Key Benefits
Hospital: Major medical expenses
Cover: Unlimited According to Defined Primary Health Care Protocols
| Overall Annual Benefit/Limit |
Cover |
|---|---|
| Hospitalisation | 100% |
| Blood Transfusion | 100% |
| Radiology | 100% |
| GPs and Specialists In-hospital | 100% |
*Benefits are only available through registered Network Health Professionals.
Day-to-Day Benefits
| Benefit | Cover |
|---|---|
| General Practitioners | Unlimited consultations |
| In-Practice Procedures | Unlimited |
| Pathology | Specified tests only |
| Radiology | Long bones, chest and trauma and basic radiology (excluding MRI and CT Scan) |
| Dentistry | Extractions and fillings only |
| Sonar Scans (Pregnancy) | Three scans per Beneficiary per pregnancy |
Contributions
| Individuals |
|
|||
|---|---|---|---|---|
| Age Band | Main | Adult | Child | |
| 0 | 25 | 401 | 341 | 161 |
| 26 | 30 | 425 | 362 | 161 |
| 31 | 35 | 446 | 380 | 161 |
| 36 | 40 | 471 | 400 | 161 |
| 41 | 45 | 497 | 422 | 161 |
| 46 | 50 | 527 | 445 | 175 |
| 51 | 55 | 544 | 465 | 175 |
| 56 | 60 | 567 | 481 | 175 |
| 61 | 65 | 609 | 518 | 175 |
| 66+ |
|
656 | 556 | 175 |
| Groups |
|
|||
|---|---|---|---|---|
| Age Band | Main | Adult | Child | |
| 0 | 25 | 362 | 306 | 144 |
| 26 | 30 | 384 | 326 | 144 |
| 31 | 35 | 404 | 343 | 144 |
| 36 | 40 | 425 | 361 | 144 |
| 41 | 45 | 447 | 382 | 144 |
| 46 | 50 | 472 | 401 | 159 |
| 51 | 55 | 492 | 419 | 159 |
| 56 | 60 | 512 | 435 | 159 |
| 61 | 65 | 551 | 467 | 159 |
| 66+ |
|
591 | 502 | 159 |
TOPAZ 2025 BENEFITS GUIDE
|
OVERALL ANNUAL BENEFIT
(OVERALL ANNUAL LIMIT) |
|
Unlimited According To Defined Primary Healthcare Protocols
Ex Gratia Not Applicable |
|
|---|---|---|---|
| Category A: Primary Healthcare Benefits |
% Tariff
|
Benefits available only at Network Health Professionals
|
|
| 1. | Nurse | 100% | Registered Nurse |
|
|
1.1 Consultations/Visits |
Unlimited
N$280 per visit (Maximum tariff regardless of time spent on consultation) |
|
|
|
1.2 Medication/Injections | Payable from Acute Medication/Injections | |
|
|
1.3 Procedures | Unlimited | |
| 2. | General Practitioner | 100% | According to defined protocols |
|
|
2.1 Consultations/Visits (Out-Of-Hospital)
|
Unlimited
N$475 per visit (First consultation) (Maximum tariff regardless of the type of first consultation) N$360 per visit (Follow-up consultation) (Code 0125 - extended consultation every 15 minutes or part thereof not payable) |
|
|
2.2. GP Virtual/Telephonic Consultations (Telephonic/virtual writing of prescriptions not payable) | Prorated from date of joining Seven virtual/telephonic consultations per Beneficiary | ||
|
2.3 Acute Medication/Injections
(Paid at the maximum Namibia medicine price on generics) |
Payable from Acute Medication/Injections | ||
|
|
2.4 Chronic Medication/Injections
- Subject to Chronic Medication Registration (Paid at the maximum Namibia medicine price on generics) |
Payable from Chronic Medication/Injections | |
|
|
2.5 Procedures (Out-of-Hospital) |
Specified minor procedures in room only
(Requires prior approval) |
|
|
3.
