Our Benefits - Options & Benefits

Key Benefits

Hospital: Major Medical Expenses

Cover: In-hospital services payable to a maximum of 100% of the NAMAF Tariff

Overall Annual Benefit /Limit	Cover – Benefits are Only Available at Network Health Professionals
Hospitalisation	100%
Blood Transfusion	100%
Radiology	100%
GPs and Specialists In-hospital	100%

Day-to-Day Benefits

Benefit	Cover
General Practitioners	Unlimited consultations
Acute Medicine & Injections	Unlimited
Chronic Medicine & Injections	Unlimited
In-Practice Procedures	Unlimited
Pathology	Specified tests only
Radiology	Long bones, chest and trauma and basic radiology (excluding MRI & CT Scan)
Dentistry	Extractions & fillings only
Sonar Scans (Pregnancy)	3 scans per Beneficiary per pregnancy

Contributions

Individuals
Age Band		Main Member	Adult Dependant	Child
0	25	339	288	136
26	30	359	305	136
31	35	377	321	136
36	40	398	338	136
41	45	420	356	136
46	50	444	376	148
51	55	460	392	148
56	60	479	406	148
61	65	514	437	148
66+		553	469	148

Groups
Age Band		Main Member	Adult Dependant	Child
0	25	305	259	122
26	30	323	275	122
31	35	341	290	122
36	40	359	304	122
41	45	378	322	122
46	50	399	339	134
51	55	415	353	134
56	60	432	367	134
61	65	464	394	134
66+		499	423	134

OVERALL ANNUAL BENEFIT (OVERALL ANNUAL LIMIT)			Unlimited According To Defined Primary Healthcare Protocols Ex-Gratia is Not Applicable
Category A: Primary Healthcare Benefits		% Tariff	Benefits Available Only at Network Health Professionals
1.	Nurse	100%	Registered Nurse
	1.1 Consultation/Visits		Unlimited N$255 per visit (Maximum tariff regardless of time spent on consultation)
	1.2 Medication/Injections		(According to Topaz and Topaz plus medicine formulary) N$240 per claim per Beneficiary per day
	1.3 Procedures		Unlimited
2.	General Practitioner	100%	According to defined protocols
	2.1 Consultations/Visits (Out-Of-Hospital)		Unlimited. $365 per visit (First consultation) (Maximum tariff regardless of the type of first consultation) N$295 per visit (Follow-up consultation) (Maximum tariff regardless of the type of Follow-up consultation) (Code 0125 - extended consultation every 15 minutes or part; therefore, not payable)
	2.2 Virtual Consultations (Subject to prior approval)		3 virtual consultations per Family
	2.3 Acute Medication/Injections (Paid at the maximum Namibia Medicine Price on generics)		(According to Topaz and Topaz Plus acute medicine formulary) N$240 per claim per Beneficiary per day
	2.4 Chronic Medication/Injections - Subject to Chronic Medication Registration (Paid at the maximum Namibia Medicine Price on generics)		N$3 500 per Family
	2.5 Procedures (Out-Of-Hospital)		Specified Minor Procedures in Room only (Requires prior approval)
3.	Medical Specialist Consultations/Visits	100%	No Benefit
4.	Pharmacy	100%
	4.1 Acute Medication/Injections Paid at the maximum Namibia Medicine Price on generics		(According to Topaz and Topaz Plus Acute Medicine Formulary) N$240 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		Payable from Chronic Medication/Injections
	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 & CT Scan)
7.	Basic Dentistry	100%	N$1 790 per Beneficiary N$3 550 per Family (1 plastic denture per Family every 2 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%	3 scans per Beneficiary per pregnancy Groups have cover from the date of joining Individuals have a 9-month waiting period
10.	Antenatal Consultation (General Practitioner)	100%	Limited to 6 consultations per Beneficiary (2601 & 2602 only) Groups have cover from the date of joining Individuals have a 9-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 are only available 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 & supplements) (Acute and chronic, including vitamins and supplements)		Unlimited (According to Topaz and Topaz Plus HIV medicine formulary) (Vitamins & supplements maximum of N$100)
	12.3 Pathology		Unlimited
	12.4 Counselling (pre-, post & adherence)		3 Sessions
	12.5. Post Exposure Prophylaxis (PEP) (Rape Cover 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 6-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 (3 days)
	13.4 Medicine, Fixed Tariff Procedures, Hospital Apparatus and To-Take-Out Medicine
	13.5 Radiology & Pathology (In-Hospital)		General Practitioners and Medical Specialists (In-Hospital Services)
14.	Private Hospitalisation		No Benefit
15.	General Practitioners & Medical Specialists (In-Hospital services) – Additional Hospital Benefit Cover is excluded	100%	N$25 000 per Family 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 Sub-Limit 16 Groups have cover from the date of joining Individuals have a 9-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$550 per Family

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
4429	54429	Quantitative PCR (DNA/RNA) (Note: only for HIV management and according to National Guidelines)
4450	54450	HCG: Monoclonal immunological: Qualitative
4519	54519	Prostate-specific antigen
4531	54531	Hepatitis: per antigen or antibody (Maximum of 3 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, and trauma, excluding MRI and CT Scans. Referral from treating General Practitioner only. The following procedures are covered:

TARIFF CODE (038)	TARIFF DESCRIPTION
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

Sonar Scans:

Pregnancy ultrasounds are limited to 3 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, a follow-up visit

Dentistry

Only basic dentistry is covered—no benefit for specialised dentistry.

HIV/AIDS

A. Treatment – Unlimited: According to the National Guidelines for Antiretroviral Therapy.
B. Counselling – 3 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 Cover – Covered according to the defined protocol in the National Guidelines for Antiretroviral Therapy.

Tenofovir (300mg) plus Lamivudine (300mg) fixed-dose combination daily, Plus Lopinavir/ritonavir combination BD for 28 days.

For children - ABC / 3TC and / LPV/r, as an alternative when ABC cannot be tolerated. Children over six years and at least weigh 5 kg and above can be given ATV/r as an option.
Plus, other supportive actions as detailed in the above guidelines.

Medicine Formulary

Topaz only covers medication as specified in the Topaz and Topaz Plus Acute, and HIV Medicine Formulary.

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