OVERALL ANNUAL BENEFIT
(OVERALL ANNUAL LIMIT)
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Unlimited According To Defined Primary Healthcare Protocols
Ex-Gratia is Not Applicable
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Category A: Primary Healthcare Benefits
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% Tariff
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Benefits available only at Network Health Professionals
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1.
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Nurse
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100%
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Registered Nurse
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1.1 Consultations / Visits
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Unlimited
N$255 per visit
(Maximum tariff regardless of time spent on consultation)
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1.2 Medication/Injections
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(According to Topaz and Topaz Plus medicine formulary)
N$240 per claim per Beneficiary per day
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1.3 Procedures
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Unlimited
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2.
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General Practitioner
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100%
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According to defined protocols
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2.1 Consultations
/ Visits (Out-Of-Hospital)
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Unlimited
N$365 per visit (First consultation)
(Maximum tariff regardless of the type of first consultation)
N$295 per visit (Follow-up consultation)
(Code 0125 - extended consultation every 15 minutes of part, therefore, not payable)
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2.2. Virtual Consultations
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Limited to 3 virtual consultations per Family
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2.3 Acute Medication/Injections
(Paid at the maximum Namibia Medicine Price on List generics)
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(According to Topaz and Topaz Plus acute medicine formulary)
N$240 per claim per Beneficiary per day
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2.4 Chronic Medication/ Injections
- Subject to Chronic Medication Registration
(Paid at the maximum Namibia Medicine Price on List generics)
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N$3 700 per Family
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2.5 Procedures (Out-of-Hospital)
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Specified Minor Procedures in Room only
(Requires prior approval)
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3.
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Medical Specialists Consultations / Visits
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100%
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5 consultations/visits per Family per annum
(0101 and 0108 only)
(Code 0129 - extended consultation every 15 minutes of part, therefore, not payable)
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4.
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Pharmacy
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100%
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4.1 Acute Medication/Injections
(Paid at the maximum Namibia Medicine Price on List generics)
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(According to Topaz and Topaz Plus medicine formulary)
N$240 per claim per Beneficiary per day
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4.2 Chronic Medication/Injections
(Subject to chronic medication registration)
(Paid at the maximum Namibia medicine price on List generics)
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Payable from Chronic Medication/ Injections
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4.3 Self-Medication
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N$700 per Family
N$120 per claim per beneficiary per day
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5.
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Pathology
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100%
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Specified tests
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6.
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Radiology
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100%
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Long bones, chest and trauma and basic radiology as per the defined list.
(Excluding MRI & CT Scan)
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7.
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Basic Dentistry
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100%
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N$1 890 per Beneficiary
N$3 650 per Family
(1 plastic denture per family every 2 years)
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8.
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Optical
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100%
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N$1 000 per beneficiary every two years (2023/2024)
(6 months waiting period, complete test, specified frames and lenses)
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8.1 Single Vision (Inclusive of test, frame and lenses)
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Sub-limit 8
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8.2 Bifocal (Inclusive of test, frame and lenses)
(Paid at maximum Namibia medicine price on List generics)
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Sub-limit 8
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9.
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Sonar Scans
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100%
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3 scans per Beneficiary per pregnancy.
Groups have cover from the date of joining.
Individuals have a 9-month waiting period.
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10.
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Antenatal Consultation (General Practitioner)
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100%
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Limited to 9 consultations per Beneficiary (2601 & 2602).
Groups have cover from the date of joining.
Individuals have a 9-month waiting period.
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11.
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Paramedical / Allied Health Professionals (Psychologists, Physiotherapists, Occupational Therapists)
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100%
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3 consultations/sessions per Family per annum
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Category B: HIV/AIDS Treatment and Other Specified Conditions
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% Tariff
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Unlimited According to Defined Protocols
Benefits are only available at Network Health Professionals
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12.
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HIV/AIDS Treatment
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100%
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As Per the National Guidelines for Antiretroviral Therapy
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12.1 Consultations(General Practitioners)
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Unlimited
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12.2 Medication (including vitamins & supplements)
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Unlimited
(According to Topaz and Topaz Plus HIV medicine formulary)
(Vitamins & supplements maximum of N$100)
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12.3 Pathology
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Unlimited
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12.4 Counselling (pre-, post and adherence)
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3 sessions
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12.5 Post Exposure Prophylaxis (PEP) (rape cover only)
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As per the National Guidelines for antiretroviral therapy
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12.6 Pre Exposure Prophylaxis (PrEP)
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No Benefits
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12.7 Prevention of Mother-to-Child Transmission (PMTCT) (excluding Milk formula)
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As per the National Guidelines for antiretroviral therapy
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Category C: Hospitalisation Benefit
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Private Hospitalisation
Benefits available at Network Health Professionals
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Planned Procedures: Waiting period of 6 months after joining.
