Our Benefits - Options and Benefits

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.

Network Health Professionals List

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	384	326	154
26	30	407	346	154
31	35	427	364	154
36	40	451	383	154
41	45	476	404	154
46	50	504	426	167
51	55	521	445	167
56	60	543	460	167
61	65	583	496	167
66+		628	532	167

Groups
Age Band		Main	Adult	Child
0	25	346	293	138
26	30	367	312	138
31	35	387	328	138
36	40	407	345	138
41	45	428	366	138
46	50	452	384	152
51	55	471	401	152
56	60	490	416	152
61	65	527	447	152
66+		566	480	152

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$270 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$385 per visit (First consultation) (Maximum tariff regardless of the type of first consultation) N$310 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$2 625 per Beneficiary N$4 200 per Family N$252 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$3 670 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$1 880 per Beneficiary N$3 730 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$150)
	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$26 250 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$580 per Family
19.	Lifestyle Management Screening Tests (Subject to Clinical Guidelines and Protocols)	100%	N$15 000 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
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.

Medicine Formulary

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

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Our Benefits - Options and Benefits | NMC

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