Key Benefits
Hospital: Major Medical Expenses
Cover: In-hospital services payable to a maximum of 100% of Tariff
| Overall Annual Benefit /Limit |
Cover – Benefits Available Only 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 | 309 | 262 | 124 |
| 26 | 30 | 327 | 278 | 124 |
| 31 | 35 | 343 | 292 | 124 |
| 36 | 40 | 362 | 308 | 124 |
| 41 | 45 | 382 | 324 | 124 |
| 46 | 50 | 404 | 342 | 135 |
| 51 | 55 | 419 | 357 | 135 |
| 56 | 60 | 436 | 370 | 135 |
| 61 | 65 | 468 | 398 | 135 |
| 66+ |
|
503 | 427 | 135 |
| Groups |
|
|||
|---|---|---|---|---|
| Age Band |
|
Main Member | Adult Dependant | Child |
| 0 | 25 | 278 | 236 | 111 |
| 26 | 30 | 294 | 250 | 111 |
| 31 | 35 | 310 | 264 | 111 |
| 36 | 40 | 327 | 277 | 111 |
| 41 | 45 | 344 | 293 | 111 |
| 46 | 50 | 363 | 309 | 122 |
| 51 | 55 | 378 | 321 | 122 |
| 56 | 60 | 393 | 334 | 122 |
| 61 | 65 | 422 | 359 | 122 |
| 66+ |
|
454 | 385 | 122 |
Topaz 2022 Benefit 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 Consultation/Visits |
Unlimited
N$255 per visit (Maximum tariff regardless of time spent on consultation) |
|
|
|
1.2 Medication/Injections |
Unlimited
(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 type of first consultation) N$295 per visit (Follow-up consultation) (Maximum tariff regardless of 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 Maximum Namibia Medicine Price on generics) |
Unlimited
(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 Maximum Namibia Medicine Price on generics) |
N$3 500 per Family | |
|
|
2.5 Procedures (Out-Of-Hospital)
|
Unlimited.
Specified Minor Procedures in Room only (Requires prior approval) |
|
| 3. |
Medical Specialist Consultations/Visits |
100% |
No Benefit |
|
4.
|
Pharmacy | 100% | Unlimited |
|
|
4.1 Acute Medication/Injections
Paid at Maximum Namibia Medicine Price on generics |
Unlimited
(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 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 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 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 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 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 & 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 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 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 months waiting period after joining Emergency Cases: Immediate Cover |
|||
| Overall Annual Limit | % Tariff | Unlimited | |
|
13.
|
State Hospitalisation
|
|
Unlimited
Private Wing of 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 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 state hospital
(GPs and Specialists limited to Sub-Limit 15 Groups have cover from 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 for Topaz.Service Availability
Please note that all benefits on Topaz are only available through registered Network Health ProfessionalsPathology
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) |
| 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 |
|---|---|
| 10100 | X-ray of the skull |
| 11120 | X-ray of the nasal bones |
| 14100 | X-ray of the mandible |
| 20100 | X-ray of 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 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 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 acromio-clavicular joint |
| 61125 | X-ray of the right acromio-clavicular 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 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, follow-up visit |
Dentistry
Basic dentistry only. 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. The child over 6 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.