Emergency Cases: Immediate cover
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Overall Annual Limit
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% Tariff
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N$115 000 per family
Pre-authorisation: 100% of tariff will be paid out.
Without Pre-authorisation: No benefit will be paid out except in the case of emergency hospital admissions and emergencies after-hours, weekends and public holidays.
Payable from the Overall Annual Limit
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13.
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State Hospitalisation
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100%
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Unlimited Private Wing of a State Hospital
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13.1 Accommodation and Theatre
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Overall Annual Limit
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13.2 Blood Transfusions
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13.3 Intensive and High Care (3 days)
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13.4 Medicine, Fixed Tariff Procedures, Hospital Apparatus and To-Take-Out Medicine
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13.5 Radiology & Pathology (In-Hospital)
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General Practitioners and Medical Specialists (In-Hospital Services)
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14.
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Private Hospitalisation
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100%
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N$115 000 per family
Pre-authorisation: 100% of the tariff will be paid out.
Without Pre-authorisation: No benefit will be paid except in case of emergency hospital admissions, after-hours emergencies, weekends, and public holidays.
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14.1 Accommodation and Theatre
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Overall Annual Limit
15 days per Beneficiary
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14.2 Blood Transfusions
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Overall Annual Limit
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14.3 Intensive and High Care (3 days, then referral to State Hospitals)
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14.4 Medicine, Fixed Tariff Procedures, Hospital Apparatus and To-Take-Out Medicine
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Overall Annual Limit
(Limited to 7 days' supply only)
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14.5 Radiology & Pathology (In-Hospital)
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Sub-limit 16
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15.
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General Practitioners & Medical Specialists
(In-Hospital Services)
- Additional Hospital Benefit Cover is excluded
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100%
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N$25 000 per Family
(Including Radiology and Pathology)
Overall Annual Limit
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Other Healthcare providers
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No benefit
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16.
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Maternity
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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
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17.
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Ambulance Services
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100%
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Unlimited
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18.1 Emergency Road Ambulance (Territory: SADC Countries)
(Subject to pre-approval)
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18.2 Ambulance/Inter-hospital Transfer
(Subject to pre-approval)
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N$550 per Family
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Detailed Benefits
These rules apply to Topaz Plus.
Pathology
The following tests are pre-approved and can be
done at the discretion of the treating General Practitioner:
TARIFF CODE(-52)
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TARIFF CODE(-37)
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TARIFF DESCRIPTION
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3755
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53755
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Full blood count
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3792
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53792
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Plasmodium falciparum: Monoclonal immunological identification
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3797
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53797
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Platelet count
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3816
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53816
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T and B-cells markers (per marker)
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3865
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53865
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Parasites in blood smear
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3869
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53869
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Faeces: including parasites
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3883
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53883
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Concentration techniques for parasites
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3885
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53885
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Cytochemical stain
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3932
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53932
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Antibodies to HIV: Elisa
(Note: HIV-DNA PCR is excluded)
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3951
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53951
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Quantitative Kahn, VDRL or other Flocculation
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3999
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53999
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Albumin
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4001
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54001
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Alkaline phosphatase
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4006
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54006
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Amylase
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4009
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54009
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Bilirubin: Total
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4027
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54027
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Cholesterol: Total
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4032
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54032
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Creatinine
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4057
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54057
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Glucose: Quantitative
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4064
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54064
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Glycosylated Haemoglobin: Chromatography
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4113
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54113
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Potassium
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4117
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54117
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Protein: Total
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4131
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54131
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Alanine aminotransferase (ALT)
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4134
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54134
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Gamma-glutamyl transferase (GGT)
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4147
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54147
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Triglyceride
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4155
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54155
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Urine acid
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4161
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54161
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Troponin isoforms: each
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4182
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54182
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Quantitative protein estimation: nephelometer or Turbidometeric method
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4429
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54429
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Quantitative PCR (DNA/RNA) (Note: only for HIV management and according to National Guidelines)
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4450
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54450
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HCG: Monoclonal immunological: Qualitative
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4519
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54519
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Prostate-specific antigen
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4531
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54531
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Hepatitis: per antigen or antibody (Maximum of 3 Antigens)
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4566
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54566
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Pap Smear: vaginal or cervical smear
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4610
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54610
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Helicobacter pylori stool antigen test
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Other Pathology tests are excluded.