|
Medical Specialists (Consultations Only) Requires prior approval |
100%
|
No Benefit |
| 4. | Pharmacy | SEP + 40% | |
| 4.1 Acute Medication/Injections (Paid at the maximum Namibia medicine price on generics) |
100% | Prorated from date of joining N$2 760 per Beneficiary N$5 520 per Family N$265 per claim per Beneficiary per day | |
| 4.2 Chronic Medication/Injections (Subject to chronic medication registration) (Paid at the maximum Namibia medicine price on generics) | Prorated from date of joining N$4 400 per Family |
||
|
|
4.3 Self-Medication | No Benefit | |
| 5. |
Pathology |
100% | Specified tests only |
| 6. | Radiology | 100% |
Long bones, chest and trauma and basic radiology as per the defined list. (Excluding MRI and CT Scan) |
| 7. | Basic Dentistry | 100% |
N$1 980 per Beneficiary N$3 960 per Family (One plastic denture per Family every two years) |
| 8. |
Optical |
100%
|
No Benefit |
|
|
8.1. Single Vision (Inclusive of Test, Frame and Lenses
|
||
|
|
8.2. Bifocal (inclusive of Test, Frame and Lenses)
(Paid at maximum Namibia medicine price on generics) |
||
| 9. |
Sonar Scans (Pregnancy) |
100% |
Three scans per Beneficiary per pregnancy
Groups have cover from the date of joining Individuals have a nine-month waiting period |
| 10. |
Antenatal Consultation (General Practitioner) |
100% | Six consultations per Beneficiary
(2601 and 2602 only) Groups have cover from the date of joining Individuals have a nine-month waiting period |
| 11. |
Paramedical (Psychologists, Physiotherapists, Occupational Therapists) |
100%
|
No Benefit
|
| Category B: HIV/AIDS Treatment and Other Specified Conditions | % Tariff |
Unlimited According to Defined Protocols
Benefits Available Only at Network Health Professionals |
|
|---|---|---|---|
| 12. | HIV/AIDS Treatment | 100% | As per national guidelines for antiretroviral therapy |
|
|
12.1 Consultations (General Practitioners)
|
Unlimited | |
|
|
12.2 Medication
(including vitamins and supplements) |
(According to Topaz and Topaz Plus HIV medicine formulary)
(Vitamins and supplements maximum of N$156) |
|
|
|
12.3 Pathology | Unlimited | |
|
|
12.4 Counselling (pre-, post- and adherence) | Three sessions | |
|
|
12.5. Post-Exposure Prophylaxis (PEP) (Rape cover and occupational injuries only) |
As per the national guidelines for antiretroviral therapy
|
|
|
|
12.6 Pre-Exposure Prophylaxis (PrEP) |
No Benefit
|
|
|
|
12.7 Prevention of Mother-to-Child Transmission (PMTCT)
(excluding milk formula) |
As per the national guidelines for antiretroviral therapy
|
|
| CATEGORY C: Hospitalisation Benefit |
|
Private Wing of State Hospital | |
|---|---|---|---|
|
Planned procedures: Groups have cover from the date of joining
Individuals have a six-month waiting period after joining Emergency Cases: Immediate Cover |
|||
| Overall Annual Limit | % Tariff | Unlimited | |
|
13.
|
State Hospitalisation
|
|
Unlimited
Private Wing of a State Hospital |
|
|
13.1 Accommodation and Theatre
|
100% of State Tariffs for Private Patients
|
Overall Annual Limit
|
|
|
13.2 Blood Transfusions | ||
|
|
13.3 Intensive and High Care (Three days)
|
||
|
|
13.4 Medicine, Fixed Tariff Procedures, Hospital Apparatus, and To Take Out Medicine | ||
|
|
13.5 Radiology and Pathology (In-Hospital) | Payable from General Practitioners and Medical Specialists (In-Hospital Services) | |
| 14. | Private Hospitalisation |
|
No Benefit |
| 15. |
General Practitioners and Medical Specialists (In-Hospital services) – Additional Hospital Benefit cover excluded |
100% | N$27 170 per Family (Including radiology and pathology) Overall Annual Limit |
| 16. | Other Healthcare Providers |
100%
|
No Benefit |
| 17. |
Maternity
(Requires prior approval) |
|
Unlimited hospitalisation in a state hospital (GPs and Specialists limited to benefits available under General Practitioners and Medical Specialists (In-Hospital Services) Groups have cover from the date of joining Individuals have a nine-month waiting period. |
| 18. |
Ambulance Services
|
100% |
|
|
|
18.1 Emergency Road Ambulance (Territory: SADC Countries)
(Subject to pre-approval) |
Unlimited | |
|
|
18.2 Ambulance/Inter-hospital Transfer (Subject to prior approval) |
N$600 per Family | |
| 18.3 Other transport (Subject to pre-approval, MHC guidelines and Travel Expense Re-imbursement Protocol) | No Benefit | ||
| 19. | International Medical Travel Insurance | 100% | No Benefit |
| 20. |
Lifestyle Management Screening Tests
(Subject to Clinical Guidelines and Protocols) |
100% |
N$15 000 per Family |
| 20.1 Lifestyle Management Tests (Subject to Clinical Guidelines and Protocols) | 100% | Sub-limit 20 | |
| 20.2 Rapid Tests | 100% | N$1 500 per Family Sub-limit 20 | |
Detailed Benefits:
These rules apply to Topaz.
