Involuntary use of Non DSP Hospital / Day Clinic for PMB’s - 100% of AT)
  • Casualty Cover (Treatment delivered on day of injury – Trauma only) Unlimited visits at a public hospital
  • Neo-natal confinement 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
  • Elective Caesarean No benefit. Limited to the benefit of natural delivery
  • 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 Prescribed Minimum Benefits
  • Immunocompromise and Opportunistic Infections 100% of Topmed Tariff . Limited to R49 404 per family per annum
  • TTO Medication (Received on discharge) No benefit
  • Medical Practitioners and Specialists Designated Service Provider Network – 100% of Topmed Tariff Non Designated Service Provider Network – 70% of Topmed Tariff
  • Secondary Facilities (Step-down nursing, hospice and rehabilitation) Benefits and treatment provided through Case Management Programme. Limited to PMB only
  • Dentistry No benefit
  • Maxillo-Facial Surgery Limited to Prescribed Minimum Benefits
  • Impacted Wisdom Teeth No benefit
  • Orthognathic Surgery No benefit
  • Scopes (Gastroscopies and Colonoscopies) (Pre-authorisation required) Limited to Prescribed Minimum Benefits
Radiology and Pathology during hospitalisation
  • Radiology and Pathology Limited to Prescribed Minimum Benefits
  • MRI scans, CT scans, radioisotope studies (Pre-authorisation required) Limited to Prescribed Minimum Benefits
Auxillary Services during hospitalisation
  • Blood transfusions 100% of Cost
  • Physiotherapy, speech therapy, occupational therapy, social workers and dieticians Limited to Prescribed Minimum Benefits
  • Clinical and medical technologists Limited to Prescribed Minimum Benefits
  • Internal medical and surgical accessories (additional Pre-authorisation required) Limited to Prescribed Minimum Benefits only

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) No benefit
  • 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 GP Network Provider: Basic primary care including specified minor trauma treatment. Limited to 2 GP consults per beneficiary per annum (excluding CDL treatment plan consults and emergency GP visits). Additional consultations subject to clinical protocols and pre-authorisation.
    GP Non-Network Provider: Limited to 3 visits per family per annum to a maximum of R1 308. Emergencies and after hours services only. No benefit for facility fees
    Specialist Network Provider: 100% of Agreed Tariff limited to R1 584 per family per annum including radiology & pathology
    Specialist Non Network Provider: 70% of Topmed Tariff
  • Prescribed Acute Medication Subject to acute medication formulary. Scripting Providers to supply medication, non-scripting Providers to supply a script for dispensing from Network Pharmacy
  • Reproductive Health – Oral, injectable and IUD contraceptives No benefit for contraceptives. Pregnancy tests, family planning sessions and pre-natal care provided by Network Provider
  • Vitamins and Minerals No benefit
  • OTC Medication 100% of Topmed Tariff limited to R228 per family per annum and R76 per script. (Topmed Reference Price and formulary applies)
  • Optical 100% of Cost limited to 1 eye test per beneficiary per annum at a Network Provider including 1 pair of mono or bi-focal lenses with selected frames every 24 months or limited to R588 for contact lenses. A benefit of R150 will be paid towards frames selected outside of the Network provider range
  • Dentistry (Conservative and Specialised) Basic Dentistry at a Network Dentist. 1 set of plastic dentures per family per annum per 24 months
  • Clinical Psychology and Psychiatric Treatment No benefit
Radiology and Pathology – Out of Hospital
  • Basic radiology Basic x-rays as requested by a Network GP and subject to protocols
  • MRI scans, CT scans, radioisotope studies (Pre-authorisation required) No benefit
  • Basic pathology Basic blood tests as requested by a Network GP and subject to protocols
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 No benefit
  • Clinical and Medical Technologists No benefit
  • External medical and surgical appliances (Pre-authorisation required) Limited to Prescribed Minimum Benefits
Chronic Medication (Registration required)
  • Chronic Conditions Limited to PMB. 100% of Cost prescribed and obtained from a Network Provider
  • Prescribed Minimum Benefit: Non-Formulary and/ or Non-Designated Service Providers No benefit
Disease Management Programmes (Registration required)
  • HIV / AIDS Case Managed and limited to Prescribed Minimum Benefits
  • Organ Transplant Case Managed and limited to Prescribed Minimum Benefits
  • Kidney Dialysis Case Managed and limited to Prescribed Minimum Benefits
  • Oncology Case Managed and limited to Prescribed Minimum Benefits
  • Oncology Speciality Medicines and Biologicals No benefit
  • Stomatherapy Limited to Prescribed Minimum Benefits
TopBaby
  • No Maternity Programme applicable No Maternity Programme applicable. All pre-natal benefits obtained through Network Provider. Limited to 1 confinement pfpa. Benefits include 1 first trimester scan with a Network Provider
  • Baby Immunisations (Subject to Department of Health Protocols) 100% of Cost obtained from a Network Provider
Extended Benefits (Pre-authorisation required)
  • Post total hip replacement No benefit
  • Post total knee replacement No benefit
  • Post crime trauma No benefit
  • Heart Attack No benefit
  • Stroke No benefit
Deductibles and Co-Payments
  • None
Prosthesis Benefits
  • Limited to Prescribed Minimum Benefits
Network
Monthly Income
Member Adult dependant Student / minor dependant
under R1000 R381 R381 R381
R1001 – R11 000 R1 530 R1 530 R 428
Over R11 001 R2 068 R2 068 R554

Monthly Income below R1 000

Monthly Income between R1 001 and R11 000

Monthly Income above R11 000


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