Radiology
Topaz Plus 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:
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TARIFF CODE (038)
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TARIFF DESCRIPTION
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10100
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X-ray of the skull
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11120
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X-ray of the nasal bones
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14100
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X-ray of the mandible
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20100
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X-ray of the soft tissue of the neck
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30100
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X-ray of the chest, single view
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30110
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X-ray of the chest two views, PA and lateral
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30120
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X-ray of the chest, complete with additional views
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30150
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X-ray of the ribs
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30155
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X-ray of the chest and ribs
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34200
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Ultrasound study of the breast
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40100
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X-ray of the abdomen
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40105
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X-ray of the abdomen supine and erect, or decubitus
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40110
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X-ray of the abdomen with multiple views, including chest
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40210
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Ultrasound study of the whole abdomen, including the pelvis
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51110
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X-ray of the cervical spine, one or two views
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51120
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X-ray of the cervical spine, more than two views
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53110
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X-ray of the lumbar spine, one or two views
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53120
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X-ray of the lumbar spine, more than two views
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55100
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X-ray of the pelvis
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56100
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X-ray of the left hip
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56110
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X-ray of the right hip
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56120
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X-ray of pelvis and hips
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61100
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X-ray of the left clavicle
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61105
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X-ray of the right clavicle
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61110
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X-ray of the left scapula
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61115
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X-ray of the right scapula
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61120
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X-ray of the left acromioclavicular joint
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61125
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X-ray of the right acromioclavicular joint
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61130
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X-ray of the left shoulder
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61135
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X-ray of the right shoulder
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62100
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X-ray of the left humerus
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62105
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X-ray of the right humerus
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63100
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X-ray of the left elbow
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63105
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X-ray of the right elbow
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64100
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X-ray of the left forearm
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64105
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X-ray of the right forearm
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65100
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X-ray of the left hand
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65105
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X-ray of the right hand
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65120
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X-ray of a finger
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65130
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X-ray of the left wrist
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65135
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X-ray of the right wrist
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65140
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X-ray of the left scaphoid
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65145
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X-ray of the right scaphoid
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71100
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X-ray of the left femur
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71105
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X-ray of the right femur
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72100
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X-ray of the left knee, one or two views
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72105
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X-ray of the right knee, one or two views
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72110
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X-ray of the left knee, more than two views
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72115
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X-ray of the right knee, more than two views
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72120
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X-ray of the left knee, including patella
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72125
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X-ray of the right knee, including patella
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72150
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X-ray of both knees standing - single view
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73100
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X-ray of the left lower leg
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73105
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X-ray of the right lower leg
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74100
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X-ray of the left ankle
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74105
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X-ray of the right ankle
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74120
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X-ray of the left foot
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74125
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X-ray of the right foot
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74130
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X-ray of the left calcaneus
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74135
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X-ray of the right calcaneus
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74140
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X-ray of both feet - standing - single view
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74145
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X-ray of a toe
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Sonar Scans:
Pregnancy ultrasounds are limited to 3 sonar per beneficiary per pregnancy. The following procedures are covered:
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TARIFF CODE (038)
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TARIFF DESCRIPTION
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43250
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Ultrasound study of the pregnant uterus, first trimester
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43260
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Ultrasound study of the pregnant uterus, second trimester
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43270
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Ultrasound study of the pregnant uterus, third trimester, first visit
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43273
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Ultrasound study of the pregnant uterus, third trimester, the follow-up visit
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Dentistry
Only basic dentistry is covered—no benefit for specialised dentistry.
HIV/AIDS
A. Treatment - Unlimited: According to the
National Guidelines for Antiretroviral Therapy (2014).
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 are alternatives 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.
Optical
There is a six-month waiting period with a pair of glasses only every two years per beneficiary. A pair of glasses will consist of an eye test, specified frames, non-glass lenses or non-glass bifocal lenses.
Paramedical/Allied Health Professionals
Limited to three consultations/sessions per family per annum. Paramedical includes services by a Psychologist (086), Physiotherapist (072) and Occupational Therapist (066).
Medical Specialists Consultations
Limited to five consultations per family per annum. Benefits only apply to the first consultation(0101) and follow-up consultation (0108) in the doctor's room.