Service Availability
Please note that all benefits on Topaz are only
available through a registered
Network of Health Professionals
Pathology
The following tests are pre-approved and can be done at the discretion of the treating General Practitioner:
|
TARIFF CODE(-52)
|
TARIFF CODE(-37) | TARIFF DESCRIPTION |
|---|---|---|
| 3755 | 53755 | Full blood count |
| 3792 | 53792 | Plasmodium falciparum: Monoclonal immunological identification |
| 3797 | 53797 | Platelet count |
| 3816 | 53816 | T and B-cells markers (per marker) |
| 3865 | 53865 | Parasites in blood smear |
| 3869 | 53869 | Faeces: including parasites |
| 3883 | 53883 | Concentration techniques for parasites |
| 3885 | 53885 | Cytochemical stain |
| 3932 | 53932 | Antibodies to HIV: Elisa (Note: HIV-DNA PCR is excluded) |
| 3951 | 53951 | Quantitative Kahn, VDRL or other Flocculation |
| 3999 | 53999 | Albumin |
| 4001 | 54001 | Alkaline phosphatase |
| 4006 | 54006 | Amylase |
| 4009 | 54009 | Bilirubin: Total |
| 4027 | 54027 | Cholesterol: Total |
| 4032 | 54032 | Creatinine |
| 4057 | 54057 | Glucose: Quantitative |
| 4064 | 54064 | Glycosylated Haemoglobin: Chromatography |
| 4113 | 54113 | Potassium |
| 4117 | 54117 | Protein: Total |
| 4131 | 54131 | Alanine aminotransferase (ALT) |
| 4134 | 54134 | Gamma-glutamyl transferase (GGT) |
| 4147 | 54147 | Triglyceride |
| 4155 | 54155 | Urine acid |
| 4161 | 54161 | Troponin isoforms: each |
| 4182 | 54182 | Quantitative protein estimation: nephelometer or Turbidometeric method |
| 4188 | 54188 | Urine dipstick per stick (irrespective of the number of tests on stick) |
| 443908 | 544391 | Quantitative PCR - viral load: HIV |
| 4450 | 54450 | HCG: Monoclonal immunological: Qualitative |
| 4519 | 54519 | Prostate-specific antigen |
| 453101 - 453109 | 54531 - 545320 | Hepatitis: per antigen or antibody (Maximum of three Antigens) |
| 4566 | 54566 | Pap Smear: vaginal or cervical smear |
| 4610 | 54610 | Helicobacter pylori stool antigen test |
Other Pathology tests are excluded.
Radiology
Topaz is limited to basic radiology: Essentially long bones: CXR: trauma, excluding MRI and CT Scans. Referral from treating General practitioner only. The following procedures are covered:| TARIFF CODE (038) | TARIFF DESCRIPTION |
|---|---|
| 00090 | Consumables in radiology procedures |
| 10100 | X-ray of the skull |
| 11120 | X-ray of the nasal bones |
| 14100 | X-ray of the mandible |
| 20100 | X-ray of the soft tissue of the neck |
| 30100 | X-ray of the chest, single-view |
| 30110 | X-ray of the chest two views, PA and lateral |
| 30120 | X-ray of the chest, complete with additional views |
| 30150 | X-ray of the ribs |
| 30155 | X-ray of the chest and ribs |
| 34200 | Ultrasound study of the breast |
| 40100 | X-ray of the abdomen |
| 40105 | X-ray of the abdomen supine and erect, or decubitus |
| 40110 | X-ray of the abdomen with multiple views, including chest |
| 40210 | Ultrasound study of the whole abdomen, including the pelvis |
| 51110 | X-ray of the cervical spine, one or two views |
| 51120 | X-ray of the cervical spine, more than two views |
| 53110 | X-ray of the lumbar spine, one or two views |
| 53120 | X-ray of the lumbar spine, more than two views |
| 55100 | X-ray of the pelvis |
| 56100 | X-ray of the left hip |
| 56110 | X-ray of the right hip |
| 56120 | X-ray of pelvis and hips |
| 61100 | X-ray of the left clavicle |
| 61105 | X-ray of the right clavicle |
| 61110 | X-ray of the left scapula |
| 61115 | X-ray of the right scapula |
| 61120 | X-ray of the left acromioclavicular joint |
| 61125 | X-ray of the right acromioclavicular joint |
| 61130 | X-ray of the left shoulder |
| 61135 | X-ray of the right shoulder |
| 62100 | X-ray of the left humerus |
| 62105 | X-ray of the right humerus |
| 63100 | X-ray of the left elbow |
| 63105 | X-ray of the right elbow |
| 64100 | X-ray of the left forearm |
| 64105 | X-ray of the right forearm |
| 65100 | X-ray of the left hand |
| 65105 | X-ray of the right hand |
| 65120 | X-ray of a finger |
| 65130 | X-ray of the left wrist |
| 65135 | X-ray of the right wrist |
| 65140 | X-ray of the left scaphoid |
| 65145 | X-ray of the right scaphoid |
| 71100 | X-ray of the left femur |
| 71105 | X-ray of the right femur |
| 72100 | X-ray of the left knee, one or two views |
| 72105 | X-ray of the right knee, one or two views |
| 72110 | X-ray of the left knee, more than two views |
| 72115 | X-ray of the right knee, more than two views |
| 72120 | X-ray of the left knee, including patella |
| 72125 | X-ray of the right knee, including patella |
| 72150 | X-ray of both knees standing - single view |
| 73100 | X-ray of the left lower leg |
| 73105 | X-ray of the right lower leg |
| 74100 | X-ray of the left ankle |
| 74105 | X-ray of the right ankle |
| 74120 | X-ray of the left foot |
| 74125 | X-ray of the right foot |
| 74130 | X-ray of the left calcaneus |
| 74135 | X-ray of the right calcaneus |
| 74140 | X-ray of both feet - standing - single view |
| 74145 | X-ray of a toe |
Pregnancy Sonar Scans:
Pregnancy ultrasounds are limited to three sonars per beneficiary per pregnancy. The following procedures are covered:
| TARIFF CODE (038) | TARIFF DESCRIPTION |
|---|---|
| 43250 | Ultrasound study of the pregnant uterus, first trimester |
| 43260 | Ultrasound study of the pregnant uterus, second trimester |
| 43270 | Ultrasound study of the pregnant uterus, third trimester, first visit |
| 43273 | Ultrasound study of the pregnant uterus, third trimester, follow-up visit |
| TARIFF CODE (039 004) | TARIFF DESCRIPTION |
|---|---|
390001 |
Routine obstetric ultrasound at 10 to 20 weeks gestational age preferable at 10 to 14 weeks gestational age to include nuchal translucency assessment (Including Doppler and colour Doppler) |
390002 |
Routine obstetric ultrasound at 20 to 24 weeks to include detailed anatomical assessment, including the foetal heart (Including Doppler and colour Doppler) |
390015 |
Obstetric ultrasound before 10 weeks gestational age for complicated pregnancy, i.e. suspected ectopic pregnancy abortion or discrepancy between gestational age and dates. Not to be used for routine diagnosis of pregnancy (Including Doppler and colour Doppler) |
390016 |
Ultrasound after 24 weeks - motivation required (Including Doppler and colour Doppler) |
| TARIFF CODE (014) | TARIFF DESCRIPTION |
|---|---|
| 5106 | Obstetric ultrasound before 10 weeks gestational age for complicated pregnancy, i.e. suspected ectopic pregnancy abortion or discrepancy between gestational age and dates. Not to be used for routine diagnosis of pregnancy. |
| 3615 | Routine obstetric ultrasound at 10 to 20 weeks gestational age, preferably at 10 to 14 weeks gestational age, to include nuchal translucency assessment. (Note: This code is also referred to as a first-trimester scan and is a stand-alone code that may not be combined with any other codes. The code specifically includes Doppler studies) |
| 3617 | Routine obstetric ultrasound at 20 to 24 weeks to include detailed anatomical assessment. (Note: This code is also referred to as a second-trimester scan and is a stand-alone code that may not be combined with any other codes. The code specifically includes Doppler studies) |
| 5107 | Ultrasound after 24 weeks. (Note: This code is also referred to as a second-trimester scan and is a standalone code that may not be combined with any other codes. The code specifically includes Doppler studies) |
Dentistry
Only basic dentistry is covered—no benefit for specialised dentistry.
HIV/AIDS
A. Treatment – According to the national guidelines for antiretroviral therapy. Medicine according to HIV/AIDS medicine formulary.B. Counselling – Three sessions pre-, post- and adherence.
C. Pathology – Baseline and monitoring laboratory tests as detailed in the national guidelines for antiretroviral therapy, excluding HIV resistance testing.
D. Rape and Occupational Injuries Cover – Covered according to the defined protocol in the national guidelines for antiretroviral therapy.